Main Policies of Urban Medical Insurance in Rudong County from 2065438 to 2009

First, the normal payment ratio and standard of participating in medical insurance

(a) the basic medical insurance premium payment standard

1, insured by the employer:

The unit pays 8% of the payment base, and the individual employee pays 2% of the payment base, which is withheld and remitted by the insured unit.

2. Personal insurance: 65438+ 00% of the payment base.

(II) Payment standard of hospitalization medical insurance premium: 5.5% of the payment base shall be paid by the unit or individual insured.

(3) The premium of mutual medical insurance for serious illness is the same as that of basic medical insurance, and it is paid by 1%, of which 0.5% is paid by the employer and 0.5% by the individual.

(4) The continuous payment period of basic and inpatient medical insurance personnel before retirement must be over 15 years, and those who are less than 15 years must pay back.

(5) Medical insurance payment standard for urban residents: urban elderly residents (male 60 years old, female 50 years old and above) pay 120 yuan; Young and middle-aged unemployed residents in cities and towns (18 years old and above, 59 years old for men and 49 years old and below for women), paid by individuals 180 yuan.

(VI) Payment standard of children's supplementary medical insurance: individuals pay 40 yuan.

(7) The employer pays the fees every month. Basic medical insurance Individuals shall pay the medical insurance premium for the next year from the end of June to March of the following year, residents shall pay it from the end of June to February 20th of 10, and children shall pay it from September to 20th of each year.

Second, personal accounts.

Personal accounts are divided into fixed accounts and monthly accounts.

Fixed accounts of employees participating in basic medical insurance: calculated according to the minimum monthly payment base of 2,299 yuan and the lowest level account allocation ratio of 3.5%, rounded to 80 yuan per month and 960 yuan throughout the year. After deducting the supplementary medical insurance premium that should be paid, 60 yuan is actually a 900 yuan for the whole year, which is distributed once at the beginning of the year. The difference (monthly statement), after paying the medical insurance premium every month, is calculated and included according to the actual payment base of each person.

Monthly account calculation formula: monthly payment base × corresponding proportion-monthly fixed account.

Corresponding proportion: 3.5% under the age of 35, 4.5% under the age of 36-45, and 5.5% over the age of 46, of which: the monthly payment base is more than 4,306 yuan, and the above proportion is increased by 0.5 percentage points.

Retirees over 70 years old (including 70 years old) of basic medical insurance actually transfer 87.5 yuan per month, including 67.5 yuan in fixed account and 20 yuan monthly account. The annual fixed account is 865,438+00 yuan, which was transferred at the beginning of the year, and the monthly account is in 240 yuan for the whole year, totaling 65,438+0050 yuan. Retirees under the age of 70 are actually transferred to 85 yuan every month, including: 65 yuan with fixed accounts and 20 yuan with monthly accounts. The fixed account in 780 yuan is transferred once at the beginning of the year, and the monthly account is in 240 yuan throughout the year, totaling 1020 yuan.

Retirees' low-level medical insurance (medical care) personal accounts are 300 yuan per person per year, and residents' medical insurance personal accounts are 90 yuan per person per year.

Three, the original chronic disease special outpatient treatment

After the fixed account (hospitalization insurance in 600 yuan) is used up, the self-payment standard for basic (hospitalization) medical insurance personnel to enjoy special outpatient treatment for chronic diseases is 600 yuan. Limit standard: 2000 yuan for one chronic disease, 4000 yuan for two or more chronic diseases, 50% for employees and 75% for retirees. The outpatient radiotherapy and chemotherapy limit for non-hospitalized malignant tumors is 4,000 yuan, and the reimbursement rate is 60% for on-the-job staff and 80% for retirees.

From 20 1 1, chronic diseases will no longer be declared, and outpatient co-ordination system will be established. That is, if the personal account (or equivalent personal account) is exhausted and the individual still needs medical treatment after paying 600 yuan, please go to People's Hospital, Chinese Medicine Hospital, Second Hospital, Third Hospital, Fourth Hospital, Armory, Juzhen, Fengli, Shuangdian and Matang Hospital for medical treatment and settlement. Calculated for the whole year, within 3,000 yuan, 60% of employees are reimbursed and 80% of retirees are reimbursed. The medical insurance center does not accept sporadic reimbursement for such business.

