Wuhan employee health insurance reimbursement standard

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Wuhan workers health insurance contributions and treatment reimbursement standards

First, how to apply for registration and payment

units to participate in the basic health insurance for employees, fill in the "social insurance registration form", show relevant documents and materials to the jurisdiction of the social security for registration procedures; flexible employment to participate in the basic health insurance, should be held with their own household registration, identity card, has been for the basic urban pension insurance certificate, etc. Relevant information, to the residence of the jurisdiction of the social insurance agency for registration procedures.

Second, the provisions of the medical insurance entitlement period

Employers and their employees to pay the basic medical insurance premiums in accordance with the provisions of the first month, its employees and retirees began to enjoy the basic medical insurance benefits; flexible employees to pay the basic medical insurance premiums for six months, from the seventh month to enjoy the basic medical insurance benefits.

Third, what kinds of medical treatment

Employee health insurance medical treatment, including general outpatient, outpatient treatment of some serious (chronic) diseases, hospitalization.

Fourth, the composition and use of individual accounts

Basic medical insurance individual account is established in the name of the insured person's insurance account, by the individual in accordance with the relevant provisions of the basic medical insurance, use, disposal. Individual accounts are managed by ic cards, and no cash can be withdrawn; the funds and interest in the individual accounts are owned by the individuals. Where units and individuals pay medical insurance premiums in full and on time, the individual account in accordance with the following ratios: in the staff (including flexible employment) under 35 years old, 36 to 45 years old, 46 years old to the retirement of the contribution base, and the proportion of the allocation of retirees under 70 years old and 71 years old or older according to their last year's average monthly retirement fee (retirement fee is less than 80% of the previous year's average monthly salary of city employees, the previous year) 80% of the city's average monthly salary of workers as the base) and the proportion of the allocation.

Individual account can be used to pay for the insured person in the designated retail pharmacies, designated hospital outpatient, outpatient treatment of some serious (chronic) diseases, outpatient rescue and hospitalization of the medical costs of the individual out-of-pocket (excluding personal out-of-pocket) expenses.

V. Outpatient treatment of serious illnesses

Insured workers with social security cards in the designated hospital outpatient outpatient treatment of serious (chronic) diseases, in line with the medical costs paid by the Employees' Health Insurance Fund, the outpatient serious disease coordinating fund to pay 80% (in-service) and 85% (retired), outpatient chronic disease coordinating fund to pay 60% (in-service) and 65% (retired). Some outpatient serious illnesses (malignant tumors, kidney dialysis, anti-rejection treatment after kidney transplantation, anti-rejection treatment after liver transplantation) the fund pays 87% (active) and 90% (retired).

For the use of Class B drugs or diagnostic and therapeutic items belonging to the category of medical insurance, the individual first pays 10% out-of-pocket, and the remaining balance will be paid by the medical insurance fund in accordance with the above ratio.

VI. Starting standard for hospitalization

The starting standard for hospitalization refers to the hospitalization of the insured person, according to the regulations should be paid by the individual first a certain amount of medical expenses. More than the starting standard of medical costs, by the medical insurance fund and the individual in accordance with the prescribed proportion. The starting standard for hospitalization is:

(a) 200 yuan for community health centers

(b) 400 yuan for first-level hospitals;

(c) 600 yuan for second-level medical institutions;

(d) 800 yuan for third-level medical institutions.

If the insured person is hospitalized twice or more in one insurance year, the hospitalization threshold will be reduced by half (except for community health centers). Disabled people who are entitled to low-income insurance are exempted from the hospitalization starting standard fee.

VII. Hospitalization Treatment

Expenses above the starting standard of basic medical insurance and within the annual payment limit (240,000 yuan) will be paid by the medical insurance fund in different proportions according to the level of the hospital and the cost segments.

(a) annual cumulative basic medical insurance costs within 100,000, the proportion of the medical insurance fund are:

1, community, first-class hospital fund to pay 92% (in-service) retired);

2, second-class hospital fund to pay 89% (in-service) retired);

3, third-class hospital fund to pay 86% (in-service) retired);

4, enjoying the benefits of low income insurance Disabled people, the proportion of payment of the integrated fund increased by 2%.

(ii) annual cumulative basic medical insurance within the cost of 100,000-200,000, the health insurance fund pays 94%,

(iii) annual cumulative basic medical insurance within the cost of 200,000-240,000, the health insurance fund pays 98%.

(d) the use of medicines or diagnostic and therapeutic items belonging to the category of medical insurance category B, the first 10% of the individual out-of-pocket payment, the balance of the medical insurance fund in accordance with the above ratio.

VIII. Large medical insurance treatment

In an insurance year, the insured person in the outpatient critical illness, outpatient rescue and hospitalization of the medical insurance coverage of the costs incurred by more than the basic medical insurance payment limit (240,000), paid by the large medical insurance fund, the payment ratio is 98%. The use of medicines or diagnostic and treatment items belonging to the medical insurance category B, first by the individual out-of-pocket payment of 10%, the balance of the large medical insurance in accordance with the above ratio.

