Payment standard of medical insurance for urban and rural residents in Tianjin in 2023

Recently, Tianjin Medical Insurance Bureau, Municipal People's Social Security Bureau, Municipal Taxation Bureau and Municipal Education Commission issued the "Publicity Outline of Basic Medical Insurance for Urban and Rural Residents in 2023", which covers the coverage, payment standard and reimbursement treatment of basic medical insurance for urban and rural residents in 2023, and is closely related to everyone.

one

Scope of insurance liability

(1) Unemployed residents in urban and rural areas, flexible employees engaged in new forms of employment, etc. Have a local household registration or hold valid certificates such as Tianjin Residence Permit, Hong Kong and Macao Residence Permit, Taiwan Province Residence Permit, China People's Permanent Identity Card and Foreign People's Permanent Identity Card.

(2) Students and children

1. Students in school: students studying in full-time schools such as institutions of higher learning, secondary vocational schools, ordinary primary and secondary schools and special education schools in this city;

2. Children in kindergartens: children in kindergartens, nurseries and nurseries in this city;

3. Children and newborns who are not enrolled in kindergartens: they have household registration in this city or hold valid certificates such as Tianjin residence permit, Hong Kong and Macao residence permit, Taiwan Province residence permit, China permanent resident identity card and foreign permanent resident identity card.

two

Payment standard

(1) Unemployed residents in urban and rural areas, flexible employees engaged in new forms of employment, etc. , will participate in the basic medical insurance for urban and rural residents in this city in 2023 (hereinafter referred to as residents' medical insurance). Those who choose high-grade payment will be in 980 yuan every year, and those who choose low-grade payment will be in 350 yuan every year.

(two) students and children in accordance with the low-grade individual payment standards, each person in 350 yuan every year, enjoy high-grade payment reimbursement treatment.

(3) Poor people, some entitled groups, spouses of retired cadres and orphans with no fixed income who participate in the residents' medical insurance in 2023 will be fully subsidized according to the proportion of 100%, and individuals do not need to pay.

(4) Persons with difficulties, such as the minimum living security object, marginal family members of the minimum living security, other severely disabled persons (those who do not enjoy the treatment of poor people in this city, the minimum living security object and marginal family members of the minimum living security) (hereinafter referred to as "other severely disabled persons") and college students who enjoy the national student loan, will participate in the residents' medical insurance in 2023, with a fixed subsidy of 90% and the rest 10% of the expenses. Other severely disabled people choose higher payment grades to participate in residents' medical insurance, and the individual payment part no longer enjoys the fixed subsidy insurance policy.

three

registration fee

(a) centralized reporting payment period

In 2023, the centralized reporting and payment period of residents' medical insurance in this city is from September 2022 to 65438+February. Adult residents, students and children who meet the conditions of insurance shall go to the designated place to handle the registration and payment procedures of residents' medical insurance in 2023 with valid documents and related materials.

(2) Classified registration

1. Students and children in child-care institutions should register for insurance at the social security sub-center in their respective districts with their schools or child-care institutions as units. College students applying for national student loans are still registered by the school. Each school should do a good job in identity verification and information comparison for its special personnel, and do a good job in dynamic management of insurance participation according to regulations.

2. Students and children who leave school or kindergarten for reasons such as dropping out of school, dropping out of school, etc. can apply for insurance registration in the comprehensive service institutions of their respective streets (towns). Among them,/kloc-those under the age of 0/8 will continue to be registered as students, and/kloc-those over the age of 0/8 will be registered as adult residents.

3 newborns from the date of birth, at any time within one year to the local street (town) comprehensive service institutions for insurance registration. Newborns who meet the scope of application of the "newborn birth" reform in this Municipality shall go through the insurance registration procedures in accordance with the relevant provisions and procedures of "newborn birth".

4 rural residents, with the administrative village as the unit, to the village street (town) comprehensive service institutions for insurance registration.

