Medical Insurance Guide

1. Insurance participation and payment

1. Insurance scope and insured objects

Urban employees in Taizhou urban area Basic medical insurance covers all employees of urban enterprises, state agencies, institutions, social groups, private non-enterprise units and urban flexible employment personnel within the urban area (including municipal, Jiaojiang, Huangyan, and Luqiao districts). If the above objects should participate in basic pension insurance, they must first participate in basic pension insurance when participating in basic medical insurance.

2. Payment Standards 3. Standards and Benefit Categories

The payment standards for each settlement year of medical insurance (from July 1 of each year to the end of June of the following year) are collected monthly. , the average monthly salary of employees in the province in the previous year is the payment base, and each insurance type is levied according to the corresponding proportion. It is announced in June every year and adjusted in July.

Unit-type basic medical insurance civil servant subsidy

Insurance for major diseases

Insurance types

Unit-based individual unit-individual transfer

Agency

Business

Business 82/442

Enterprise 5//442

Individual/5//82

Note: 1. Critical illness insurance is operated by commercial insurance, and the payment ratio is 0.6-0.7. It is tentatively set at 10 yuan for the 2006 accounting year, with units and individuals each paying 40, and the overall fund paying 20; 2. Taizhou College enjoys civil servant subsidies Types of insurance.

Different payments correspond to different treatment categories: enterprise basic medical treatment (inpatient overall payment), enterprise basic medical treatment (outpatient personal account payment, hospitalization overall payment), civil servant medical subsidy treatment (outpatient and inpatient civil servant subsidy) .

3. How to apply for medical insurance for new staff

(1) New faculty and staff who have not participated in basic medical insurance at this level and in the three districts of Taizhou City must submit two insurance certificates after entering the school. Bring a 2-inch color photo with a white background (name and department written on the back of the photo) and a copy of your ID card to the school personnel office, which will handle the insurance enrollment procedures.

(2) New faculty and staff who are subject to job transfer or introduction shall be handled according to the following conditions:

① Faculty and staff who have participated in basic medical insurance at the same level and in the three districts of Taizhou City , he or she will submit the existing medical insurance card to the school personnel office, and the school personnel office will handle the insurance enrollment procedures again.

② Employees who have participated in basic medical insurance in the province other than Taizhou City and the third district must submit two 2-inch white background color photos (with name and department written on the back of the photo) and identity after entering the school Send a copy of the ID card to the school personnel office, which will handle the insurance enrollment procedures. One month after payment, the personnel office will notify him or her to go to the Taizhou Social Security Center to issue an "Employee Cross-Coordinating Region Medical Insurance Relationship Transfer Form" to the The medical insurance institution in the original insured place handles the relationship transfer, and the Municipal Medical Insurance Center handles the corresponding personal account registration and back payment according to this form, and the original payment period will be recognized. Note: The relationship transfer should be processed within 3 months of interruption of payment. It will be invalid if it exceeds 3 months, and the transfer outside the province will be invalid.

(3) What to do if the number of personnel involved in medical insurance is reduced?

① Transfer and termination of personnel relations: The school personnel office will fill in the "Insured Unit Staff Change Increase and Decrease Form" to transfer out, and the corresponding medical insurance benefits will be suspended from the date when the business takes effect. The corresponding connection procedures should be completed as soon as possible. If the procedures are not completed for more than 2 months, the insurance participation will be suspended.

② Handling the medical insurance relationship for retirees: After the unit's retirement documents are issued, the school personnel office will fill in the "Insured Unit Employees Change Increase and Decrease Form" and go through the relevant retirement payment procedures, requiring the retiree to provide medical insurance. Card, certificate.

③ Handling the medical insurance relationship for deceased persons: The school personnel office is responsible for filling out the "Insured Unit Employees Change Increase and Decrease Form" for cancellation, and the corresponding medical insurance benefits will be stopped from the date of business effectiveness.

④ Time for new personnel to enjoy medical insurance benefits: they will enjoy medical insurance benefits from the next day after paying for insurance.

