Interpretation of Zhaoqing's New Policy on Medical Insurance Reimbursement Process and Reimbursement Ratio in 2023

Medical insurance refers to social medical insurance, which is a social insurance system established to provide basic medical needs for workers within the scope of protection. The basic medical insurance premiums paid by individual employees are all included in individual accounts; The basic medical insurance premium paid by the employer is divided into two parts, one part is included in the personal account, and the other part is used to establish the overall fund. In this paper, please introduce the related knowledge of medical insurance reimbursement in Zhaoqing. Mainly includes Zhaoqing medical insurance reimbursement process, Zhaoqing medical insurance reimbursement ratio, Zhaoqing medical insurance reimbursement policy related information.

I. Zhaoqing Medical Insurance Reimbursement Process and Conditions for Reimbursement of Required Materials 1, employees who pay medical insurance according to regulations and retirees who meet the conditions for enjoying medical insurance.

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.

Reimbursement materials 1, ID card

2. Social security card

3, designated medical institutions or other materials required by the Municipal Social Insurance Fund Administration.

Reimbursement process general outpatient reimbursement process:

1. When the insured goes to the designated medical institutions inside and outside the city for medical treatment and hospitalization (outpatient service), he/she shall show his/her ID card and social security card and other materials required by the Municipal Social Insurance Fund Administration.

2. At the time of discharge or outpatient checkout, the insured person shall directly handle the medical insurance reimbursement procedures at the designated medical institution's designated medical insurance window.

Special disease outpatient reimbursement process:

1, the insured person suffers from a specific disease and goes to the designated hospital to fill out the Application Form for Outpatient Service of Zhaoqing Basic Medical Insurance Insured Person with a Specific Disease.

2, by the outpatient diagnosis expert group according to the diagnostic criteria of specific diseases for diagnosis.

3. After the medical department of the hospital is audited and sealed, the hospital or the insured person will send the application materials to the medical insurance department (unit) of the social security bureau of the insured place for qualification examination.

4, approved the production of specific disease outpatient manual (card), the insured with the manual (card) and the original ID card to the designated outpatient department or hospital for medical treatment, in the outpatient settlement directly charge to an account.

What diseases are there in Zhaoqing special disease clinic?

Note: Outpatient specific diseases should be filed first, and then reimbursed.

Hospitalization reimbursement process:

1. those who go to local designated hospitals are admitted to the hospital with the original ID card and A 4 copy (children who have no ID card for the time being are admitted to the hospital with the original and a copy of the household registration book).

2. Within 2 working days after admission, the patient or his/her family will prompt the doctor to issue a hospitalization diagnosis and related materials on the provided copy, and the resident administrator and social security bureau will confirm his/her identity and bookkeeping qualification.

3, when discharged from the hospital, the expenses paid by the overall fund shall be accounted for by the designated medical institutions and then settled with the Social Security Bureau.

Note: Medical expenses incurred by those who fail to comply with the above provisions will not be paid.

Second, Zhaoqing medical insurance reimbursement ratio and related policy reimbursement standards First, general outpatient reimbursement:

1. When the insured person conducts outpatient treatment in the town (community) level outpatient department or hospital that has implemented the general medical treatment fee policy according to the regulations, he can reimburse the general medical treatment fee 7 yuan every time, and the number of times is not limited.

2. When the insured person vaccinates in designated medical institutions, the vaccination expenses of rabies vaccine, rabies immunoglobulin, chickenpox vaccine, influenza vaccine and Haemophilus influenzae B vaccine can be reimbursed by 30%.

3, upper limb fracture or lower limb fracture of the insured person, in the city designated hospital outpatient treatment of traditional Chinese medicine non-surgical treatment of each case can be reimbursed to 200 yuan.

4, non local treatment of general outpatient expenses will not be reimbursed.

For example:

(1) An insured person visited a community health service center twice because of upper respiratory tract infection (the general treatment fee policy has been implemented). The first treatment fee (including general treatment fee) is in 30 yuan, and the second treatment fee (including general treatment fee) is in 20 yuan. Medical insurance fund payment: 7 yuan for the first time and 7 yuan for the second time.

(2) An insured person is injected with rabies vaccine in a designated medical institution, and the vaccine cost is 100 yuan. Payment from medical insurance fund: 100×30%=30 yuan.

(3) An insured's left humerus fracture was treated by non-surgical treatment of traditional Chinese medicine in a designated hospital in the city, and the cost was 250 yuan, including the cost of non-surgical treatment of traditional Chinese medicine in 230 yuan. Payment from medical insurance fund: 200 yuan.

Second, the special disease outpatient reimbursement:

1, there is no qifubiaozhun for specific disease clinics, and the proportion of project expenses reimbursement in the catalogue is 85% for employees and 90% for retirees; For malignant tumor treatment, 90% of employees are reimbursed and 95% of retirees are reimbursed.

2. If the insured suffers from a variety of outpatient specific diseases, he can choose up to three diseases to enjoy the corresponding outpatient medical treatment. The monthly limit of outpatient service for specific diseases is valid in the current month, and shall not be accumulated or accumulated. The monthly payment amount is included in the calculation range of the insured's annual cumulative maximum payment limit.

For example:

An on-the-job insured person suffering from nasopharyngeal carcinoma (registered for outpatient treatment of specific diseases of malignant tumors) received outpatient radiotherapy in a tertiary hospital in this city. The cost of a course of treatment is 6300 yuan, including 300 yuan at his own expense. * * * Individual pays: (6300-300)× 10%=600 yuan; Overall fund payment: (6300-300)×90%=5400 yuan; Total individual payment: 300+600=900 yuan.

Third, hospitalization reimbursement:

1, minimum payment standard: first-time tertiary hospital for employees 1 100 yuan, second-time tertiary hospital for retirees in 730 yuan, second-time tertiary hospital in 450 yuan, 584 yuan, first-time hospital in 360 yuan, local hospital at the same level 150%, starting from the second in one social security year.

2. Reimbursement ratio: 85% of the basic medical expenses above the threshold and below the maximum payment limit are paid by the overall fund and15% by the individual; For malignant tumor treatment, the overall fund pays 90%, and the individual pays10%; 90% of the basic medical expenses for retirees above Qifubiaozhun and below the maximum payment limit shall be paid by the overall fund and10% by individuals; For malignant tumor treatment, the overall fund pays 95% and the individual pays 5%.

For example:

(1) The medical expenses of an on-the-job insured person who was hospitalized in a tertiary hospital in this city for the first time this year were 30,500 yuan, including the self-funded part and the self-funded part in 500 yuan. Minimum payment standard: 1 100 yuan, * * individual payment: (30500-500-100) ×15% = 4335 yuan, and total individual payment: 500+65438.

(2) The medical expenses of a retired insured person who was hospitalized in a tertiary hospital in this city for the first time this year due to common diseases were 30,500 yuan, including the self-funded part and the self-funded part in 500 yuan. Minimum payment standard: 880 yuan, * * individual payment: (30500-500-880) ×10% = 2912 yuan, individual total payment: 500+880+29 12 yuan, and overall fund payment:.