policies related to medical insurance treatment

1. Basic medical insurance for urban employees and subsidies for large medical expenses for employees (1) Outpatient service 1. Outpatient service for special diseases: Qifubiaozhun is 211 yuan, which is reimbursed according to the proportion of reimbursement for ordinary hospitalization in medical institutions of the same level. 2. Chronic disease outpatient service: Qifubiaozhun is 211 yuan, with 82% for employees and 91% for retirees. (II) General hospitalization 1. Qifubiaozhun: 111 yuan for community health service center, first-level medical institution 211 yuan, second-level medical institution 411 yuan, and third-level medical institution 811 yuan. The Qifubiaozhun for the second and subsequent hospitalization within the year is 51% of the normal Qifubiaozhun. 2. Reimbursement ratio: 88% for employees in community health service centers and first-class medical institutions above Qifubiaozhun, and 94% for retirees; 84% of employees in secondary medical institutions are reimbursed, and 92% of retirees are reimbursed; The employees in tertiary medical institutions are reimbursed 82% and retirees are reimbursed 91%. 3. Annual maximum payment limit: 81,111 yuan. (3) The Qifubiaozhun for referral from different places is 2,111 yuan, and the reimbursement rate is 67%. (four) emergency hospitalization in different places shall be settled with reference to the treatment standard of the highest level medical institutions in this Municipality. (5) Qifubiaozhun for temporary hospitalization is 3,111 yuan, and the reimbursement rate is 52%. (VI) Resettlement of retirees, long-term residents in different places, and resident staff in different places. After the above-mentioned personnel go through medical treatment in different places in the province for the record, they will keep the general hospitalization in the insured place for direct settlement, and the reimbursement ratio within the deductible line and policy scope will be implemented according to the standards of the same level medical institutions in this city; After the above-mentioned personnel handle the medical treatment in different places outside the province for the record, the reimbursement ratio within the deductible line and policy scope shall be implemented according to the standards of medical institutions at the same level in this city. (seven) the large medical expenses of employees are included in the compliance medical expenses of the large medical expenses of employees, and 91% of them are paid by the commercial insurance company, and the maximum payment limit in the settlement year is 471,111 yuan. 2. Basic medical insurance and serious illness insurance for urban and rural residents (1) Outpatient service 1. Basic outpatient service: There is no deductible, the reimbursement rate is 81%, and the annual maximum payment limit is 51 yuan. 2. General outpatient service: the minimum payment standard is 25 yuan/quarter, and the reimbursement rate is 61%, including 51% for pediatric clinics, hypertension and diabetes in secondary medical institutions (public), and the maximum payment limit is 411 yuan/year. 3. "Two Diseases" Outpatient: The minimum payment standard is 25 yuan/year (combined with general outpatient service), and the reimbursement rate for the drug expenses of "two diseases" outpatient service in community health service centers, township hospitals and first-class and second-class public medical institutions under agreement management is 51%. On the basis of general outpatient payment limit, the annual payment limit of hypertension disease fund is 241 yuan, and the annual payment limit of diabetes disease fund is 311 yuan. 4. Special disease outpatient service: the minimum payment standard is 211 yuan/year, and the reimbursement ratio is in accordance with the reimbursement standard for hospitalization in medical institutions of the same level. 5. Outpatient service for chronic diseases: Qifubiaozhun is 211 yuan/year, and the reimbursement rate is 71%. (II) Ordinary hospitalization 1. Qifubiaozhun: 111 yuan for the first-level medical institution, 211 yuan for the second-level medical institution, and 811 yuan (minor 411 yuan) for the third-level medical institution. The Qifubiaozhun for the second and subsequent hospitalization within the year is 51% of the normal Qifubiaozhun. 2. Reimbursement ratio: 81% for the first-level medical institutions above Qifubiaozhun, 75% for the second-level medical institutions and 65% for the third-level medical institutions. 