2. Medical insurance personal account

1. Personal account transfer

There are three channels for transferring funds into personal accounts: the payment part of the civil servant subsidy insurance unit is based on age. The unit payment part of the basic medical insurance is allocated according to age groups, and the individual payment part of the basic medical insurance is all allocated.

Personal accounts are transferred to the medical insurance IC card at one time in July every year, and the entire medical insurance settlement annual quota is divided into age groups only on July 1 each year. The medical insurance system actually transfers it on a monthly basis, and the specific allocation is The income ratio is as follows:

Ages with civil servant subsidies but no civil servant subsidies

Under 35 years old (1 0.8 2)

*Payment base*12 (0.8 2)

*Payment base*12

36~45 years old (2 1.8 2)

*Payment base*12 (1.8 2)

*Payment base*12

46 years old to retirement (3 2.8 2)

*Payment base*12 (2.8 2)

*Payment base*12

Retired

Personnel (4 5)

*Payment base*125*Payment base*12

Note: 1 in the above table , 2, 3, and 4 are allocated for civil servant subsidies, 0.8, 1.8, 2.8, and 5 are allocated for basic medical unit contributions, and 2 are allocated for basic medical individual contributions. When handling retirement and adjusting insurance benefits, the corresponding account amount will be adjusted starting from the month following the medical insurance procedures.

2. Purpose of personal accounts

Personal accounts are divided into two parts: the current year's quota and the balance of previous years, referred to as the current year's personal account and the previous years' personal account. When the balance is carried forward in July every year, all the balances on the card will be transferred to the balance of the past years after the carry-over. The current year's quota is directly used to pay for outpatient and inpatient medical expenses before the backward civil servant subsidy is paid as a whole, and the balance over the years is used to pay for the self-pay part of the individual's cash payment, that is, "the balance over the years truly belongs to oneself."

3. Personal account inquiry

Because our city’s current medical insurance transactions adopt an offline method, that is, medical institutions regularly upload settlement data after completing IC card settlement with insured persons. to the medical insurance institution, so the medical insurance institution is currently unable to provide real-time personal account inquiries. Insured persons are kindly requested to check the most recent medical insurance settlement receipts, which contain account expenditures and balances.

4. Personal account transfer and withdrawal

When an insured person with an account is transferred to a different place (transfer outside the province is not allowed and can only be withdrawn), the personal account balance can be transferred to the transferred account (You must provide the bank, account name, and account number of the medical insurance institution in the transferred place), or you can withdraw it (if there is no personal account in the transferred place); if the insured person who has an account terminates his insurance or the insurance benefits are lowered, he will withdraw the account The balance can be withdrawn; if the insured person with an account dies, the balance of the account can be inherited and withdrawn by his family members. If the above persons have an account overdraft when transferring (the one-year available limit is credited to the card when the IC card is carried forward in July each year, but the payment must be made until June of the following year before the limit is actually credited), they should make up for it in cash. The overdraft amount can only be transferred.

3. Medical insurance card certificate

1. Use and transfer

The medical insurance medical certificate consists of the medical insurance IC card and the medical insurance calendar. You must bring your medical insurance card when seeking medical treatment, purchasing medicines, and going to medical insurance institutions to handle relevant procedures at designated medical institutions. The medical insurance card is for personal use only and should be kept properly. It should not be bent, twisted, scratched or rubbed. It should be kept away from environments such as high voltage, strong electromagnetic fields or low and high temperatures, and should be kept away from contact with mobile phones and liquid substances.

