Wuxi social security maternity reimbursement regulations

Insurance editorial to help you answer, more questions can be online Q&A.

It should be possible, as long as you have paid for 6 months, you can be reimbursed.

Notice on adjusting the treatment and settlement of maternity insurance in urban areas (Xilao Social Worker [2008] No. 8)

Related units:

In order to improve the treatment of maternity insurance, improve the procedures for the settlement of maternity insurance expenses, according to the relevant provisions of the state and the province, in accordance with the principle of determining the amount of expenditure by the amount of income and balancing revenues and expenditures, the following treatment is hereby proposed for the adjustment of maternity insurance treatment for employees in urban areas and the settlement of methods The following opinions are put forward:

I. Maternity insurance treatment

Female workers in line with the provisions of family planning to give birth or implementation of family planning surgery, the relevant maternity insurance treatment is adjusted as follows:

1. Female workers who give birth (including miscarriage due to childbearing), the wages of the unit during the period of maternity leave by the unit of their own wages, and the Maternity Insurance Fund in the form of a maternity allowance to the unit to be reimbursed. The maternity allowance is based on the average monthly social insurance contributions for the 12 months prior to the birth or miscarriage, and is determined on the basis of the period of maternity leave for the birth or miscarriage. The maternity allowance is: three months for a normal birth, three and a half months for a caesarean section; for multiple births, half a month is added to the normal birth or caesarean section for each additional birth; one month is added to the above for those who have a late birth; three months for a miscarriage of more than seven months' gestation, one and a half months for a miscarriage of more than three months' gestation but less than seven months' gestation and one month for a miscarriage of less than three months' gestation.

Wuxi City on the "implementation of & lt; Jiangsu Province, urban enterprise workers maternity insurance provisions & gt; the views of" (Xizheng Fa [2001] No. 278) Article 3 of the "difficult labor" refers to cesarean section. The term "late childbearing" refers to those who are entitled to late childbearing leave.

2. When a female worker gives birth (including abortion due to childbirth) at a designated medical institution for maternity insurance, the medical expenses incurred in accordance with the clinical path for childbirth shall be settled by the Maternity Insurance Fund, and the worker shall not bear the expenses (except for those medical expenses that are beyond the scope of the clinical path for childbirth).

3. The necessary examination fees incurred by female workers at the designated medical institutions for maternity insurance during pregnancy shall be settled by the Maternity Insurance Fund in accordance with the limit if they are in line with the stipulated examination items and fee standards, and the part of the fees exceeding the scope of the examination items and the limit shall be borne by the individuals if they are lower than the limit, with the total limit of the examination items being tentatively set at 1,100 yuan.

4. Female workers who give birth (including miscarriage due to childbirth) and enjoy maternity leave of 90 days or more in accordance with the state regulations will be given a one-time nutritional supplement, which is 2% of the average wage of urban employees in the previous year. The average wage of employees from July 1 each year in accordance with the standards announced by the statistical department.

5. Medical expenses incurred for the placement (removal) of intrauterine devices, abortions, induced abortions, sterilizations and reanimation surgeries due to the implementation of family planning, which are in line with the scope of medicines, diagnostic and therapeutic items and standards of medical services and facilities stipulated in the basic medical insurance for employees, shall be paid by the Maternity Insurance Fund in accordance with the actual situation, but shall not exceed the maximum payment limit. The maximum payment limits are as follows: for IUD surgery, 140 yuan for IUD placement, 120 yuan for removal, ordinary, and 350 yuan for embedded; for abortion (early) surgery, 300 yuan for abortion, and 360 yuan for medical abortion; for induced abortion, 1,500 yuan; for sterilization surgery, 500 yuan for tubal ligation, and 300 yuan for vasectomy; and for recanalization surgery, 1,600 yuan for recanalization of female employees, and 1,200 yuan for recanalization of male employees. For male employees, it is 1,200 yuan.

6. Medical expenses incurred by female workers in medical institutions for diseases caused by childbirth in accordance with the scope of medicines, diagnostic and treatment items and standards of medical service facilities under the basic medical insurance for employees shall be paid by the Maternity Insurance Fund, while medical expenses for other diseases shall be paid in accordance with the provisions of basic medical insurance for employees if they participate in the basic medical insurance for employees.

Definition of illnesses caused by childbirth: The "illnesses caused by childbirth" stipulated in Article 7 of the Provisions on Maternity Insurance for Urban Enterprises and Employees of Jiangsu Province (Decree No. 161 of the Provincial Government) are tentatively defined as intrahepatic cholestasis of pregnancy, diabetes mellitus of pregnancy, postnatal hemorrhage, puerperal infection, diffuse intravascular coagulation, and other illnesses that occur in the course of the pregnancy or the period of maternity leave for female workers. infection, diffuse intravascular coagulation (DIC), and hypertensive syndrome of pregnancy.

7. If a female worker who originally participated in maternity insurance with her employer becomes unemployed, and during the period when she receives unemployment benefits, she complies with the provisions on family planning and gives birth in a designated medical institution for maternity insurance (including abortion due to childbirth), the medical expenses for maternity shall be paid by the Maternity Insurance Fund in accordance with the quota settlement standard of the medical institutions at the same level, and the one-time nutritional supplement shall be paid in accordance with the relevant provisions of this Circular.

For a male employee participating in maternity insurance whose spouse is not covered by maternity insurance, when giving birth in accordance with the provisions of family planning, the maternity medical expenses shall be paid by the Maternity Insurance Fund at 50% of the quota settlement standard of medical institutions at the same level.