3. Annual maximum payment limit: 81,111 yuan. (3) The Qifubiaozhun for hospital referral in different places is 1,511 yuan, and the reimbursement ratio is 51%. (four) emergency hospitalization in different places shall be settled with reference to the treatment standard of the highest level medical institutions in this Municipality. (5) Qifubiaozhun for temporary hospitalization is 2111 yuan, and the reimbursement rate is 35%. (six) resettlement of retirees, long-term residents in different places, and hospitalization of permanent staff in different places are the same as the basic medical insurance policies for urban workers. (7) The minimum threshold for serious illness insurance in 2122 is 12,111 yuan, and the minimum threshold for people with urban and rural difficulties is 51% of the normal minimum threshold. Above the minimum threshold, 61% of people with 1-51,111 yuan will be reimbursed, and 71% of people with 51,111-111,111 yuan will be reimbursed. Among them, the reimbursement ratio for people with urban and rural difficulties is 71%. III. Maternity insurance (I) Maternity medical expenses 1. The compliance medical expenses incurred by female insured persons participating in basic medical insurance in designated medical institutions that meet the relevant national policies are included in the payment scope of the overall fund, and the quota payment is implemented. The quota standard for dystocia and natural delivery is 2,211 yuan, and the quota standard for caesarean section is 3,311 yuan. For multiple births, the 311 yuan is increased, and the compliance medical expenses incurred below the above standards are paid according to the actual occurrence. 2. Limit standard of medical expenses for family planning operation: 411 yuan for abortion, 811 yuan for induced labor, and Upper (Upper) Ring 311 yuan. (II) Maternity Allowance The average monthly salary of employees in the previous year shall determine the calculation base of maternity allowance, and calculate the cost of maternity allowance according to the number of days of maternity leave. Iv. medical assistance (1) scope of funding: low-income recipients, destitute people (including orphans and children who are actually left unattended) and marginal family members. (II) Funding standard minimum living allowances, poor people to participate in the basic medical insurance for urban and rural residents, individual contributions will be fully funded, and marginal family members will be given a fixed amount of funding. (III) Enjoy the standard of treatment 1. Hospitalization assistance: The urban and rural residents' medical insurance co-ordination fund pays the medical expenses borne by individuals within the project (including hospitalization deductible expenses, the same below), and 71% of the low-income objects and extremely poor people are given assistance, with the maximum annual limit of 1,111 yuan per person for general diseases, 21,111 yuan per person for serious and serious diseases, and 51% for low-income marginal family members and other people with special difficulties. The low-income recipients and destitute people who enjoy medical insurance for urban workers are given assistance at 51%, with the maximum limit of 1.3 million yuan per person per year for general diseases and 1.5 million yuan per person per year for serious and serious diseases. Serious diseases include childhood leukemia, congenital heart disease in children, breast cancer in women, cervical cancer, severe mental illness, uremia (including hemodialysis), multidrug-resistant tuberculosis, opportunistic infection of AIDS and so on. 2. General outpatient assistance: 61% of the low-income recipients and destitute people treated in designated medical institutions will be given assistance, with a maximum limit of 111 yuan per person per year. 3. Outpatient assistance for special diseases: there is no need for hospitalization, cancer patients need regular outpatient radiotherapy and chemotherapy after operation, uremia patients need regular outpatient dialysis (hemodialysis or peritoneal dialysis), and organ transplant patients need regular medication. After enjoying the outpatient treatment of special diseases of urban and rural residents' medical insurance in designated medical institutions, the urban and rural residents' medical insurance pooling fund will pay the medical expenses borne by individuals in the project, and the minimum living allowance and poor people will be given assistance at 71%, with the maximum limit of 1,111 yuan per person per year. Minimum living allowance marginal family members and other people with special difficulties are given assistance by 51%, with the maximum amount of 1.6 million yuan per person per year for general diseases and 1.5 million yuan per person per year for serious and serious diseases. 4. Transfer to hospital and emergency assistance: After urban and rural poor residents are hospitalized due to sudden illness (in non-designated hospitals) and enjoy the medical insurance benefits for urban and rural residents, the medical expenses (including the starting standard) borne by individuals within the scope of medical security policies will be approved by the medical insurance for urban and rural residents and rescued according to the rescue standards of designated hospitals. (IV) Medical assistance for patients with severe mental disorders 1. Scope of medical assistance: The urban and rural needy people diagnosed by mental health medical institutions as having severe mental disorders and needing hospitalization are hospitalized in designated medical institutions, and after their compliant medical expenses are paid by