The medical insurance IC cards of all insured persons must be transferred to a designated branch of China Construction Bank in July each year before they can be used:

Savings Counter of CCB City Branch: No. 86-2, Jiaojiang Gongren Road

China Construction Bank Savings Counter in the Development Zone: No. 238 Donghuan Avenue

Jiaojiang City Gate Savings Office: Next door to Jiaojiang Real Estate Trading Center

Jiaojiang Cuihua Savings Office: Yan No. 218 Yu Road

Jiaojiang City Branch Savings Office: No. 44 Jiefang North Road

Jiaojiang Zhongshan Branch Fuqian Office: No. 451 Shifu Avenue

Huangyan District Hengjie Road Savings Bank: No. 220, Huangyan Hengjie Road

Huangyan District Tiannan Savings Bank: No. 460, Huangyan Hengjie West Road

Huangyan District Construction Bank Counter: Huangyan Tianchang North Road No. 209

Zhenzhong Road Savings Office, Luqiao District: No. 117 Ginzuo Street, Luqiao

Chengbei Branch, Luqiao District: No. 108 Jinshui Road, Luqiao

Linhai Construction Bank No. Second Savings Office: No. 65 Chicheng Road, Linhai

2. Collect

The newly issued medical insurance card shall be collected by the unit's medical insurance manager with his or her ID card. Individual insured persons shall collect it by themselves Collect with your ID card. If you entrust the application, you should bring the ID card of the entruster and the ID card of the agent. The new IC cards have been carried forward and can be used directly during the year.

3. Loss report and replacement (inquiry hotline: 8556022)

Because the medical insurance IC card is lost or damaged, the loss report and replacement card business should be handled in a timely manner. Fund losses caused by failure to report the loss in time are due to Personal responsibility. The insured person can first report the loss by phone (the ID number must be checked) to prevent unnecessary losses, and then go to the medical insurance institution to handle the written loss report and card replacement business within 3 days (with the ID card, you can entrust someone else to do it for you). The loss reporting period is After 15 days, if you find it within 15 days, you can call the medical insurance center to cancel the loss report (ID card number must be checked). After the loss report period expires, you must present the loss report form stamped by the medical insurance institution to get a new card; if you have lost your certificate and calendar, you can apply for a new certificate and calendar on the spot by bringing your ID card and an original photo.

When exchanging certificates and calendars, you should bring the old certificates and calendars with you. When exchanging the old certificate for a new one, you can only exchange for one copy. The old copy will be stamped and invalidated and returned to the person for safekeeping. There is a cost of 20 yuan for replacing an IC card and 3 yuan for replacing a certificate and calendar.

IV. Concepts related to medical insurance

Medical expenses that are not covered by basic medical insurance

(1) In the drug catalog stipulated by the provincial labor and social security department and the provincial , medical expenses beyond the scope of diagnosis and treatment items, medical service facilities and payment standards stipulated by the municipal labor and social security department;

(2) Seeking medical treatment and purchasing goods at non-designated medical institutions and non-designated retail pharmacies without the approval of the social security agency medicine;

(3) Transferring to other places for medical treatment without approval;

(4) Carrying out special examinations and special treatments without approval;

(5) Medical expenses incurred due to violations of laws, crimes, suicide, self-mutilation, fights, drug abuse, alcoholism, etc.;

(6) Medical expenses incurred while traveling abroad;

(7) Medical expenses payable for traffic accidents, medical accidents, widespread food poisoning and other liability claims.

Designated medical institutions, designated retail pharmacies

Designated medical institutions in the city: Taizhou Hospital, Taizhou Central Hospital, Taizhou Municipal Hospital, Taizhou Traditional Chinese Medicine Hospital, Taizhou First People's Hospital , Huangyan District Hospital of Traditional Chinese Medicine, Taizhou Hospital Luqiao Campus, Luqiao Hospital of Traditional Chinese Medicine, maternal and child health clinics in various districts and township health centers, etc.

Provincial designated medical institutions: First Affiliated Hospital of Zhejiang University School of Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Obstetrics and Gynecology Hospital Affiliated to Zhejiang University School of Medicine, Shaw Hospital Affiliated to Zhejiang University School of Medicine, Zhejiang Provincial Cancer Hospital , Zhejiang Provincial People's Hospital, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Zhejiang Hospital, Hangzhou Third People's Hospital, Zhejiang Provincial Tongde Hospital.