5. Other unemployed residents and flexible employees engaged in new forms of employment shall apply for insurance registration with valid certificates at the street (town) comprehensive service institution where the household registration is located or where they often live.

6. Persons staying in nursing homes, children's welfare homes, social welfare institutions and other welfare institutions shall apply for insurance registration at the social security sub-center in their respective districts.

7 medical assistance objects (minimum living security objects, poor people, marginal family members of minimum living security, etc.). ), some entitled groups, other severely disabled people, and spouses of retired cadres with no fixed income are respectively responsible for providing relevant information to the municipal medical insurance center by the Civil Affairs Bureau, the Municipal Veterans Bureau, the Municipal Disabled Persons' Federation, and the municipal veteran cadre management department, and the municipal medical insurance center is responsible for uniformly handling insurance registration. The insurance period of the above-mentioned personnel shall be determined by the competent department, and centralized and unified insurance registration shall be implemented. 65438+At the end of February, it will be fully guaranteed and enjoy the basic medical insurance treatment according to the natural year.

8. Employees who pay medical insurance due to the termination or rescission of the labor contract with the employer (hereinafter referred to as "employees who interrupt medical insurance"): After the termination or rescission of the labor contract or within three months after the expiration of receiving unemployment benefits, they can apply for insurance registration at the street (town) comprehensive service institution where their household registration is located or where they often live with valid certificates, and they can continue to apply for insurance payment for urban and rural residents in this city in the next year within the reporting period of centralized payment.

(3) Declaration and payment

1. Schools, kindergartens, welfare institutions and other units shall apply to the tax authorities for the agency of the social insurance system (hereinafter referred to as the agency system) after registering in the district social security sub-center, and then determine the payment grade and approved payment amount according to the residents' insurance information. Within the prescribed time limit, they choose to authorize (entrust) the payment agreement or the bank terminal to query the payment voucher to pay in one lump sum.

2. After rural residents, other unemployed residents and flexible employees engaged in new forms of employment go to the street (town) comprehensive service institutions for insurance registration, the street (town) comprehensive service institutions will determine the payment grade through the agency system, verify the payment amount, and print the Notice of Social Insurance Payment of Tianjin Taxation Bureau in State Taxation Administration of The People's Republic of China, People's Republic of China (PRC) (hereinafter referred to as the Notice of Payment).

Administrative village on behalf of rural residents to declare payment, street (town) comprehensive service agencies for rural residents to apply for insurance registration, according to the residents' insurance information through the agency system to determine the level of payment, approved payment amount, and within the prescribed time limit, choose the bank to query the payment voucher payment method to pay.

3. The minimum living guarantee object, marginal family members of the minimum living guarantee, other severely disabled people and other people with difficulties can print the payment notice in the nearest street (town) comprehensive service institution after unified registration by the municipal medical insurance center, choose to pay at the commercial bank outlets and tax service hall agreed by the tax authorities, or pay in one lump sum through mobile APP, online tax bureau and POS card.

4. Students who enjoy the national student loan are uniformly collected by the school. After the social security agency in the jurisdiction handles the insurance registration, the institutions at all levels choose the payment method of authorized (entrusted) payment agreement or bank inquiry payment voucher for one-time payment.

5. From 2023, all kinds of freshmen in colleges and universities in this city will participate in residents' medical insurance, cancel the mechanism of paying residents' medical insurance premiums according to the academic year, and adopt the method of annual declaration and payment of residents' medical insurance premiums.

6. According to the Implementation Measures of Basic Old-age Insurance for Urban and Rural Residents in Tianjin (J 19 [2065438]No.), since 2023, elderly people in urban and rural areas who receive living allowances should voluntarily choose the payment grade to participate in residents' medical insurance, and will no longer withhold the residents' medical insurance fees that should be paid by individuals from their living allowances.

7. Payment method: All payers should choose to pay at the outlets of commercial banks and the tax service hall agreed by the tax authorities within the prescribed time limit, or pay in one lump sum through mobile APP, online tax bureau and POS card.

