Reimbursement standard of medical insurance for employees in Wuhan

Want to know more about Wuhan employees' medical insurance payment and treatment reimbursement standards? Come and have a look with me.

Payment and treatment reimbursement standard of medical insurance for employees in Wuhan

First, how to apply for insurance registration and payment

Units to participate in the basic medical insurance for employees, fill in the "social insurance registration form", and produce relevant documents and materials to the social security office in their respective jurisdictions for insurance registration; Flexible employment personnel to participate in the basic medical insurance, should hold my account, ID card, urban basic old-age insurance certificate and other relevant information, to the social insurance agency in the jurisdiction where the residence is located to go through the registration formalities.

Second, the medical insurance treatment period

After the employer and its employees pay the basic medical insurance premium of 1 month according to the regulations, their employees and retirees begin to enjoy the basic medical insurance benefits; Flexible employees enjoy basic medical insurance benefits from the seventh month after paying the basic medical insurance premium for six months.

3. What are the ways to seek medical treatment?

Medical insurance for employees includes general outpatient service, outpatient treatment for some serious (chronic) diseases and hospitalization.

Four, the composition and use of personal accounts

Personal account of basic medical insurance is an insurance account established in the name of the insured, which is used and managed by individuals in accordance with the relevant provisions of basic medical insurance. Personal account shall be managed by ic card, and cash shall not be withdrawn. The funds and interest in personal accounts are owned by individuals. After all units and individuals pay medical insurance premiums in full and on time, their personal accounts will be included in the following proportions: employees under 35 years old, employees aged 36 to 45 years old, and employees aged 46 (including flexible employees) will be included in the payment base, and retirees under 70 years old and over 765,438+0 years old will be paid according to their average monthly retirement fee in the previous year (if the retirement fee is lower than 80% of the average monthly salary of employees in the previous year, it will be

Personal account can be used to pay the expenses paid by the insured person (excluding personal expenses) in the medical expenses such as purchasing medicine at designated retail pharmacies, treating some serious (chronic) diseases in outpatient clinics of designated hospitals, outpatient rescue and hospitalization.

Five, outpatient intensive care

Insured employees with social security cards who treat severe (chronic) diseases in designated hospitals meet the medical expenses paid by the medical insurance fund for employees. The outpatient co-ordination fund for severe (on-the-job) diseases pays 80% (on-the-job) and 85% (retired), and the outpatient co-ordination fund for chronic diseases pays 60% (on-the-job) and 65% (retired). Some serious outpatient diseases (malignant tumor, renal dialysis, anti-rejection therapy after renal transplantation and anti-rejection therapy after liver transplantation) are paid by the fund for 87% (in-service) and 90% (retired).

For the use of Class B drugs or medical treatment items within the scope of medical insurance, the individual pays 10% first, and the balance is paid by the medical insurance fund according to the above proportion.

Six, hospitalization Qifubiaozhun

Qifubiaozhun means that when the insured person is hospitalized, according to the regulations, the individual must pay a certain amount of medical expenses first. Medical expenses exceeding Qifubiaozhun shall be paid by medical insurance funds and individuals according to the prescribed proportion. Qifubiaozhun for hospitalization is:

(1) 200 yuan, a community health service center.

(2) 400 yuan, a first-class hospital;

(2) 600 yuan, a secondary medical institution;

(3) 800 yuan, a tertiary medical institution.

In an insurance year, if the insured is hospitalized twice or more, the hospitalization Qifubiaozhun will be halved (except for community health service centers). Persons with disabilities who enjoy subsistence allowances are exempted from hospitalization Qifubiaozhun fees.

Seven. be hospitalized

The expenses above the basic medical insurance Qifubiaozhun and within the annual payment limit (240,000) shall be paid by the medical insurance fund in different proportions according to the hospital level and cost segment.

(a) the annual accumulated basic medical insurance expenses are less than 654.38 million+,and the proportion of medical insurance funds is:

1, 92% (on-the-job) retired from community and first-class hospital funds;

2, secondary hospital fund to pay 89% (on-the-job retirement);

3, tertiary hospital fund to pay 86% (in-service retirement);

4, enjoy the treatment of the disabled, the overall fund payment ratio increased by 2%.