Designated retail pharmacies: Longxiang Pharmacy in the Development Zone, Jiaojiang Fu Pharmacy, Jianchuntang Pharmacy, Huangyan Wuzhou Pharmacy, Tongrentang Pharmacy, Renji Pharmacy, Luqiao Jianmin Pharmacy, Baohetang Pharmacy, Linhai Fang Yiren Pharmacy, etc.

Medical Insurance Drug Catalog, Medical Insurance Medical Service Item Catalog

The payment scope of the medical insurance fund in our city uniformly follows the "Zhejiang Province Basic Medical Insurance Drug Catalog, Medical Service Item Catalog", both catalogs are Access management is implemented, and the medical insurance fund will not pay for the use of drugs, medical services and medical materials outside the two catalogs, and all are at personal expense. Drugs, medical services and medical materials in the two catalogs of medical insurance are divided into "Category A" and "Category B": All expenses incurred in "Category A" items shall be paid in accordance with the relevant provisions of medical insurance; expenses incurred in "Category B" items shall be paid first. After the insured person personally pays a certain proportion, he will pay according to the relevant regulations of medical insurance. That is, the total medical expenses of the insured person after excluding the self-paid part and the out-of-pocket part are the settlement expenses entered into the medical insurance fund, which are called prescribed medical expenses.

5. Medical insurance and medical treatment benefits and expense settlement

Outpatient accounts and civil servant subsidy payment

Outpatient clinics for basic medical treatment benefits of enterprises are provided by enterprises or individuals themselves;

Insured persons with an account directly bring their medical insurance card to the outpatient clinic of a designated medical institution. After settling with the medical insurance IC card, the individual only needs to pay the "cash payment" amount on the settlement invoice.

The specific settlement method is as follows:

The prescribed medical expenses incurred by the basic medical treatment clinic can be paid from the personal account of the current year. After the personal account is used up in the current year, the personal cash payment (if any Individual accounts in previous years will be paid first from individual accounts in previous years);

The prescribed medical expenses incurred by civil servant medical subsidy treatment clinics can be paid from the personal account of the current year. After the individual account of the current year is used up, the civil servant subsidy fund will be divided into age groups. The subsidy will be proportional (75% for those under 45 years old, 85% for those aged 46 to retirement, and 90% for retirees), and the remaining amount will be paid in personal cash (if there is an individual account for the past years, it will be paid from the individual account for the past years first);

Purchasing drugs in pharmacies

is basically the same as outpatient service. Over-the-counter drugs stipulated by the state can be purchased by insured persons at designated retail pharmacies of their own choice. Prescription drugs must be prescribed by a physician at a designated medical institution and must be signed and stamped by the physician. Only with a special seal for prescription can you buy it at designated retail pharmacies.

Local hospitalization coordination, personal accounts, civil servant subsidy payment

Insured persons who need to be hospitalized due to illness should go through the hospitalization procedures at designated medical institutions with their medical insurance card and personal ID card. After settling with the medical insurance IC card, individuals only need to pay the "cash payment" amount on the settlement invoice.

The minimum payment standard (deductible line) and maximum payment limit for overall hospitalization payment within a medical insurance year are announced at the end of June each year: the minimum payment standard is about 10% of the average salary of provincial employees in the previous year. The second The hospitalization deductible is reduced by 50%, and the deductible is borne by the individual; the maximum payment limit is about 4 times the average salary of provincial employees in the previous year. (The minimum payment standard for medical insurance in 2006 is tentatively set at 1,200 yuan, and the maximum payment limit is tentatively set at 81,000 yuan)

The specific settlement method is as follows (segment calculation, cumulative payment):

Provisions For medical expenses that are above the minimum payment standard but less than 2 times the average salary of provincial employees in the previous year (tentatively set at 40,500 yuan in the 2006 medical insurance year), current employees are responsible for RMB 20 and retirees are responsible for RMB 15; the medical expenses are more than 2 times the average salary of provincial employees in the previous year and For the maximum payment limit, current employees are responsible for 15%, and retirees are responsible for 10%; (Third-level and second-level hospitals in the city are based on the above standards, and the minimum payment standard and personal payment ratio for third-level hospitals outside the city are both 20% higher)