(1) bank counter payment: the payer will pay at the appointed commercial bank outlet with the bank's inquiry of payment voucher or payment notice. The agreed commercial banks include: Bank of China, Agricultural Bank, Industrial and Commercial Bank of China, China Construction Bank, bank of tianjin, Postal Savings Bank, China Everbright Bank, Rural Commercial Bank, China Merchants Bank, China CITIC Bank, Bank of Communications, binhai rural commercial bank, Bohai Bank, Industrial Bank, Shanghai Pudong Development Bank, Minsheng Bank and Qilu Bank.

(2) Payment by Tianjin Tax Mobile APP: The payer can log on to the website of Tianjin Electronic Taxation Bureau in State Taxation Administration of The People's Republic of China, China, or scan the QR code with his mobile phone through the payment notice, download and register the "Tianjin Tax" mobile APP, and then pay the fee by himself through the Tianjin Tax Mobile APP.

(3) Payment by Electronic Taxation Bureau: The payer can log on to the website of Tianjin Electronic Taxation Bureau in State Taxation Administration of The People's Republic of China, People's Republic of China (PRC), and pay by himself as a natural person.

(4) WeChat and Alipay payment: the payer pays by himself through the residents' medical insurance payment module of WeChat and Alipay APP, or scans the QR code of residents' medical insurance cloud payment.

(5) Payment by the tax service hall: the payer goes to the tax service hall, swipes the card or scans the code with cash or uses the intelligent POS machine to pay the fee.

(6) UnionPay payment: the payer pays by himself through the residents' medical insurance payment module of UnionPay APP.

(4) information change

1. Change of insurance information: If the information such as name and citizen ID number is changed, the insured shall go through the change procedures at the social security agency of the city (district) or the street (town) comprehensive service agency, and then go through the information change at the tax service office of the local competent tax bureau.

2. Change of other information: If the information of the settled payer involves the change of address, street (town) and other information, he/she shall go through the change formalities with his/her valid certificate at the district social security sub-center where the insured is registered. In the street (town) comprehensive service institutions to apply for insurance registration, it should be through the street (town) comprehensive service institutions to the district social security sub-center to submit relevant materials for change procedures; If the payment and settlement are not handled, you can go through the change formalities directly in the street (town) comprehensive service institution or district social security sub-center with your valid certificate.

(5) Refund processing

Insured persons who have settled the payment and met the relevant provisions on surrender, but have not yet entered the period of enjoying residents' medical insurance benefits, can apply to the tax service hall of the competent tax bureau or go through the formalities of refund through the personal prepayment function of Tianjin Electronic Taxation Bureau and the social security fee of Tianjin Tax Mobile APP, and the relevant departments will go through the formalities of refund.

Insured persons who have entered the period of enjoying residents' medical insurance benefits will no longer go through the formalities of refund. College students who have obtained national student loans within one year of enrollment can apply for a refund within the year when they have obtained student loans. If the fee is refunded due to death, the reporting time limit is before 65438+February 3 1 of the insured year, and it will not be accepted after the deadline.

four

Insurance payment and treatment enjoyment

(1) Anyone who participates in the insurance payment in accordance with the regulations during the centralized declaration and payment of residents' medical insurance in 2023 will enjoy the treatment of 2023 10/to February 1. Insured persons who participate in the medical insurance for residents in this city can enjoy the relevant benefits such as residents' serious illness insurance for free, and individuals do not need to pay extra.

(2) Newly enrolled students and children who did not participate in the residents' medical insurance in that year will enjoy the residents' medical insurance benefits in that year from September 1 day to February 3 1 day, and pay the residents' medical insurance fee in 2023 in schools and kindergartens.

