Wuxi 2023 medical insurance reimbursement new regulations

The urban workers' medical insurance is implemented at the municipal level, the city's unified policy, unified standards, unified handling process.

Wuxi urban workers medical insurance policy

Medical insurance almost everyone has, we all know that the medical insurance card can not only be used in the designated pharmacy to buy drugs, but also in the designated medical institutions to use. But when it comes to how to use, details of the vouchers and other issues, but not many can answer up. At the same time, for different groups of people (employees (retired workers), ordinary residents (including students, children)), the reimbursement rate of various situations are not the same, so here is a specific sub-population of different people to give you an introduction.

I, Wuxi City District Employee Basic Medical Insurance Treatment

(a) general outpatient

◆ first from the individual account, can be used in the designated medical institutions, designated retail pharmacies.

◆Outpatient co-ordination:Patients can visit their own recognized community hospitals after signing a service agreement, and can only use it after their personal accounts are exhausted. The actual maximum amount available each year is: 5,000 yuan for active employees and 6,000 yuan for retirees, and the proportion of personal burden of medical expenses within the system is: 30% and 15% respectively. The first visit by the contracted community health service center; if you need to go to other medical institutions, you should be referred by the contracted community health service center according to the needs of the condition, and apply for the referral procedures in the transfer of medical institutions to the card for medical treatment.

◆ outpatient chronic diseases: hypertension, coronary heart disease and other 12 kinds of chronic diseases: should first be identified to the municipal hospital, choose a medical institution that you think is convenient (can not be a community health service center), as their own outpatient chronic agreed medical institutions, to the Social Security Center in the district offices registered and agreed, the person under the age of 70 years old, the individual out-of-pocket full of 800 yuan, the health insurance fund to pay 70%, the annual maximum payment limit of 3,500 yuan. The maximum payment limit is 3500 yuan; 70 years of age or older retirees, individual out-of-pocket full 600 yuan, the health insurance fund to pay 80%, the annual maximum payment limit of 4000 yuan.

(B) general hospitalization

1, hospitalization in accordance with the provisions of the hospitalization costs:

◆ tertiary hospitals: in the tertiary medical institutions discharged from the settlement of medical expenses in the 10,000 yuan (including 10,000 yuan) or less, the working staff co-ordination fund to pay 84%, the proportion of individual out-of-pocket payment of 16%; medical costs in the 10,000 yuan to 40,000 yuan (including 40,000 yuan), the co-ordination fund to pay 88%, the proportion of individual out-of-pocket payment of 12% (retirees individual out-of-pocket payment), the proportion of individual out-of-pocket payment of 12% (retirees individual out-of-pocket payment). 12% (retiree individual out-of-pocket ratio of 50% of the above standards, the same below);

◆ second level of hospitals: in the first and second level of settlement of medical institutions discharged from the hospital, the medical costs of active employees in 10,000 yuan (including 10,000 yuan) below, the integrated fund to pay 88%, the individual out-of-pocket proportion of 12%; medical costs of 10,000 yuan to 40,000 yuan (including 40,000 yuan), 90% of the integrated fund, the individual out-of-pocket proportion of 10% (retiree out-of-pocket proportion of 10%); medical costs of 10,000 yuan to 40,000 yuan (including 40,000 yuan), 90% of the integrated fund to pay Proportion of 10% (retirement out-of-pocket by half);

◆ community hospitals: community health centers in the discharge settlement, medical costs in 40,000 yuan (including 40,000 yuan) below, the integrated fund to pay 92%, the individual out-of-pocket proportion of 8% (retirement out-of-pocket by half);

2, large costs: 40,000 yuan or more of medical costs and individual out-of-pocket proportion of the fund to pay a unified 92% and 8%.

3, hospitalization start fee: the first hospitalization should be paid hospitalization start fee (threshold fee) third-level hospital in-service 950 yuan, 750 yuan for retirement; second-level hospital in-service 750 yuan, 600 yuan for retirement, a hospital unified 400 yuan, community health centers unified 300 yuan, the second hospitalization during the year for the above standard 50%, the third and above hospitalization for the above standard 25%.