If the insured person has an account and the current year's quota has not been used up, the above deductible amount can be paid from the first year's account;

If the insured person also enjoys civil servant medical subsidy benefits, the above deductible amount (can include The remaining part (the personal responsibility for serious illness) is paid from the current year's personal account and is subsidized by the Civil Servant Subsidy Fund in proportion to the age group; (50% for those under 45 years old, 60% for those aged 46 to retired, and 70% for retirees)

Finally, if there is a surplus in the individual account of the insured person over the past years, the final out-of-pocket amount that must be paid in personal cash can be paid from the individual account over the past years;

After the above payments (including major illness payments) are completed , the remaining amount is paid in personal cash.

Coordinated payment for outpatient special diseases

Suffering from special diseases (referring to various types of malignant tumors, radiotherapy and chemotherapy, systemic lupus erythematosus, hemophilia, aplastic anemia, chronic renal function For employees with diseases within the scope of dialysis treatment for failure, anti-rejection treatment after tissue or organ transplantation, decompensated liver cirrhosis, and mental illness), after going through the approval procedures for special diseases, their accumulated outpatient medical expenses for special diseases in one medical insurance year It can be treated as a hospitalization and settled with a medical insurance IC card at a designated medical institution. The specific settlement method is the same as that of local hospitalization. This benefit is open to all insured persons, and they must provide the "Taizhou Urban Basic Medical Insurance Special Disease Diagnosis Certificate and Outpatient Treatment Approval Form" issued by a designated second-level and above medical institution, diagnosis certificate, medical records and relevant examination and laboratory reports, Pathological slide reports and other information;

Critical disease insurance payment

The portion of hospitalization prescribed medical expenses (including special disease outpatient services) above the overall maximum payment limit will be paid by the critical disease insurance on a pro rata basis . Critical illness insurance is borne by commercial insurance companies, but is collected and paid by medical insurance institutions and bundled with basic medical insurance.

The specific settlement method is as follows:

It is stipulated that the portion of medical expenses exceeding the maximum payment limit of 100,000 yuan shall be paid by the critical disease insurance 90%, and the individual shall be responsible for 10%; for the above part, It is stipulated that for every 10,000 yuan increase in medical expenses, the individual's self-pay ratio will increase by 1; the cumulative payment for major disease insurance in a medical insurance year shall not exceed 200,000 yuan.

Transfer for medical treatment

Due to illness, it is really necessary to transfer to other hospitals or other places (in principle, transfer is limited to designated medical institutions within the province. If transfer to other provinces is required under special circumstances, transfer to Shanghai is currently limited) (Taizhou Municipal Basic Medical Insurance Transfer Approval Form) must be filled out by a designated medical institution and stamped by the hospital and the employer to complete the transfer approval procedures. (To be filled out by designated tertiary medical institutions when transferring to other places)

For diseases covered by medical insurance in designated medical institutions in the province or Shanghai municipal public tertiary hospitals, the medical expenses will be paid in advance by the person. If the individual advance exceeds 10 The above part of 10,000 yuan will be advanced by the school (with the 100,000 yuan medical fee payment receipt and the notice of continued payment, the medical fee advanced by the school will be remitted to the hospital account by the Finance Department, and the unused medical fee after discharge will be remitted by the hospital. The medical expenses advanced by the school will be returned to the school account, and the remaining balance will be paid back within one month after settlement and reimbursement by the medical insurance institution). Then go to the medical insurance institution for settlement and reimbursement. Both the minimum payment standard and the personal self-pay ratio during settlement are increased by 20%, and those who transfer to Shanghai must first pay 10% of the total medical expenses themselves, and the rest are the same as the local hospitalization settlement.

Resettlement in another place

Retirees’ relocation and employees working and studying abroad (more than 3 months) must submit the "Taizhou Urban Basic Medical Insurance Resettlement" stamped and approved by the unit. (Resident) Personnel Application Form", grade certificates of local designated medical institutions (optional 2 designated medical institutions in the same coordinated area), and medical insurance certificates. When registering for medical treatment in another place, you can enjoy the medical benefits of resettlement in other places; the medical expenses are: I will pay in advance and then go to the medical insurance institution to settle and reimburse. The specific settlement method is the same as for local hospitalization (outpatient service).

