Proportion of outpatient medical insurance reimbursement in Foshan city

1. What is the reimbursement ratio of medical insurance for outpatient service of Foshan employees?

Proportion of reimbursement for medical insurance outpatient service for employees:

Employees can only be reimbursed for medical expenses of more than 2,000 yuan after going to the hospital for emergency treatment, and the reimbursement ratio is 50%. For retirees under the age of 70, expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then this 500 yuan can be reimbursed 50%, that is, 250 yuan.

Two, residents' medical insurance outpatient reimbursement ratio:

Outpatient settlement procedure: Insured patients will pay the medical expenses incurred in the outpatient service of designated medical institutions directly by swiping the card at the resident medical insurance settlement counter with the special medical insurance prescription and social security card. In an insurance year, if the total outpatient expenses are below 50 yuan, the medical insurance fund will pay 40%, and the expenses above 50 yuan will be borne by individuals.

Three, rural medical insurance outpatient reimbursement ratio:

1, 60% of the medical expenses of village clinics and village center clinics are reimbursed, and the prescription drug fee limit for each visit 10 yuan, and the prescription drug fee limit for temporary rehydration of hospital doctors is 50 yuan.

2. Reimbursement of 40% for medical treatment in town health centers, with the limit of examination fee and operation fee for each visit, and the limit of prescription fee 100 yuan.

3, the secondary hospital reimbursement of 30%, each examination fee and operation fee limit 50 yuan, prescription drug fee limit 200 yuan.

4, tertiary hospital reimbursement of 20%, each visit examination fee and operation fee limit 50 yuan, prescription drug fee limit 200 yuan.

5. Traditional Chinese medicine invoices are accompanied by prescriptions, with a limit of 1 yuan.

6, the township cooperative medical outpatient compensation limit is 5000 yuan.

Proportion of reimbursement for outpatient special diseases

Medical insurance for employees: within a medical insurance year, the reimbursement rate of medical expenses that meet the prescribed treatment scope is the same as that of ordinary hospitalization. In 400 yuan, the deductible line of special disease outpatient service.

Medical insurance for urban and rural residents: within a medical insurance year, the proportion of reimbursement for medical expenses that meet the prescribed treatment scope is the same as that of ordinary hospitalization. In 400 yuan, the deductible line for special disease clinics.

Fourth, reimbursement materials

1. On-site settlement: ID card/social security card of the insured.

2. Sporadic reimbursement: the expenses shall be paid in advance by the individual, and the following relevant materials shall be presented to the social security institution where the insured person is located for reimbursement of hospitalization medical expenses within three months after discharge (limited to 65438+ 0 visits per day).

(1) Original and photocopy of the insured's ID card (those who have not obtained the second-generation ID card can present other valid documents, such as household registration book).

(2) The original and photocopy of the agent's ID card.

(3) The following materials issued by the medical institution: the original receipt or invoice of medical expenses stamped with the special financial seal of the medical institution, the original detailed list of medical expenses with the same amount and date as the receipt (invoice), the original disease diagnosis certificate stamped with the seal of the medical institution, the original discharge summary stamped with the seal of the medical institution, and the original and photocopy of outpatient medical records (emergency only).

(4) The social security card of the insured. If the insured fails to receive or activate the social security card, it shall provide the original and photocopy of the bankbook or debit card with the name and account number on the card surface, or the certificate of comparison between the card number and account number issued by the issuing bank.

(5) To transfer to a medical institution outside the city, provide the Registration Form for the Transfer of the Insured Persons of Foshan Basic Medical Insurance or the Application Form for the Insured Persons of Foshan Medical Insurance to Seek Medical Treatment in a Medical Institution outside the city.

(6) Other certificates required by social security institutions.

(7) Qualified disabled persons can hold the People's Republic of China (PRC) Disabled Persons' Card.

Verb (abbreviation of verb) reimbursement process

1. The residents' medical insurance fund will not pay the outpatient treatment expenses for specific diseases that occur in designated medical institutions outside the city; However, the residents' medical insurance fund will not pay for those who are hospitalized due to illness with the approval of social security institutions.

2. If the insured person needs to be transferred to a superior medical institution in the city for treatment due to illness, if the medical institution issues a transfer certificate and handles the transfer formalities for the first time in the year, the transfer to the medical institution is not included in the payment standard; Two or more transfers, according to the calculation of Qifubiaozhun hospitalization again. If you are treated in a high-level medical institution and your condition is stable, and you leave the acute, critical or severe period and are transferred from a tertiary or secondary hospital to a primary hospital for further treatment, the payment standard will not be counted at the time of transfer.

3. Under normal circumstances, when you need to be hospitalized due to illness, you can go to your designated hospital with the medical insurance card and medical records, and settle with the medical insurance card. That is to say, some of them are paid by themselves at their own expense, and some medical insurance centers and hospitals reimburse and settle accounts.

legal ground

People's Republic of China (PRC) social insurance law

Article 73 Social insurance agencies shall establish and improve business, financial, safety and risk management systems. Social insurance agencies shall pay social insurance benefits in full and on time. ;

People's Republic of China (PRC) social insurance law

Eighth social insurance agencies to provide social insurance services, responsible for social insurance registration, personal rights and interests records, social insurance benefits payment and other work.

Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.