Four, medical insurance hospitalization deductible line

The deductible line of special tertiary medical institutions outside the county 1 1,000 yuan, county people's hospital, Chinese medicine hospital in 600 yuan, and other hospitals in the county in 500 yuan. On the basis of the above standards, the children will be reduced by 300 yuan, 1 10,000 yuan and 1 10,000 yuan respectively. Within one year, the number of hospitalizations decreased by 20% on the basis of the above standards, and the lowest is not lower than that of 200 yuan. In the process of continuous treatment, the deductible line is calculated according to the standards of higher medical institutions. For malignant tumor patients who have been hospitalized continuously for a long time and hospitalized many times within one year after radiotherapy and chemotherapy, the hospitalization deductible line is calculated every 90 days.

V. Proportion of reimbursement for hospitalization expenses by stages

Children with basic (hospitalization) insurance expenses and expenses.

Medical Insurance The low-level medical insurance for urban residents and retirees is basically 0- 1 10,000 yuan, 88% 92% 0-5,000 yuan, 65% 75%110,000 yuan, 93% 97% 0.5- 1 10,000 yuan. 00,000 yuan 90%10-120,000 yuan 80% 200,000-300,000 yuan 95%-6. Specification for medical treatment of insured persons V. Proportion of reimbursement of hospitalization expenses by stages.

1, the insured must go to the headquarters of designated medical institutions with his medical insurance card, and the attending doctor will write the medical records in time according to the relevant regulations of the health administrative department. The medical expenses without medical history and medical records on the medical insurance certificate, and the medical expenses without using the social security card (IC card) (except for equipment failure and emergency) are not included in the settlement.

2. The insured person is hospitalized in this county due to illness: register with the hospitalization charge office with the admission notice and social security card (IC card) issued by the doctor, and hand in the social security card (IC card) to the hospital charge office to record the daily medical expenses. When discharged from the hospital, the expenses paid by the overall fund shall be settled by the designated medical institutions and medical insurance centers on a monthly basis. The expenses that the individual should bear in proportion and those that are not within the scope of reimbursement shall be settled by the individual in cash.

3, approved to go outside the county, must go to the county people's hospital, traditional Chinese medicine hospital and central hospital for transfer procedures, signed by the employer or neighborhood committee, reported to the medical center for examination and filing. Hospitals must be designated hospitals for medical insurance in our county. Namely: Shanghai: Zhongshan, Huashan, Ruijin, Changzheng, Changhai, Dongfang Hepatobiliary, Municipal Cancer Chest Hospital and Ninth People's Hospital; Nanjing: Provincial People's Hospital, Drum Tower, Provincial Cancer Institute, Nanjing General Hospital of Nanjing Military Region, Provincial Hospital of Traditional Chinese Medicine, Zhong Da Hospital and Dermatology Institute; Nantong City: Tongda Affiliated Hospital, First Hospital, Traditional Chinese Medicine Hospital, Cancer Hospital, tongji hospital, Third Hospital, Sixth Hospital and Ruici Hospital; Suzhou: Department of Hematology, Affiliated Hospital of Jiangsu Medical University. Children's hospitals and maternal and child health centers in Nantong, Nanjing and Shanghai have been added to children's specialized hospitals outside the county.

4. Provide official computer bills, outpatient prescriptions, medical records, hospitalization and discharge records (summary), hospitalization expenses list, social security card (IC card), transfer application form (school certificate) and ID card supervised by the finance and taxation department. Children's insurance participants also need to provide insurance payment receipts, school certificates and household registration books. The expenses for external treatment are required to be settled in the current year (expenses incurred in February of 65438 must be settled in the following year 10).

5. Patients with malignant tumor undergoing radiotherapy and chemotherapy, severe chronic renal insufficiency, hyperthyroidism, hypothyroidism, rheumatoid arthritis, aplastic anemia, lupus erythematosus, ankylosing spondylitis and Parkinson's syndrome should go to designated hospitals to buy medicines, otherwise they will not be reimbursed.

Friendly reminder of medical insurance center:

Social medical insurance cannot be repeated; Social medical insurance and new rural cooperative medical care cannot be duplicated.

Please use the social security card (IC card) for medical settlement in this county, and the medical expenses medical insurance center that does not use the card will not be accepted; Please go to the designated hospital for medical insurance when going abroad, and submit formal and effective computer bills and other materials for reimbursement. The medical insurance center does not accept handwritten bills.