8. Out-of-town emergency treatment

If a patient is hospitalized due to an emergency out of town while away on business or on leave, he must report to his/her unit within 5 working days. Bring the hospitalization notice or copy to the center to go through the registration and filing procedures. The medical expenses are paid in advance by the patient and then settled and reimbursed by the medical insurance institution. The specific settlement method is the same as that for local hospitalization (outpatient service).

9. Window settlement and reimbursement

Window settlement and reimbursement is only applicable during the period of approved transfer for medical treatment, off-site resettlement, out-of-town emergency treatment, computer failure in designated medical institutions or loss of medical insurance IC card (required) The medical expenses incurred shall be reimbursed in cash (certified by the medical insurance office of the designated medical institution or the medical insurance institution shall stamp the corresponding bill), and other cases will not be reimbursed and shall be borne by the unit or individual themselves.

For reimbursement, insured persons need to bring medical insurance calendars, medical insurance IC cards, medical expense lists, medical expense receipts, medical institution grade certificates and medical records, discharge summaries of inpatients, copies of medical orders and other relevant information.

Reimbursement time: 5th to 15th of each month. Those who go out for emergency treatment should be reimbursed within 30 days from the date of discharge (outpatient service).

10. Instructions for medical insurance settlement invoices

The invoices after settlement at designated medical institutions and designated retail pharmacies with medical insurance IC cards will have medical insurance settlement items:

"Cash payment" refers to the amount of cash payment to be made by the insured person;

"Card payment amount" refers to the amount to be paid to the personal account of the insured person, including the total amount of personal account payment for the current year and previous years, which is determined by the medical institution in The IC card will be deducted;

"Civil servant subsidy" refers to the amount paid by the civil servant subsidy fund, which is advanced by the medical institution;

"Coordinated payment" refers to the prescribed medical expenses for hospitalization The amount paid by the overall pooling fund shall be paid in advance by the medical institution;

"Critical illness assistance" refers to the amount paid by the critical illness insurance fund after the annual prescribed hospitalization expenses exceed the maximum limit of pooled payment, and shall be paid by the medical institution. Institutional accounting and advance payment;

The "deductible amount" refers to the cumulative self-pay amount borne by the individual during this hospitalization. The amount is equal to the "cash payment" amount - the self-pay amount + the personal account payment amount in the past years (the individual account payment amount in the past years) The balance of the account goes to oneself). After an individual’s cumulative “deductible amount” exceeds a certain limit within a medical insurance year, eligible units should reimburse them. (Our school’s personal “deductible amount” in one medical insurance year will be subsidized by the school if the outpatient cost exceeds 1,500 yuan and the retirement cost exceeds 1,200 yuan. The standard is 90 for current work and 95 for retirement; the hospital cost exceeds 1,500 yuan for current work and 1,200 yuan for retirement. The above part will be subsidized by the school, please keep the annual invoice as proof of subsidy)

The "card balance" refers to the remaining available amount in the medical insurance IC card, which is the current year's personal account limit and the previous years' personal account. The sum of the balances. Since our city's medical insurance system currently adopts an offline transaction method, and the IC card advances one year's available limit when carrying forward each year, therefore due to settlement data, payment abnormalities and other factors may cause the balance on the IC card to differ from the true book balance in the medical insurance system. Doesn’t match. The balance in the card will be automatically checked and adjusted when the IC card is carried forward every year, that is, the true balance of the account is based on the book balance in the medical insurance system (the balance on the first transaction invoice of the medical insurance year).