8. The medical expenses of female workers for the treatment of gravidas and ectopic pregnancy, if they participate in maternity insurance, shall be paid by the Maternity Insurance Fund with reference to the provisions of the Employee's Basic Medical Insurance, and those expenses that should be paid by the Employee's Basic Medical Insurance Fund shall be paid by the Maternity Insurance Fund. If a person does not participate in maternity insurance but does participate in the basic medical insurance for employees, the basic medical insurance fund for employees shall pay the expenses in accordance with the provisions of the basic medical insurance for employees.

II. Settlement of Expenses

1. Maternity Allowance. Maternity allowance is paid directly to the employer by the social insurance administration organization (hereinafter referred to as the social insurance administration organization) as compensation to the employer.

2. Maternity medical expenses. Maternity medical fees (excluding pregnancy check-up fees) incurred by female workers at the designated medical institutions for maternity insurance shall be settled on a monthly basis between the social security administration organization and the designated medical institutions. Any amount exceeding the limit shall not be settled, and any amount below the limit shall be settled on an actual basis. The difference between the actual settlement amount and the limit standard will be paid to the designated medical institution at 60% in conjunction with the year-end assessment.

The limit settlement standard for maternity medical fees is RMB 3,500 for vaginal delivery and RMB 5,300 for cesarean section in tertiary medical institutions, and RMB 2,700 for vaginal delivery and RMB 3,800 for cesarean section in other medical institutions.

Limit settlement standards for abortion medical expenses incurred due to childbirth are: 800 yuan for pregnancy less than three months, 2,000 yuan for pregnancy more than three months and less than seven months, and 2,700 yuan for pregnancy more than seven months.

3. Medical fees for pregnancy checkups, family planning surgeries, medical fees for illnesses caused by childbirth, and medical fees for treatment of gravidas and ectopic pregnancies are settled directly between social security agencies and the designated medical institutions for maternity insurance.

4. The one-time nutritional allowance is paid directly by the social security agency to the woman worker who has given birth.

5. For the maternity medical expenses of unemployed female workers and spouses of male workers, as well as the medical expenses for childbirth or family planning incurred by the workers in overseas medical institutions due to special circumstances, the unit or the person himself/herself will go to the social security agency with the relevant information to go through the procedures of settling the maternity insurance benefits, and the social security agency will settle the payment to the unit or the person himself/herself in accordance with the provisions of the law.

6. For medical expenses of family planning surgery in family planning technical service institutions recognized by the health department or population planning department, after the individual advances the expenses, the person will go to the social security agency with the relevant information to go through the settlement procedures.

Third, settlement management and medical services

1. Only those expenses incurred for pregnancy checkups, childbirth, abortion, family planning surgeries, illnesses caused by childbirth, as well as surgeries for treatment of gravidas and ectopic pregnancies that have been incurred by employees participating in the maternity insurance and for which they have been making contributions for six consecutive months by their employers are eligible for the maternity insurance benefits according to the regulations. Female workers who have paid contributions for six consecutive months at the time of childbirth or miscarriage are entitled to maternity allowances and one-time nutritional subsidies paid by the Maternity Insurance Fund.

2. The employer or employee shall go to the social security office for settlement of the maternity insurance benefits with relevant vouchers within 6 months after the birth or family planning operation.

3. The following expenses will not be settled by the Maternity Insurance Fund:

(1) medical expenses incurred for pregnancy termination due to suicide, self-inflicted injuries, brawls, alcoholism, drug abuse, illegal acts, traffic accidents, medical accidents, etc.

(2) expenses incurred for medical accidents caused by childbirth or family planning surgeries;

(3) meal expenses, food expenses, and expenses incurred for childbirth or family planning surgeries;

(3) expenses incurred for meals, meals, and meals for family planning surgeries. (3) Expenses incurred for meals, excess beds, painless delivery, analgesic pumps, and other special services that I have requested to enjoy as a result of the surgery.

(4) Expenses for infant medical care, nursing care, health care, and daily necessities for newborn babies;

(5) Other expenses exceeding the scope and standard of maternity insurance.

4. The designated medical institutions for maternity insurance are those recognized by the health department as qualified in midwifery technology. The social security agency shall sign a maternity medical service agreement with the designated medical institution for maternity insurance, clearly define the rights and obligations of both parties, settle the relevant expenses with the designated medical institution for maternity insurance in a timely manner according to the regulations, and verify the use of the relevant expenses.

5. Maternity insurance designated medical institutions shall conduct reasonable examinations and treatments, standardize charges, and perform the obligation of informing patients of self-paying items if they use self-paying items or provide special medical services, so as to strictly control the burden of personal expenses.

Four, this approach from January 1, 2009 onwards. Opinions on the Treatment of Relevant Issues in the Implementation of Maternity Insurance for Enterprise Employees in Urban Areas (Xilao Social Work [2001] No. 106), Notice on the Adjustment of Relevant Treatments of Maternity Insurance for Enterprise Employees in Urban Areas (Xilao Social Work and Medical [2004] No. 23), Notice on the Adjustment of Relevant Treatments of Maternity Insurance for Enterprise Employees in Urban Areas (Xilao Social Work [2007] No. 5), and Notice on Staphylococcal and Ectopic Pregnancy (Xilao Social Worker [2008] No. 1), and Circular on the Opinions on the Handling of Issues Relating to Diseases Caused by Maternity of Female Employees (Xilao Social Worker [2008] No. 2) are all abolished at the same time.