(three) the newborn within four months from the date of birth (inclusive) for the annual insurance payment procedures, from the date of birth to enjoy the annual medical insurance benefits for residents; If you go through the formalities of insurance payment in that year after four months from the date of birth, you will enjoy the medical insurance benefits of residents in that year from the day after payment. Newborns born from September 2022 to June+February 65438 who have gone through the insurance payment procedures in 2023 will enjoy the annual residents' medical insurance benefits from the date of birth to June 65438+February 3 1 day, and from June 65438+1 October1day to June 65438 the following year.

(4) If the procedures for registration and payment of residents' medical insurance in 2023 are not handled during the centralized declaration and payment of residents' medical insurance in this city, the relevant procedures for residents' medical insurance in that year can be handled at any time in 2023.

1. Insured persons who have participated in the basic medical insurance for 2 years or more (excluding supplementary payment) and re-participated in the local residents' medical insurance within 3 months after the payment was interrupted shall enjoy the treatment from the day after the insurance payment. If it is more than 3 months, it will enjoy a waiting period of 6 months, and the medical expenses incurred during the waiting period will not be reimbursed by residents' medical insurance;

2. Insured persons who have participated in the basic medical insurance for 2 years or more (excluding overdue payment) and re-participate in the medical insurance for employees in this Municipality within 3 months after the interruption of payment shall enjoy treatment from the month when the insurance payment is made. Pay more than 3 months, enjoy a 6-month waiting period, and the medical expenses incurred during the waiting period will not be reimbursed by employee medical insurance.

3. Insured persons who have not continuously participated in the basic medical insurance for 2 years or more (excluding supplementary payment) participate in the medical insurance for residents in this Municipality, and are given a waiting period of 6 months. The medical expenses incurred during the waiting period will not be reimbursed by the medical insurance for residents;

(five) residents' serious illness insurance benefits enjoy the same treatment as residents' basic medical insurance.

five

Treatment standard

(1) Basic medical insurance for residents

The insured signs a contract with the family doctor of the primary medical institution. From the month of signing the contract, the amount of personal outpatient medical insurance increased by 200 yuan, and the payment ratio increased by five percentage points. The specific measures shall be implemented in accordance with the current residents' medical insurance policy.

(2) Residents' serious illness insurance

Within a year, the insured person is hospitalized (including outpatient special diseases), and after being reimbursed by the basic medical insurance, the medical expenses above the deductible line and below 300,000 yuan (inclusive) within the policy scope shall be included in the scope of residents' serious illness insurance according to regulations. Since 2023, the reimbursement rate of urban and rural residents' major illness insurance has increased by 5 percentage points, and the medical expenses borne by individuals within the scope of residents' medical insurance policies have been included in the coverage of residents' major illness insurance. The employee's serious illness shall be implemented by reference.

Treatment standard for serious illness of residents in 2023

Deductible line: determined according to 50% of the per capita disposable income of residents in the previous year. The deductible line of major illness insurance for residents receiving medical assistance is reduced by 50% on the basis of the general population, the reimbursement ratio is increased by 5 percentage points, and the top line is cancelled.

(3) Medical assistance

Since 2023, medical assistance recipients will enjoy medical assistance treatment according to the following standards.

1. Outpatient assistance: The medical expenses incurred by the medical assistance object in the outpatient department of the designated medical assistance institution that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue reimbursement scope shall be given outpatient assistance according to the prescribed proportion and limit. The standard of assistance is: 50% of the individual pays part of the assistance within the policy scope, and there is no minimum payment standard. The maximum amount of assistance for destitute people is 1000 yuan, and other assistance targets are 400 yuan.

2. Hospitalization (including outpatient specific diseases) assistance: If the medical expenses incurred by the medical assistance object during hospitalization (including outpatient specific diseases) in the designated medical assistance institutions in this Municipality meet the basic medical insurance drug list, diagnosis and treatment project list and medical service facilities list, within the scope of basic medical insurance and serious illness insurance reimbursement policies, the medical assistance object shall be given hospitalization assistance according to the prescribed proportion. The criteria for assistance are: there is no deductible for medical assistance for poor people and low-income recipients, and the proportion of assistance is 75% and 70% respectively; The minimum living allowance threshold for hospitalization assistance for marginal family members is determined according to 10% of the per capita disposable income of residents in this city published last year, and the assistance ratio is 65%.