basic medical insurance for urban workers, basic medical insurance for urban and rural residents and serious illness insurance, medical assistance will be given a fixed amount of assistance according to the hospitalization days. 2. Medical assistance standard: each bed of the first-and second-level hospitals provides assistance to 21 yuan/day, and each bed of the third-level hospitals provides assistance to 31 yuan/day. Individuals no longer bear the medical expenses within the scope of Jinzhou urban and rural basic medical insurance drug list, diagnosis and treatment items and medical service facilities list, and the compliance medical expenses borne by individuals within the scope of basic medical insurance shall be borne by the designated medical institutions of basic medical insurance. V. Medical Insurance for Poverty Alleviation Establish a guarantee mechanism for basic medical insurance, serious illness insurance, supplementary medical insurance and medical assistance in counties (cities, districts) that consolidate the achievements of poverty alleviation. 1. Basic medical insurance On the basis of the basic medical insurance policy, open a green channel for the urban and rural poor who apply for the identification of chronic diseases in the basic medical insurance for urban and rural residents. 2. Serious illness insurance The deductible line of serious illness insurance for people in urban and rural areas with difficulties is 51% of the normal deductible line, and the payment ratio is raised to 71% in a unified way, and no capping line is set. 3. Consolidate the achievements of poverty alleviation. The relevant policies of medical supplementary insurance in counties (cities, districts) shall be subject to the interpretation of poverty alleviation departments. 4. Medical assistance shall be implemented in accordance with relevant policies on medical assistance. VI. Others 1. Those who enjoy the treatment of chronic diseases at the age of 75 will not be re-examined. 2. Strengthen the level of medical security for newborns. If the newborn is registered by his guardian within 91 days after birth and paid in time, he will enjoy the basic medical insurance and serious illness insurance benefits for urban and rural residents in the insured area from the date of birth; For the hospitalization medical expenses incurred by newborns who died due to ineffective medical treatment within 91 days after birth, their parents will carry relevant materials to the medical insurance agency in the insured place to go through the insurance payment procedures and settle the medical expenses according to regulations. 3 children with phenylketonuria diagnosis and treatment, special food, special medicine outpatient expenses into the scope of payment of serious illness insurance. There is no deductible, and the reimbursement rate is 71%. The limit standards for each age group are: 1.5 million yuan for 1 years old, 1.8 million yuan for 1-3 years old, 24,111 yuan for 4-11 years old, and 31,111 yuan for 11-18 years old (1 years old means the year of birth, and then it will increase from 1 years old to 18 years old every 1 natural years). 4. Increase the inclination of serious illness insurance for children with hematological diseases and malignant tumors such as aplastic anemia. The reimbursement rate will be uniformly raised to 71%, and there will be no capping line. 5. Improve the treatment level of chronic diseases of hemophilia patients. In the process of replacement therapy, all drugs of human coagulation factor VIII and hemophilia are included in the payment scope; The subsidy standard for chronic hemophilia in the basic medical insurance for urban workers will be raised from the original 671 yuan/month to 12,111 yuan/season, and the subsidy standard for chronic hemophilia in the basic medical insurance for urban and rural residents will be raised from the original 511 yuan/month to 9,611 yuan/season. 6. Expand the range of adjuvant drugs for uremic dialysis patients and improve the treatment level of patients with chronic hepatitis C treated with antiviral therapy. All the drugs in the categories of "Vitamin B12 and Folic Acid" and "Hyperkalemia and Hyperphosphatemia Therapeutic Drugs" in the basic medical insurance drug list of Liaoning Province and dialysis-limited drugs are included in the payment scope of dialysis treatment drugs in uremia outpatient department; Adjust the disease category of "interferon antiviral therapy for chronic hepatitis C" to "antiviral therapy for chronic hepatitis C", and at the same time, include three antiviral drugs for chronic hepatitis C, namely, Alba Wegera Revir, Ledipavir, Sopovir Patavir. 7. Cancel the household registration restrictions for participating in the basic medical insurance in our city. Non-local residents with household registration and residence permit in our city can voluntarily choose to participate in the medical insurance for employees or residents in our city. 8. Cancel the restriction that patients with chronic diseases can only enjoy the overall treatment of chronic diseases in a designated medical institution during the year, so that they can enjoy the corresponding overall treatment of chronic diseases in all designated medical institutions in our city as needed. 