Reiterate a few concepts:

Self-payment refers to the expenses incurred by using drugs or services outside the medical insurance catalog and the 10 parts of the expenses paid in advance for medical treatment outside the medical insurance list, which cannot be included in the medical insurance payment Prescribed medical expenses cannot be included in the out-of-pocket amount that can be reimbursed by the employer; self-care refers to the use of drugs or services in the medical insurance catalog, but the individual must first bear part of the expenses incurred, and cannot be included in the prescribed medical expenses paid by medical insurance, but can be The out-of-pocket amount that can be reimbursed by the employer; the out-of-pocket amount refers to the proportion of the prescribed medical expenses that fall within the scope of medical insurance payment and can be reimbursed by the employer; cash payment includes all self-pay amounts, in whole or in part (within the past years) When there is a personal account) the deductible amount, all or part of the deductible amount (when there is a personal account and civil servant subsidy for the year).

VI. Personal medical insurance audit supervision and penalties

The cumulative number of outpatient visits per month is more than 15 times; the cumulative number of outpatient visits within 3 consecutive months is more than 30 times; monthly outpatient medical expenses The accumulated outpatient expenses in a medical insurance year exceed 8,000 yuan for employees and the retired persons exceed 10,000 yuan; the single dispensing and purchasing expenses at designated retail pharmacies exceed 200 yuan; the accumulated hospitalization medical expenses in a medical insurance year reaches 50,000 Yuan; insured persons who have any of the above situations in outpatient service, drug purchase, or hospitalization will be included in the key review and management objects.

For those listed as key review management objects, their original medical insurance IC card accounting settlement method has been changed to direct cash settlement. They should bring relevant information to the medical insurance institution to complete the registration procedures, explain the situation, and cooperate with the review.

Insured persons give their medical insurance cards to others or use others’ medical insurance cards to seek medical treatment and purchase medicines; violate regulations by repeating or overdosing prescriptions; meet discharge conditions and are unwilling to be discharged; commit fraud and cause medical insurance losses. If the fund is lost; if the loss of the medical insurance card is not reported in time and the loss is caused by the medical insurance fund; for insured persons who have the above and other violations of medical insurance regulations, the medical insurance institution will suspend their medical insurance benefits, notify the employer, recover the losses, and may be compensated by the labor The administrative department shall impose fines according to the circumstances, and those that constitute a crime shall be transferred to judicial organs for handling in accordance with the law.

7. Maternity insurance:

Our school has participated in Taizhou City’s urban employee maternity insurance. Relevant policy questions are as follows:

(1) Question: What is maternity insurance?

Answer: Maternity insurance is a social system through national legislation that provides timely living security and material assistance to working women when the state and society temporarily interrupt their labor due to having children. Its purpose is to maintain, restore and improve the health of childbearing women by providing maternity benefits, medical services and maternity leave, so that babies can receive careful care and nourishment.

(2) Question: What are the conditions for enjoying maternity insurance benefits?

Answer: 1. Your employer must participate in maternity insurance and fulfill its payment obligations in accordance with regulations.

2. Employees who give birth or undergo family planning surgery must meet the conditions stipulated in the "Population and Family Planning Law of the People's Republic of China", that is, those who have their first child in compliance with the national family planning policy, Or those who meet the conditions for having another child and have been approved by the family planning department, or those who meet the above-mentioned birth conditions but have a miscarriage (induced labor) after pregnancy.

(3) Question: How to calculate maternity allowance?

Answer: Maternity allowance = payment base × 600 × number of months of maternity leave. Standard compensation is given to the employer. During the maternity leave of female employees, the employer shall pay maternity leave wages according to regulations. If the maternity leave salary is lower than the maternity allowance, it will be paid as maternity allowance; if it is higher than the maternity allowance, it will be paid based on actual calculation, and the difference will be borne by the employer.

(4) Question: What does the cost of childbirth medical care include?

Answer: Maternity medical expenses refer to the prescribed medical expenses such as prenatal examination fees, delivery fees, bed fees, treatment fees, treatment fees, medicine fees, postpartum visit fees, etc. incurred by female employees due to childbirth. .

(5) Question: How are the standards for childbirth medical expenses determined?

