Zhuhai social security hospitalization reimbursement scope

Insurance Bian Xiao helps you answer, and more questions can be answered online.

The conditions for reimbursement are as follows:

1. The applicant has gone through the insurance formalities and paid the medical insurance premium in full.

2, cooperative medical designated medical institutions for medical treatment;

3. The medical expenses incurred by the insured in hospitalization in medical institutions shall be paid in cash in advance, and relevant documents and materials shall be kept.

More Zhuhai medical insurance reimbursement can be concerned: Zhuhai Dream WeChat official account

Reimbursement materials

Materials to be submitted for declaration:

Individuals will arrange medical expense documents and related materials in chronological order and submit them to the unit (or social security office) for reimbursement.

1, original receipt;

2, hospitalization expenses statement;

3, discharge diagnosis certificate;

4. Copy of observation certificate or death certificate;

5, drugs, examination and treatment costs, emergency observation need to be stamped with the "emergency chapter" of the medical insurance prescription or emergency prescription of the emergency department;

6, social security card, "urban medical insurance manual";

7, the hospital full checkout certificate and unit description.

Reimbursement process

Handler:

1. The agent submits the reimbursement documents and other materials to Zhuhai Social Insurance Fund Management Center and its office for acceptance;

2. After receiving the application materials, the accepting department will complete the examination, settlement and payment on the same day;

3 Zhuhai Social Insurance Fund Management Center and its office review the materials and approve the application. The applicant will be reimbursed after receiving the "Social Medical Insurance Medical Expense Reimbursement Form".

Note: If the application materials are incomplete and all contents need to be corrected, the applicant shall correct the materials within 5 days from the date of receiving the Notice of Corrected Materials. If no correction is made within the time limit, the application shall be deemed to have been withdrawn.

However, after the materials are corrected, the applicant may reapply within the statutory validity period. The applicant shall be reimbursed after receiving the Social Medical Insurance Medical Expense Reimbursement Form.

Proportion and scope of reimbursement

Proportion of hospitalization reimbursement for medical insurance:

1. 92% is paid by employees and 94% by medical insurance retirees for the first-class insured persons of basic medical insurance.

2 basic medical insurance for the second time, pay 90%.

Among them, the one-time material cost with a unit price of more than 2,000 yuan shall be paid by the insured at his own expense, and the rest shall be included in the approved hospitalization medical expenses according to the proportion of 70%.

Medical insurance hospitalization reimbursement scope:

(1) Qifubiaozhun

Except for students and minors, the Qifubiaozhun for each hospitalization of the insured is:

1. Level-I Hospital 300 yuan. 2.500 yuan, level 2 hospital. 3. Secondary hospital 1000 yuan.

Qifubiaozhun for students and minors is determined according to 50% of the above standards.

Among them, if the insured has been hospitalized for more than 4 times in the same social security year, the Qifubiaozhun from the fifth hospitalization (including the fifth) shall be determined according to 50% of the corresponding standard; If the insured person is hospitalized continuously in the same hospital, the Qifubiaozhun shall be paid once every 3 months (unless otherwise specified).

(2) Maximum payment limit

The insured person's maximum payment limit for hospitalization in each social security year (including the individual pays part) is determined according to the time of continuous insurance payment, specifically:

1. If the continuous insurance payment time is within 6 months (including 6 months), the annual maximum payment limit of basic medical insurance is 20,000 yuan.

2. If the continuous insurance payment time is from 6 months to 1 year (including 1 year), the annual maximum payment limit of basic medical insurance is 80,000 yuan.

3. If the continuous insurance payment time exceeds 1 year, the annual maximum payment limit of basic medical insurance is 300,000 yuan.

Continuous insurance payment time refers to the actual insurance payment time from the month of insurance payment to the month of discharge, in which the insured person's interruption of payment for no more than 3 months is regarded as continuous insurance, and the interruption of payment for more than 3 months is regarded as new insurance.