3. Medical assistance for serious and serious diseases: medical assistance for serious and serious diseases shall be provided to the medical assistance recipients whose personal hospitalization expenses are still heavy after payment of basic medical insurance, serious illness insurance and hospitalization medical assistance. The minimum payment standard is 6,543,800 yuan, the assistance ratio is 50%, and the maximum assistance limit is 200,000 yuan.

six

advanced redemption

(1) Residents' medical insurance and serious illness insurance

The medical expenses paid by the insured shall be declared together with the residents' medical insurance and serious illness insurance.

1. Acceptance review: The medical expenses incurred by the insured in the administrative village, family and special account shall be reported to the community workstation or the street (town) comprehensive service agency with relevant materials. After the street (town) comprehensive service institution accepts it, it shall enter the residents' medical insurance payment system, upload it in time and hand over the application materials to the district medical insurance sub-center (or residents' medical insurance service center). If it is not declared in time, it can be implemented according to the relevant provisions of the first reimbursement of employee medical insurance.

The medical expenses incurred by the insured in schools, kindergartens and welfare institutions shall be reported to the local medical insurance sub-center (or residents' medical insurance service center) by himself or the school with relevant materials. The medical insurance sub-centers in all districts (or residents' medical insurance service centers) should enter the residents' medical insurance payment system in time and complete the fee uploading work, and the municipal medical insurance center and the municipal settlement center should complete the transfer payment work in time.

Students and children who leave school or kindergarten for reasons such as dropping out of school, dropping out of school, not finding employment at the end of the semester, etc., shall be responsible for the reimbursement of medical expenses in advance by the street (town) comprehensive service agencies registered in this Municipality; Non-local household registration shall be handled by the local medical insurance sub-center, and the reimbursement procedures shall be handled in accordance with the first reimbursement process.

2. Payment of expenses: medical insurance reimbursement of medical expenses is socialized in principle. The municipal medical insurance center and the municipal medical insurance settlement center will regularly transfer the audited payment amount to the activated personal social security card account through the bank that pays the agent. For the insured who have not yet received the social security card, when going through the formalities for reporting the advance medical expenses for the first time, they should go through the formalities for opening the settlement account at the local street (town) comprehensive service institution or district medical insurance sub-center.

(2) Maternity insurance for residents

1. Registration: After the insured person is pregnant, he/she should go to the street (town) family planning management department where his/her residence or household registration is located to register the birth service in time; Insured persons who have registered maternity shall register maternity insurance benefits at designated medical institutions at the grassroots level. If you can't handle it online for some reason, you can go to the street (town) comprehensive service institution or the district medical insurance sub-center.

2. Acceptance, review and payment: If the insured fails to swipe his card for medical treatment in this city due to special reasons and meets the requirements, he shall report to the comprehensive service institution of the street (town) to which he belongs. After the medical insurance agency reviews, the maternity insurance for urban and rural residents shall be paid according to the prescribed standards. If the insured person is hospitalized during the insured year, the expenses incurred in this hospitalization shall be paid according to the maternity insurance benefits for urban and rural residents in the insured year.

In accordance with the requirements of the national and municipal treatment list system, timely clean up and standardize the residents' maternity insurance system, do a good job of policy convergence, and incorporate residents' maternity medical expenses into the basic medical security. Specific measures shall be formulated separately.

seven

Management of medical treatment in different places

(1) Personnel scope

Residents who have participated in medical insurance for urban and rural residents in different places for a long time and those who temporarily go out for medical treatment in different places can apply for medical treatment in different places for direct settlement.

1. Inter-provincial long-term residents: mainly refer to the insured who work and live in different places for a long time, including retirees who are resettled in different places, long-term residents in different places and permanent residents who work and live in different places for a long time.