What are the conditions and standards for enjoying basic medical insurance benefits?

A From the third month after continuous participation in basic medical insurance and full payment, the insured person can enjoy basic medical insurance benefits for hospitalization, specific outpatient service and outpatient service according to regulations.

Hospitalization treatment: the insured person is hospitalized due to illness and can enjoy basic medical insurance treatment according to regulations.

Calculation of hospitalization medical insurance benefits: reimbursement amount = (hospitalization medical expenses-self-funded items-Qifubiaozhun) × proportion of overall fund payment.

1. Basic hospitalization medical expenses: refers to the hospitalization medical expenses that meet the requirements of basic medical insurance drugs, diagnosis and treatment items, medical service facilities and payment standards.

2. Qifubiaozhun: The Qifubiaozhun for basic medical expenses incurred by the insured person in hospital should be determined according to the hospital level.

Qifubiaozhun for hospitalization medical expenses is

Inside and outside the city

Qifubiaozhun

Hospital grade

City hospital

A hospital outside the city

Emergency treatment outside the city

Tertiary hospital

1300 yuan

2000 yuan

According to the standard of municipal secondary hospital: 800 yuan.

Secondary hospital

Eight hundred yuan

1500 yuan

Level I and other hospitals

500 yuan

1000 yuan

3. Maximum payment limit: according to the years of continuous insurance payment, the insured can enjoy the maximum social security payment for hospitalization and specific outpatient service in a social security year. As shown in the following table:

Continuous insurance time

Overall fund payment limit

comment

Less than 2 months

0 yuan

Should be insured but not insured or continuous after insurance.

Suspension of payment for more than three months (including three months)

When employees go through the insurance payment procedures,

From the month when the insured should apply for insurance or interrupt payment, the doctor will be assessed.

Premiums and late fees charged according to relevant regulations, among which

Medical insurance benefits from handling insurance procedures and paying hands.

From the next month, according to the new insurance, during this period,

The fund will not pay for occasional medical expenses.

More than 2 months but less than 6 months.

1 ten thousand yuan

Over 6 months but less than 1 year.

twenty thousand yuan

1 year and 2 years.

50 thousand yuan

More than two years and less than three years.

65438+ ten thousand yuan

More than 3 years

200,000 yuan/year

Please note:

(1). During the social security year, the basic medical treatment paid by the overall fund for hospitalization and specific outpatient service shall not exceed the annual maximum payment limit of basic medical insurance.

(2) If the insured changes the form of insurance during the year, the accumulated payment amount of the inpatient and specific outpatient co-ordination fund shall not exceed the annual maximum payment limit of basic medical insurance, and the limit standard shall be calculated according to the provisions of the insured's medical expenses at that time.

4, the overall fund payment ratio:

Overall fund payment ratio

Basic medical expenses for hospitalization

First-class hospital

Secondary hospital

The tertiary hospital in the city

A tertiary hospital outside the city

incumbent

retire

incumbent

retire

incumbent

retire

incumbent

retire

Qifubiaozhun above 50 thousand yuan of medical expenses.

95%

100%

90%

95%

85%

90%

80%

85%

More than 50,000 yuan and less than or equal to 6,543.8+10,000 yuan.

75%

80%

70%

75%

65%

70%

60%

65%

More than 1.5 million yuan and less than 1.5 million yuan.

55%

60%

50%

55%

45%

50%

40%

45%

65438+500,000 yuan but less than 200,000 yuan

45%

50%

40%

45%

35%

40%

Thirty percent

35%

B The insured can enjoy the hospitalization and special outpatient treatment of supplementary medical insurance according to the regulations from the seventh month after continuously participating in supplementary medical insurance and paying in full.

① Supplementary medical insurance hospitalization segmented subsidy

The basic medical expenses incurred by the insured due to illness and hospitalization in line with the list of social insurance drugs, diagnosis and treatment items and the scope of medical service facilities shall be subsidized by the supplementary medical insurance fund in accordance with the following proportions:

More than 50 thousand yuan, less than or equal to 6.5438+10 thousand yuan, 20% subsidy;

More than150,000 yuan, less than or equal to150,000 yuan, 30% subsidy;

If it exceeds 6.5438+0.5 million yuan and does not exceed the basic medical expenses corresponding to the maximum payment limit of basic medical insurance, the subsidy will be 40%.

② Subsidies exceeding the maximum payment limit of basic medical insurance.

The basic medical expenses incurred by the insured due to illness exceed the basic medical expenses corresponding to the maximum payment limit of the basic medical insurance, and the supplementary medical insurance fund shall give subsidies according to the following proportions:

Less than or equal to 6.5438 million yuan, 85% subsidy;

65438+ 10,000 yuan, 70% subsidy.

Hope to adopt