Medical Insurance Policy of Zhengzhou Railway Bureau

Whenever we are sick and hospitalized, the high medical expenses are always particularly worrying, but usually, the medical insurance we pay can help us solve this big problem, so how is the railway medical insurance reimbursement policy stipulated? How to declare? 1. How to stipulate the reimbursement policy for railway medical insurance 1? The insured employees and their families of the units affiliated to the Railway Bureau belong to the basic medical insurance coverage. If you are hospitalized for the first time within a medical insurance year (February 1 to 1), you need to pay the hospitalization deductible 630 yuan to enter the scope of medical insurance reimbursement. Qifubiaozhun 630 yuan needs to pay his own expenses. If the insured is hospitalized for the second time or later in a medical insurance year, the minimum qifubiaozhun will be halved to 3 15 yuan, but if he is hospitalized for the same disease again within 15 days, he will be settled in one lump sum (i.e. there is no minimum qifubiaozhun). The annual maximum payment limit of basic medical insurance is. The expenses beyond the basic medical insurance coverage will go into serious illness co-ordination, and the annual maximum payment limit of serious illness insurance is 230,000 yuan. 2, the insured hospitalization Qifubiaozhun and self-funded projects will not be reimbursed, a project according to 85% of the employees; 90% of retired employees; Family members will be reimbursed 60%, and Class B projects will be reimbursed according to the above proportion after taking a certain proportion. The annual basic medical insurance pays a maximum of 36,000 yuan, and enters a serious illness after exceeding 36,000 yuan. The reimbursement rate of serious illness insurance is 90%, and the annual maximum payment limit is 230,000 yuan. 3. The scope of medical insurance drugs is divided into two categories: Class A drugs refer to drugs with positive clinical efficacy and low price; Class B drugs refer to drugs that are clinically selected, with definite curative effect, relatively high price and certain indications. 4. The scope of medical insurance diagnosis and treatment projects and service facilities standards are divided into two categories: basic medical insurance projects (Class A and Class B) and self-funded projects. Basic medical insurance items are reimbursed according to medical insurance regulations, and self-funded items are not reimbursed. 5. During hospitalization, you shall abide by the relevant regulations on hospitalization management and shall not leave the hospital without authorization; When the insured is discharged from the hospital, he is only allowed to take continuing treatment drugs related to the main diseases in the hospital, and injections are not allowed. Generally no more than three drugs. Under special circumstances, (it is pointed out that the conditions in the hospital are neither better nor worse than the admission time difference), and the amount of drugs discharged from the hospital is not more than 1 week. Second, the railway medical insurance reimbursement process Social medical insurance reimbursement is reimbursement after discharge or transfer. Settlement procedures for hospitalization and outpatient treatment of special diseases: Before 10 every month, the designated medical institutions will report the expense list, hospitalization list and related materials of the patients discharged last month to the medical insurance agency, which will be used as the basis for monthly pre-allocation and year-end final accounts after examination; The medical insurance agency pre-allocated the hospitalization and outpatient co-ordination expenses for special diseases last month; Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately. Emergency settlement procedure: the medical expenses incurred by the insured in emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall go through the reimbursement procedures according to the provisions with the hospital emergency medical records, inspections, laboratory tests, invoices and detailed list of medical expenses. Settlement procedure for resettlement personnel: the unit where the resettlement personnel work shall designate 1-2 designated medical institution and report it to the medical insurance agency for the record; The medical expenses incurred by the off-site staff in the outpatient department of the designated medical institution in their place of residence shall be paid in advance by themselves or their units. After the treatment, the unit holding the insured's diagnosis and medical records, effective bills, compound prescriptions and hospitalization expenses list shall settle the accounts with the social medical insurance agency on the specified date. Referral and referral settlement: if the insured person is transferred to other medical institutions for treatment due to the conditions of designated medical institutions or specialized diseases, the approval form for referral and referral shall be filled out. The reasons for referral and transfer are put forward by the attending physician, the director of the department puts forward the opinions of referral and transfer, the medical institution medical insurance office reviews, the dean in charge signs, and the referral can only be made after the approval of the municipal medical insurance center; In principle, referrals should be made outside the city, inside the province and outside the province. The city's referral regulations are carried out between designated medical institutions. The referral outside the city is proposed by the designated medical institutions above Grade III in this Municipality; The medical expenses incurred after the insured person is referred to another hospital shall be paid by the individual or unit in cash. After the end of medical treatment, the insured person or his agent will submit the referral approval form, medical record certificate, prescription and valid documents to the medical insurance agency for reimbursement of hospitalization expenses that fall within the scope of the overall fund payment.

Legal objectivity:

Article 28 of the Social Insurance Law of People's Republic of China (PRC) conforms to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities and emergency and rescue medical expenses standards, and shall be paid from the basic medical insurance fund in accordance with state regulations.

"People's Republic of China (PRC) Social Insurance Law" Article 29 The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.