How long can Tianjin maternity insurance be reimbursed and the reimbursement ratio?

Maternity insurance is a social insurance system in which the state and society provide medical services, maternity allowance and maternity leave when pregnant and pregnant female workers temporarily stop working, and the state or society provides necessary economic compensation and medical care for maternity workers. Maternity insurance benefits in China mainly include two items. One is maternity allowance, and the other is maternity medical care. The Measures for Maternity Insurance in Ministry of Human Resources and Social Security (Draft for Comment) has been open to the public for comments since 2012165438+10. The opinion draft makes it clear that maternity insurance benefits will no longer be limited to household registration, and units that do not pay maternity insurance must pay maternity fees.

Reimbursement conditions

1, maternity insurance for female employees has been paid continuously for one year;

2. Male employees whose spouses have paid maternity insurance for one year before giving birth must be agricultural registered permanent residence or receive unemployment benefits.

Note: If the spouse is a non-employee, he must also pay social insurance as a freelancer to enjoy maternity reimbursement.

Reimbursement materials

Prenatal examination fee:

1, registration fee receipt (stamped by maternity insurance);

2, outpatient receipt "social security report nuclear union" (maternity insurance chapter);

3, outpatient expenses machine dozen details.

(two) outpatient medical bills:

1, registration fee receipt (stamped by maternity insurance);

2, outpatient receipt "social security report nuclear union" (maternity insurance chapter);

3, outpatient expenses machine dozen details;

4, outpatient family planning certificate (maternity insurance chapter, diagnosis certificate chapter);

5, prescription bottom couplet (according to the project audit);

6. Copy of inspection report (provided during project review);

7, outpatient medical records copy (provided by the project audit).

(three) the bill of hospitalization medical expenses:

1, verification of social security report for hospitalization medical expenses (maternity insurance stamp);

2. List of hospitalization expenses;

3 proof of maternal hospitalization, proof of family planning operation after hospitalization, and proof of diagnosis of complications of family planning operation;

4. Discharge summary (copy of discharge record, stamped with special seal of medical record department).

(four) maternity allowance application materials:

1, a copy of the baby's birth certificate;

2. A copy of the one-child certificate;

3. Operation Certificate (indicating the name of operation);

4, discharge summary (discharge record copy)

(5) Other materials: certificates, applications, explanations, etc.

All the above copies are copied on A4 paper!

Reimbursement process

First, pregnancy registration

Within 10 week of pregnancy, the employee shall go to the designated medical institution of Tianjin maternity insurance for pregnancy diagnosis and issue a pregnancy certificate, and register with the maternity insurance management center on 10.

Two. Submission of materials

Workers submit medical insurance certificate, pregnancy diagnosis certificate, pregnancy test sheet, birth certificate and other materials to the maternity insurance management center.

Third, the hospital registration

On the day of delivery, employees need to register at the hospital. During the period of hospitalization, employees should submit relevant materials to the maternity insurance management center for childbirth or termination of pregnancy, abortion and induced labor.

Fourth, receive reimbursement expenses.

After the materials are submitted to the maternity insurance management center, the maternity insurance can be reimbursed after the materials are approved.

Reimbursement standard

1, pregnant dissatisfaction 12 weeks to terminate pregnancy, maternity allowance 15 days;

2. If the pregnancy is terminated after12 weeks or more 16 weeks, you will enjoy 30 days of maternity allowance;

3./kloc-42 days of maternity allowance if the pregnancy is terminated after 0/6 weeks but less than 28 weeks;

4. Those who give birth or terminate pregnancy normally for more than 28 weeks are entitled to 98 days of maternity allowance, which is 8 days higher than the previous standard.

In any of the following circumstances, the maternity allowance shall be increased:

1, dystocia, increase maternity allowance 15 days;

2, multiple births, each additional baby, increase 15 days of maternity allowance; If tubal ligation is performed during delivery, the maternity allowance will be increased 14 days;

3. If a female worker gives birth late (the first child is over 24 years old) and receives the one-child certificate, the maternity allowance will be increased for 30 days.

Reimbursement ratio

1. The fixed payment items include natural delivery medical expenses, manual intervention delivery medical expenses, caesarean section medical expenses, induced labor medical expenses, high-risk induced abortion medical expenses, intrauterine device placement (removal) medical expenses, female worker sterilization medical expenses and male worker sterilization medical expenses. These include:

Manual intervention in delivery includes: artificial placental abruption, cervical laceration, hematoma incision of birth canal wall, forceps for single fetus, breech traction of single fetus, fetal head attraction, varus and fetal destruction.

Induction of labor includes: amniotic cavity injection, amniotic cavity injection, water bag induction and drug induction.

High-risk induced abortion refers to the following situations that require hospitalization for induced abortion:

(1) within 6 months after birth or induced abortion;

(2) History of cesarean section within1year;

(3) 1 year had two induced abortions and miscarried;

(4) Genital malformation;

(5) Hysteromyoma complicated with pregnancy;

(6) Have a history of uterine or cervical perforation;

(7) pregnant with equipment;

(8) Suffering from serious diseases of blood system or cardiovascular system.

Second, the items paid by the project include reoperation; Medical expenses for those who have incarcerated, broken, deformed, ectopic or menopausal IUD 1 year or more; Medical expenses for treating complications of family planning operation; Medical expenses for those who have birth complications during delivery.

Delivery complications refer to the following situations from the beginning of delivery to the end of delivery:

(1) Uterine rupture;

(2) Amniotic fluid embolism;

(3) Postpartum hemorrhage is greater than 500ml, which requires blood transfusion first aid;

(4) Third-degree perineal suture, complicated laceration;

(5) Other serious medical diseases.

3. The limited payment item is the prenatal examination fee for the birth or termination of pregnancy of female employees.

Reimbursement regulation

The employing unit shall apply to the social security department for maternity allowance in time from the month following the birth or termination of pregnancy 12 months. The social security department shall complete the examination of maternity allowance within 10 working days (usually two weeks) after receiving the application, and pay the maternity allowance before the 5th day of the following month after the examination and approval.

According to the provisions of Article 13 of the Regulations of Tianjin Municipality on Maternity Insurance for Urban Workers:

Participate in maternity insurance and implement a registration system. The employing unit shall handle the registration of maternity insurance within 30 days after the implementation of these Provisions. The social insurance agency shall complete the audit within 10 working days from the date of accepting the registration. Those who meet the conditions shall be registered, those who do not meet the conditions shall not be registered, and the employer shall be notified. Where the registered items of maternity insurance of the employer are changed, it shall go through the formalities of change at the social insurance agency within 30 days from the date of change.

According to Article 18 of the Detailed Rules for the Implementation of the Provisions of Tianjin Municipality on Maternity Insurance for Employees:

Insured persons in the city to seek medical treatment in accordance with the provisions of the maternity medical expenses to implement instant online settlement. If the maternity medical expenses are paid in advance due to special circumstances, the employer shall uniformly report to the social security agency of the insured place within 12 months from the month after the female worker gives birth or terminates pregnancy.