(C) outpatient special disease

medical expenses are exempted from the starting fee, enjoying the reimbursement of hospitalization in first-class medical institutions.

(d) Office

by the Wuxi City Social Insurance Fund Management Center, the office window in the district offices.

(E) foreign medical record

If you live for a long time or by the company stationed in a foreign worker for more than half a year, the need for medical treatment in a foreign place, you can fill out the "foreign medical application form" (stamped with the unit, and the social security center of the offices of the chapter), ID card, social security card to the social security center offices for foreign medical record and receive the "foreign medical certificate", you can choose the three hospitals as a foreign place The hospitals can choose three hospitals as fixed point hospitals in the foreign place.

Information required for reimbursement: If you have incurred hospitalization expenses in a different place and have applied for the record of medical treatment in a different place, please prepare the above information as soon as possible after discharge from the hospital for reimbursement at the offices of the Social Security Center:

◆ Personal second-generation ID card, social security card;

◆ Outpatient medical records, hospital discharge summary, valid bills and cost details;

◆ Certificate of medical treatment in a different place;

◆ Personal bank card. Bank card.

(F) Big City Card

Wuxi City (including Jiangyin and Yixing) employee health insurance participants who have received the Jiangsu Province Social Security Card can apply for registration of the Big City Card at the social insurance office within Wuxi City. If the registration is successful, the insured person can choose another place as the place of medical treatment on the basis of maintaining the medical treatment benefits of the place of insurance. You can use your Jiangsu social security card to get medical treatment at designated medical institutions.

Basic medical insurance treatment for Wuxi residents

(a) General outpatient services

◆Community health service centers are 50%, with a limit of 800 yuan (including the individual's share within the scope of the medical insurance);

◆In the city and out-of-town hospitals, the referral procedures are 45%, and 50% of the above percentage is applied to those who have not completed the referral procedures.

Reimbursement ratios

(ii) general hospitalization and outpatient

◆ should be the first visit to the community health service center, inpatient medical expenses for the starting fee of 200 yuan, in line with the provisions of the medical costs of the fund to pay 90%, 10% of the individual out-of-pocket; transferred to other urban medical institutions, inpatient hospitalization for the starting fee of 300 yuan for students and children, and other residents of 600 yuan, the first visit to a medical institution below the second level, in line with the provisions of the medical expenses for the starting fee of 300 yuan, and other residents of 600 yuan. For hospitalization in medical institutions below the second level, the fund pays 75% of the medical expenses in accordance with the regulations and the individual pays 25% out of pocket; for third-level medical institutions, the fund pays 65% and the individual pays 35% out of pocket; for transferring out of the urban area, the fund pays 55% and the individual pays 45% out of pocket; and for those who do not go through the required procedures for transferring to another medical institution, the fund pays 50% of the above standard.

◆Maximum:The maximum annual accumulated medical expenses of residents' basic medical insurance is 200,000 RMB. If the insured residents have paid contributions for 5 years or more, the maximum annual cumulative medical expenses will be increased by 50,000 RMB; the part of the annual cumulative medical expenses above the maximum limit will no longer be paid by the residents' medical insurance fund.

◆ Outpatient special disease treatment of 90% of the medical costs, the costs and general hospitalization medical costs combined to calculate the annual maximum limit.

(C) Wuxi City, the residents of basic medical insurance and reimbursement process:

1, the first insured patients with their own "residents of medical insurance medical records" and "social security card" to the individual agreement service center for medical treatment (less than 3 years of age of children, can be directly to the individual agreement service center designated by the pediatric diagnostic and treatment subjects of the medical institutions to seek medical treatment);

2, the existing medical technology can not provide service The, by themselves or their families with the above card to the individual agreed service center for referral procedures (valid for three days), transferred to the urban area with the designated qualification of employees' basic medical insurance medical institutions;

3, the insured residents in the city or out of town (within the country) in the event of an emergency, you can go to the nearest health care institutions;

4, emergency (need to comply with the "Diagnostic Standards for Emergency and Critical Diseases of Jiangsu Province") and unplanned card medical expenses, go to the community health service center agreed by the participant for reimbursement.