The maximum payment limit for large medical insurance is 300,000 yuan

Nine, the use of Class B drugs and some of the diagnostic and therapeutic items individual payment ratio

Participants in the outpatient treatment of some serious (chronic) diseases, outpatient rescue and hospitalization, the use of Class B drugs or diagnostic and therapeutic items belonging to the category of the medical insurance coverage, the first 10% out-of-pocket payment by the individual, and the balance of the proportion of the medical insurance fund to pay.

X. Individual payment ratio for the use of materials placed in the body, replacement of artificial organs and blood products

Participants in the outpatient treatment of serious diseases and hospitalization, the use of basic medical insurance coverage for appropriate relaxation of the category of items first by the individual to pay 30%, the use of domestic replacement materials individual payment of 35%, and the use of imported replacement materials individual payment of 50%.

XI, an insurance year, the basic medical insurance fund and large medical insurance maximum payment

In an insurance year, the insured outpatient treatment of some serious diseases, outpatient rescue and hospitalization of the cumulative incurred in line with the policy provisions of the medical costs, the basic medical insurance limit of 240,000 yuan of costs within the scope of the year. More than the cost of basic medical insurance limit, large medical insurance annual maximum payment limit of 300,000 yuan.

XII, non-scheduled hospital emergency rescue declaration

Participants due to emergency rescue in a non-scheduled hospital inpatient treatment within five working days, by the individual or unit of the medical treatment into a written application, and add the official seal, accompanied by the outpatient emergency medical records, relevant examination reports (mainly to illustrate the severity of the examination), 120 emergency invoices and other information to the Municipal Health Insurance Center, the 2nd floor window to declare. Municipal health insurance center in the receipt of the declaration of information within three working days after the completion of the audit, and by SMS (phone) form to inform the declarant.

XIII, for referral and transfer procedures

Participants in the designated hospitals between the transfer of hospital treatment, the transfer of the hospital online transfer procedures by the transferring hospital, you can go directly to the transferring medical institution for hospitalization; transfer to the designated referral hospital hospital hospitalization by the three-level general hospital or specialty hospitals to put forward the views of the transfer of hospitals by the Municipal Health Insurance Center to complete the online audit within two working days, the approval of the transfer of hospitalization directly into the medical institution. Hospitalization.

14, non-designated hospital expenses how to reimbursement?

The insured person referred to the non-designated hospital hospitalization by the audit, within one month after discharge, fill out the "Wuhan Municipal Social Insurance Medical Expenses Declaration Form" and bring the cost receipts (original), the cost of a summary list (original), the first page of the case, the discharge summary, outpatient (emergency) clinic medical records and examination reports, pathological examination reports, surgical records (including anesthesia records), long-term medical advice, temporary medical advice, foreign hospital class certificate, the hospital's medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, the medical certificate, and the medical certificate. Medical advice, foreign hospital grade certificate, a copy of the social security card, a copy of the ID card, etc. Municipal health insurance center window on the 2nd floor for reimbursement procedures, the city health insurance center to receive the complete reimbursement information after 15 working days after the payment to the account.

Participants who participate in both basic medical insurance and commercial medical insurance must first reimburse the basic medical expenses, make a copy of all the hospitalization data in person, and then go to the commercial insurance company for reimbursement of commercial insurance after receiving the Medical Expense Settlement List from the Municipal Medical Insurance Center.

XV. How to deal with the balance of the personal account of the terminated medical insurance?

Basic medical insurance participants can apply for a one-time payment of the balance of the individual account if they go abroad, die, or transfer out of the city and the individual account cannot be transferred.

If the above conditions are met, two months after the termination of medical insurance procedures, the insured unit (flexible employment insurance by himself or his legal heirs) with the following information to the jurisdiction of the social security agency to apply for processing.

1, fill out the complete "health insurance individual account balance of the one-time payment declaration form";

2, the payee and the termination of health insurance personnel relationship to prove the information (participating units and jurisdictions of the social security agency must be approved by the heir (payee) identity, heir (payee) and termination of the relationship between the health insurance personnel;

3, termination of the health insurance personnel "Death certificate" (copy) or settled abroad, transferred out of the city information;

4, payee bank account information copy (payee needs to open an account in the Hankou Bank); the use of social security card financial account (Hankou Bank), you must go to the bank counter to open the card to activate the account.

XVI. How to apply for relocation?

Retirees who are relocated can apply for medical insurance relocation procedures. Applicants need to apply in writing, fill out the "Wuhan Urban Workers' Basic Medical Insurance Relocation Registration Form", and go to the district social security agency for processing. The applicant should provide a copy of the certificate of transfer of hukou or residence permit or temporary residence permit of the place of transfer, a copy of ID card, and a copy of the Postal Savings Bank card or passbook.

XVII, relocation of personnel treatment

relocation of retirees to take the personal account of the commissioned bank payment or unit on behalf of the issue.

The relocation of personnel in the resettlement of designated hospitals in the outpatient emergency rescue, hospitalization and outpatient treatment of some of the serious (chronic) diseases of the medical costs first advanced by themselves, within one month after the end of treatment, by the unit with a copy of their medical records, medical expenses, such as detailed lists of vouchers, reported to the jurisdiction of the medical insurance agency for examination and approval, the municipal health insurance center from the receipt of social security services to submit complete reimbursement information within 15 working days from the date of disbursement. The first time you see this is when you are in the middle of the night, and it's not a bad time to be in the middle of the night. Our laws are gradually improving, and we look forward to helping more people.