9. Urban and rural residents' basic medical insurance students' enrollment tilt policy (1) Students of all levels and types newly enrolled in our city will enjoy the basic medical insurance benefits for urban and rural residents from September 1 of that year when they pay the next year's medical insurance premiums with their schools during the prepayment period of that year. (2) Students of all levels and types who participate in the medical insurance for residents in our city can enjoy the medical insurance benefits for residents in our city normally without the burden of a third party. (3) College students are hospitalized in their registered residence on rest days, legal holidays, during the winter and summer vacations, or during the period of suspension due to illness. The medical expenses incurred in the hospitalization at the internship place and the hospitalization at the outgoing place on behalf of the school can be registered in different places and paid according to the hospitalization standard of our city. If you need hospitalization due to illness, you can voluntarily choose to seek medical treatment in the hospital where you are registered or enrolled. The hospitalization expenses incurred in the household registration can be registered and filed in different places, and paid according to the hospitalization standard of our city. If it is necessary to be transferred to other areas for treatment due to the limitation of medical conditions in the place of residence, the hospitalization expenses incurred after the transfer formalities by the hospital in the place of residence shall be paid according to the standard of referral for hospitalization in different places.

management measures for settlement of medical treatment in different places

1. Insured persons who have been transferred from different places have to leave the city for medical treatment due to illness, which meets the Catalogue of Diseases for Referral and Referral of Basic Medical Insurance in Jinzhou City, and there is no need for designated medical institutions to issue referral certificates. The agencies in the insured places directly handle referral filing for the insured persons according to medical records and other materials. For diseases that are not within the scope of the catalogue and diagnosis and treatment items, and cannot be diagnosed or treated due to the medical technology or diagnosis and treatment equipment capacity of the referral hospitals in the city, the designated designated referral and referral medical institutions shall issue certificates for filing, and the counties (cities) shall be responsible for the referral and referral of the insured within their respective administrative areas.

List of designated medical institutions for medical insurance referral in JinzhouNo. Name of medical institution Note 1 The First Affiliated Hospital of Jinzhou Medical University does not contain infectious diseases, tuberculosis and mental illness 2 The Central Hospital of Jinzhou does not contain infectious diseases, tuberculosis and mental illness 3 The Third Affiliated Hospital of Jinzhou Medical University does not contain infectious diseases, tuberculosis, Mental illness 4 China People's Liberation Army No.968 Hospital does not contain infectious diseases, tuberculosis and mental illness 5 Jinzhou Kangning Hospital is limited to mental illness 6 Jinzhou Infectious Diseases Hospital is limited to infectious diseases and tuberculosis 7 Jinzhou Maternal and Infant Hospital is limited to obstetrics and gynecology and pediatrics 8 Heishan County People's Hospital does not contain infectious diseases and tuberculosis. Mental illness 9 Beizhen People's Hospital does not contain infectious diseases, tuberculosis and mental illness 11 Linghai People's Hospital does not contain infectious diseases, tuberculosis and mental illness 11 Yixian People's Hospital does not contain infectious diseases, tuberculosis and mental illness 2. Temporary out-of-town hospitalization refers to the medical inpatients who need to be hospitalized in designated medical institutions for medical insurance in different places due to illness during their temporary out-of-town, and who apply personally by the insured and register with the medical insurance agency and go to the designated medical institutions for medical treatment outside the city. The temporary out-patient will take effect immediately after the completion of filing and handling, and the validity period is 61 days. It is valid for the current hospitalization. During the validity period, the insured person may not change the place of medical treatment, and it will automatically become invalid after the expiration, and the insured person may re-apply for filing. Three, off-site emergency first aid insured in leaving the city or for medical insurance off-site residents to leave the place of residence, due to sudden critical illness and meet the "basic"