Three, medical insurance does not cover the content:

Participants in the following situations occurring medical costs, the social health insurance fund will not pay:

(1) in addition to the emergency, without the approval of the relevant procedures in the individual agreement outside of the fixed-point service center for the costs incurred;

(2) the insured residents to interrupt the period of payment;

(3) the costs incurred during the period of payment;

(4) the insured residents to pay the fees;

(5) the insured residents to pay the fees;

(6) the insured residents to pay the fees. (3) Expenses incurred during the period of interruption of contributions;

(3) Expenses incurred outside the urban residents' medical insurance medication list and the standard range of diagnostic and treatment services and facilities;

(4) Plastic and cosmetic surgeries;

(5) Maternity expenses;

(6) During the period of leaving the country or the country of departure;

(7) Medical expenses incurred due to crimes, fights, brawls, alcoholism, drug abuse, suicides, and self-inflicted injuries and self-inflicted injuries;

(9) Medical expenses incurred in violation of other circumstances stipulated by laws and regulations;

(10) Other medical expenses that do not meet the scope of payment of the social medical insurance regulations.

Four, foreign medical

(a) other areas of Jiangsu Province, foreign medical settlement foreign people in Wuxi for medical treatment:

1, foreign insured first to the place of application, fill out the "insured foreign medical application form", successful registration;

2, with the seal confirmation of the "application form" and ID card, to Wuxi for the local social security card, you can go to the designated hospital in Wuxi card settlement.

(B) Wuxi participants to other parts of Jiangsu Province for medical treatment:

1, participants long-term (more than 6 months) living abroad can apply for medical procedures;

2, fill out the "application form for medical treatment of participants in other places", in the place of medical treatment, selected three different levels of public health care institutions, as a designated medical institutions for medical treatment;

3, such as outpatient co-ordination treatment, should be selected under the same conditions to enjoy

4, to the Wuxi Social Security Center offices for registration procedures;

5, after successful registration, to the medical insurance agency for transfer procedures;

6, the year's medical expenses incurred until the end of June of the following year, no reimbursement will be made after the deadline.

Five, urban and rural residents of the treatment of major medical insurance

(a) to enjoy the object:

I urban residents of the basic medical insurance and urban workers basic medical insurance participants.

(2) the scope of coverage:

major medical insurance does not distinguish between types of disease, hospitalization and outpatient treatment of special diseases are included in the reimbursement of eligible medical expenses.

(C) What are the circumstances in which the major medical insurance can not be reimbursed?

Those that are not included in the city's social health insurance settlement system are not covered by the medical insurance for major diseases, including medical expenses for work-related injuries and maternity insurance.

(D) reimbursement ratio and standards:

The actual payment ratio of the major medical insurance is not less than 50%, as follows:

◆ personal burden in the 21,000 yuan - 50,000 yuan (including 50,000 yuan) part of the subsidy at 50%;

◆ personal burden in the 50,000 yuan - 100,000 yuan (including 100,000 yuan) part of the subsidy at 60%;

◆ personal burden in the part of 100,000 yuan or more, at 80%;

◆ personal burden in the part of 100,000 yuan or more, at 80%;

◆ personal burden in the part of 100,000 yuan or more, at 80%;

◆ personal burden in the part of 100,000 yuan or more, at 80%.

◆The personal burden of more than 100,000 yuan part of the 80% to be subsidized;

◆Degree of major medical insurance starting line of 21,000 yuan, the amount of subsidies do not set a ceiling line.

◆In addition, the city of Xicheng every two years in the future by the human society, finance, according to the previous year's annual per capita disposable income of urban residents, to adjust the introduction of a new starting standard.

◆This is the first time that I have ever seen a new standard.