Answer: Maternity medical expenses are subject to fixed compensation. If the compensation is within the fixed compensation standard, the actual full amount will be paid. The portion exceeding the fixed compensation standard shall be borne by the individual employee.

1. Outpatient abortion in early pregnancy (including medical abortion) 150 yuan

2. Hospital abortion in early pregnancy 900 yuan

3. Hospital induction of labor in mid-trimester 1,200 yuan

4. Normal vaginal delivery 1,500 yuan

5. Vaginal surgical midwifery (instrumental midwifery, lateral incision midwifery) 2,000 yuan

6. Cesarean section (Including analgesic pump) 3,500 yuan

(6) Question: How to reimburse medical expenses for birth complications?

Answer: The medical expenses for the following complications when an employee gives birth shall be borne by the employee personally and paid by the maternity insurance fund after 10 days: 1. Ectopic pregnancy; 2. Pregnancy-induced hypertension syndrome; 3. Before and after Placenta insertion; 4. Early placental separation; 5. Intrauterine fetal death (stillbirth); 6. Blood type incompatibility between mother and baby; 7. Cholestasis of pregnancy; 8. Uterine rupture; 9. Postpartum hemorrhage; 10. Amniotic fluid embolism; 11 , Sheehan's syndrome; 12. Eclampsia; 13. Puerperal infection.

(7) Question: How to reimburse the medical expenses for family planning surgery?

Answer: Family planning surgery includes: 1. Inserting an intrauterine ring (only ordinary IUDs can be used); 2. Removing the intrauterine ring; 3. Removing the residual ring and incarcerated ring; 4. Subcutaneous Implantation; 5. Removal of subcutaneous implantation; 6. Fallopian tube ligation; 7. Vasectomy; 8. Fallopian tube anastomosis; 9. Vas deferens anastomosis. The prescribed medical expenses incurred by employees during the above-mentioned family planning procedures shall be fully paid by the maternity insurance fund.

(8) Question: What are the regulations on the scope of medication, diagnosis and treatment items and service facility standards?

Answer: The scope of medication used by employees for childbirth or family planning surgery (except for obstetric therapeutic drugs), diagnosis and treatment items and service facility standards refer to the relevant regulations of Taizhou Urban Employees Basic Medical Insurance.

(9) Question: What are the benefits for male employees?

Answer: Male employees who have participated in maternity insurance and their spouses are unemployed in rural or urban areas and meet the conditions stipulated in the "Population and Family Planning Law of the People's Republic of China" can be reimbursed. 50 maternity medical expenses.

(10) Question: What are the designated medical institutions for maternity insurance?

Answer: Medical insurance designated hospitals and family planning technical service institutions at or above the county level within the coordinating area are all designated medical institutions for maternity insurance.

(11) Question: What are the procedures for maternity insurance?

Answer: 1. After an employee becomes pregnant or before implementing family planning, the employer or the employee should apply for a "Reproductive Medical Certificate" or "Family Planning Surgery Medical Certificate" from the Municipal Medical Insurance Center and voluntarily confirm it. A designated hospital.

2. Employees go to designated hospitals for delivery or surgery with the "Fertility Medical Certificate" or "Family Planning Surgery Medical Certificate".

3. The employer shall apply for maternity insurance benefits from the Municipal Medical Insurance Center within 30 days after the employee’s maternity leave and family planning surgery.

(12) Question: What information is required to apply for a "Fertility Medical Certificate" or a "Family Planning Surgery Medical Certificate"?

Answer: The original and copy of the employee’s ID card, the original and copy of the “Reproductive Health Service Certificate”.

(13) Question: What information is required to apply for maternity insurance benefits?

Answer: Original and copy of my ID card; "Medical Certificate of Birth" or certificate of birth status; original medical records; invoice and list of hospitalization medical expenses; "Fertility Medical Certificate" or "Family Planning Surgery Medical Certificate" .

(14) Question: What should I do if I want to go to a medical institution outside the coordinated area to give birth or undergo family planning surgery?

Answer: The employee himself must submit a written application report and submit it to the Municipal Medical Insurance Center for approval.

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