2. Proportion of reimbursement for residents' medical insurance outpatient service: Outpatient settlement procedure: The insured patients will pay the medical expenses incurred in the clinic at the designated medical institutions directly to the residents' 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 the individual.
3. Proportion of reimbursement for rural medical insurance outpatient service: 60% for medical treatment in village clinics and village center clinics, with prescription drug fee limit of 10 yuan for each visit, and 50 yuan for temporary rehydration prescription drug fee for doctors in health centers; 40% reimbursement for medical treatment in town health centers, with the examination fee and operation fee limit of 50 yuan per visit and the prescription fee limit of 100 yuan; 30% reimbursement for medical treatment in secondary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan; Third-level hospitals will be reimbursed 20% for medical treatment, and the examination fees and operation fees for each visit will be limited to 50 yuan, and the prescription drug fees will be limited to 200 yuan; The invoice of traditional Chinese medicine is attached with the prescription per paste limit 1 yuan; The annual compensation limit of township cooperative medical outpatient service is 5000 yuan.
Outpatient reimbursement process:
Carry information:
1, original ID card or social security card;
2, the original certificate of disease diagnosis issued by a specialist in a tertiary or secondary hospital of a designated medical institution;
3, outpatient medical records, inspection, test results report and other original medical information;
4. The original receipt of outpatient charges of unified financial and tax medical institutions;
5. The detailed list of outpatient expenses printed by the hospital computer or the original payment of prescriptions issued by doctors;
6. Designated pharmacies: the original unified invoice and computer-printed list of tax commodity sales;
7. If acting as an agent, provide the original ID card of the agent.
Bring all the above information to the relevant departments of the local social security center to apply for it. After examination, if the information is complete and meets the requirements, it will be handled immediately. When applying for reimbursement of outpatient medical expenses, the applicant shall first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.
Hospitalization reimbursement process:
1, when you enter or leave the hospital, you must go through the registration formalities at the medical insurance management window of each designated medical institution with the medical insurance IC card.
Individuals should pay 2000 yuan in advance for medical expenses when they are hospitalized, and make up more or less after they are discharged from hospital. Medical expenses incurred before the hospitalization registration formalities are not allowed to be included in the payment scope of basic medical insurance. If the emergency hospitalization fails to go through the hospitalization registration formalities in time, it should go through the hospitalization formalities at the medical insurance management window on the basis of the emergency certificate the next day after admission (holidays will be postponed). If the time limit exceeds, the medical expenses will be borne by itself.
2, the insured after hospitalization as a whole fund deductible is divided into three files:
Level III Hospital 1000 Yuan, Level II Hospital 600 yuan, Level I Hospital 400 yuan. In a basic medical insurance settlement year, the medical expenses for multiple hospitalizations are calculated cumulatively.
3, the insured due to illness need referral (hospital), shall be approved by the designated medical institutions (three or more) deputy chief physician or director of the diagnosis put forward referral (hospital) opinions, by the unit to fill in the application form, approved by the designated medical institutions medical insurance management department for examination and approval to report to the municipal (District) social security institutions for referral (hospital) procedures. The transfer is limited to provincial special hospitals, and the expenses shall be paid by me first, and the reimbursement standard shall be 10% first, and then the reimbursable amount shall be calculated according to local regulations.
4. When the designated medical institutions are discharged from the hospital, the designated medical institutions will calculate the reimbursement amount and the amount that the individual should pay, and the reimbursement amount will be settled by the designated medical institutions and the urban social insurance agencies, and the amount that the individual should pay will be settled by the designated medical institutions and the insured.
legal ground
Social Insurance Law of the People's Republic of China
Article 25 The state establishes and improves the basic medical insurance system for urban residents.
The basic medical insurance for urban residents combines individual contributions with government subsidies.
Those who enjoy the minimum living guarantee, the disabled who have lost the ability to work, the elderly and minors who are over 60 years old in low-income families, etc., are subsidized by the government.
Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will not pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue shall be paid from the basic medical insurance fund in accordance with state regulations.
Twenty-ninth insured medical expenses should be paid by the basic medical insurance fund, by the social insurance agencies and medical institutions, pharmaceutical business units directly settled.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places, so as to facilitate the insured to enjoy the basic medical insurance benefits.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) should be paid from the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by the public health;
(4) seeking medical treatment abroad.
Medical expenses shall be borne by the third party according to law. If the third party fails to pay or cannot determine the third party, the basic medical insurance fund shall pay in advance. After the basic medical insurance fund is paid in advance, it has the right to recover from the third party.