Medical expenses incurred by insured residents in hospitalization (including family beds) in designated medical institutions shall be subject to certain Qifubiaozhun, and the part exceeding Qifubiaozhun shall be paid according to the control method of hospitalization ratio and maximum payment limit.
The minimum qifubiaozhun is 250 yuan.
Qifubiaozhun is: 250 yuan, a community health service institution; 350 yuan, a first-class hospital; 500 yuan, a secondary hospital; 700 yuan, a tertiary hospital.
In accordance with the provisions of Qifubiaozhun above and below the maximum payment limit of hospitalization medical expenses, in different levels of designated medical institutions to pay different proportions:
1. Urban non-employed residents
Community health service institutions: 70% paid by the overall fund and 30% borne by individuals; First-class hospitals: 60% of overall funds and 40% of individuals; Secondary hospitals: 50% paid by the overall fund and 50% borne by individuals; Third-level hospitals: 40% is paid by the overall fund, and 60% is borne by individuals.
2 children's overall fund payment ratio increased by 5% according to the corresponding standards of urban non-employed residents.
Second-class outpatient serious illness expenses can be reimbursed.
According to reports, serious outpatient diseases include: special outpatient diseases (radiotherapy and chemotherapy for malignant tumors, outpatient renal dialysis, taking anti-rejection drugs after organ transplantation) and chronic diseases (hypertension, coronary heart disease, diabetes).
Outpatient treatment of special diseases: 50% from the overall fund and 50% from individuals; Outpatient treatment of chronic diseases: In one year, if the medical expenses for outpatient treatment of chronic diseases in designated medical institutions exceed 350 yuan, the excess will be paid by the overall fund according to the standard of 50%, and the maximum payment limit of the overall fund is 2,000 yuan.
Seven situations cannot be reimbursed.
1. Medical expenses incurred in non-designated medical institutions without approval; 2. Suicide and self-mutilation (except mental illness); 3. Fighting, fighting, alcoholism, drug abuse and other injuries cause crimes or violate the Public Security Administration Punishment Law; 4. Traffic accidents, accidental injuries, medical accidents, etc. 5. Being treated for beauty, plastic surgery, physical defects, etc. 6. Belonging to the scope of industrial injury insurance (including occupational diseases) or maternity insurance payment; 7. Other non-payment circumstances stipulated by the national and provincial medical insurance policies.
How to participate in insurance?
Urban residents to the domicile of the community labor and social security workstation for insurance procedures; Students who belong to the collective household registration of urban areas in Xi, where the school is responsible for centralized registration, go through the insurance formalities at the local medical insurance agency.
Xi urban residents need to bring the following materials: household registration book, ID card and photocopy, two recent two-inch bareheaded color photos with the same background (preschool children provide photos of mother and son or father and son with the same background), and valid certificates of other family members participating in medical insurance in the household registration book (subject to the insurance certificate issued by the medical insurance department).
Newborns need to provide originals and photocopies of birth certificates and other related materials.
Urban residents who enjoy the minimum living guarantee and severe disability also need to provide relevant certification materials such as the minimum living guarantee certificate and the disabled card respectively.
Children of migrant workers who live with their parents in Xi for a long time need to provide their parents' temporary residence permit, household registration book of origin, proof of going out to work and proof of long-term labor relations.
How to see a doctor?
Residents' medical insurance is managed by designated medical institutions (including designated community health service institutions). If the insured residents meet the requirements and need hospitalization, they can choose the designated medical institutions of medical insurance for urban workers in Xi for medical treatment. Emergency and rescue patients are not subject to this restriction, but they should go through the examination and approval procedures at the district medical insurance agency within 3 working days.
Insured residents suffer from diseases diagnosed by outpatient attending physicians that really need hospitalization and conform to the catalogue of inpatient diseases. Patients or their families go to the medical insurance office of designated medical institutions for treatment on the basis of patient ID card, special medical records for residents' medical insurance and hospitalization certificate issued by outpatient doctors.
How to reimburse?
After the insured residents are hospitalized, they shall pay a certain fee in advance (including Qifubiaozhun and personal out-of-pocket deposit), and the designated medical institutions shall determine the overall payment part and the personal payment part at the time of discharge.
Emergency hospitalization expenses incurred by insured residents in different places due to family visits, vacations and other reasons are included in the scope of medical insurance fund payment. When reimbursing, you need to provide the discharge summary, the first page of medical records, copies of long-term and temporary doctor's orders, hospitalization expenses list, hospitalization documents, disease diagnosis certificate and hospital grade certificate.
Startup area
Xincheng District, beilin district, Lianhu District, Yanta District, weiyang district and Baqiao District (including High-tech Zone, Economic Development Zone, Qujiang New District and Chanba Ecological Zone) will be officially launched from now on; Chang 'an District, Lintong District and yanliang district will be gradually launched before the end of June next year; Gaoling County, zhouzhi county, Huxian County and Lantian were gradually launched in 2009.
Insurance object
Residents' medical insurance is applicable to the following people who are not included in the basic medical insurance for urban workers in Xi: 1. Students in primary and secondary schools (including vocational high schools, technical secondary schools and technical schools) and other children under the age of 18 (including children of migrant workers who have been studying and living in cities with their parents for a long time); 2. Non-employed urban residents with urban household registration in this city and 18 years of age or older.
Payment standard
Children: raised according to the standard of 100 yuan per person per year. Individuals pay 30 yuan and give financial assistance to 70 yuan.
Among them, children who enjoy the minimum living guarantee for urban residents pay 10 yuan and give economic subsidies to 90 yuan; Severely disabled children (holding the Disabled Persons' Card of People's Republic of China (PRC) * * * and above), individual contributions 10 yuan, and economic subsidies to 90 yuan (including employment security fund for the disabled subsidizes 50 yuan).
Urban non-employed residents: raised according to the standard of 250 yuan per person per year. Individual contribution 180 yuan, giving economic subsidies to 70 yuan.
Among them, urban non-employed residents and low-income families over 60 years old who enjoy the minimum living guarantee pay 20 yuan and give financial subsidies to 230 yuan; Non-employed residents with severe disabilities in cities and towns will pay 20 yuan and 230 yuan (including employment security fund for the disabled 150 yuan).
In addition, people who have participated in medical insurance for urban workers can use the surplus funds in their personal medical insurance accounts to pay residents' medical insurance premiums for their immediate family members.
Reimbursement amount
The annual cumulative maximum payment limit of urban residents after insurance (total expenses of serious illness in hospitalization and outpatient service): 35,000 yuan for urban non-employed residents and 40,000 yuan for children. If the insured urban residents have paid for 10 years continuously, the maximum payment limit may be appropriately increased from next year.
Medical expenses higher than the maximum payment limit and beyond the scope of payment of basic medical insurance for urban residents are no longer borne by the overall fund, and can be solved by establishing large medical subsidies and commercial health insurance.
Refund procedure
Insured urban residents have paid the medical insurance premium for the following year, and if they die before 12+0 in that year, their family members shall go through the refund formalities at the municipal medical insurance agency with the death certificate issued by the medical institution or the public security department.