(2) The accumulated annual basic medical insurance cost is10-200,000 yuan, and the medical insurance fund pays 94%.

(three) the annual cumulative basic medical insurance costs in 200-240 thousand, the medical insurance fund to pay 98%.

(four) the use of class B drugs or treatment projects belonging to medical insurance coverage, the individual pays 10% first, and the balance is paid by the medical insurance fund according to the above ratio.

Eight, large medical insurance benefits

In an insurance year, after the expenses of the insured in outpatient serious illness, outpatient rescue and hospitalization in medical insurance coverage exceed the basic medical insurance payment limit (240,000), they will be paid by the large medical insurance fund, and the payment ratio is 98%. For the use of Class B drugs or medical treatment items within the scope of medical insurance, the individual pays 10% first, and the balance is paid by the large medical insurance according to the above proportion.

The maximum payment limit for large medical insurance is 300,000 yuan.

Nine, the use of class B drugs and part of the diagnosis and treatment project personal payment ratio

When the insured uses Class B drugs or medical treatment items belonging to medical insurance coverage in outpatient treatment, outpatient rescue and hospitalization of some serious (chronic) diseases, the individual pays 10% first, and the balance is paid by the medical insurance fund in proportion.

Ten, the use of internal materials, replacement of artificial organs and blood products personal payment ratio.

Insured outpatient treatment of serious diseases and hospitalization, the use of basic medical insurance coverage appropriate relaxation of the project by the individual to pay 30%, the use of domestic alternative materials to pay 35%, the use of imported alternative materials to pay 50%.

Eleven, an insurance year, the basic medical insurance fund and the maximum payment limit of large medical insurance.

In an insurance year, the insured person's outpatient treatment of some serious diseases, outpatient rescue and hospitalization accumulated medical expenses in line with the policy, and the annual basic medical insurance limit is 240 thousand yuan. For expenses exceeding the basic medical insurance limit, the maximum annual payment limit for large medical insurance is 300,000 yuan.

Twelve, non designated hospitals emergency rescue declaration

Within five working days after the insured is hospitalized in a non-designated hospital for emergency rescue, the individual or unit shall write a written application for medical treatment, affix the official seal, and report to the window on the second floor of the municipal medical insurance center with outpatient emergency medical records, relevant inspection reports (mainly explaining the severity of the disease), 120 emergency invoices and other materials. City medical center should complete the audit within 3 working days after receiving the application materials, and notify the applicant by SMS (telephone).

Thirteen, for referral procedures.

Insured persons can be transferred to designated hospitals for treatment, and can be directly transferred to medical institutions for hospitalization after the online transfer procedures from the transferred hospitals; Transferred to the designated referral hospital for hospitalization, the three-level comprehensive designated hospitals or specialist designated hospitals put forward referral opinions, and the municipal medical insurance center completed the online audit within 2 working days, and the approved hospital directly went to the medical institution for hospitalization.

Fourteen How to reimburse the expenses of non-designated hospitals?

If the insured person is referred to a non-designated hospital for hospitalization examination and approval, he/she shall fill in the Wuhan Social Insurance Medical Expense Declaration Form within 1 month after discharge and bring the expense receipt (original), expense summary list (original), medical record home page, discharge summary, outpatient (emergency) medical record and inspection report, pathological examination report, operation record (including anesthesia record), long-term doctor's advice, temporary doctor's advice, and other places.

At the same time, the insured who participates in basic medical insurance and commercial medical insurance must first reimburse the basic medical expenses. I copied all the hospitalization materials, the municipal medical insurance center provided the medical expense settlement list, and then I went to the commercial insurance company for commercial insurance reimbursement.

Fifteen, termination of medical insurance personnel personal account balance how to deal with?

The insured person of basic medical insurance may apply for a one-time payment of the balance of his personal account because he has settled abroad, died or transferred out of this city and his personal account cannot be transferred.

In line with the above conditions, within two months after the termination of medical insurance procedures, the insured unit (I or the legal heir insured flexible employees) shall bring the following information to the social security agency in the jurisdiction to apply.

1, fill in the complete Declaration Form for One-time Payment of Personal Account Balance of Medical Insurance;

2, the relationship between the payee and the termination of medical insurance personnel certification materials (insured units and social security agencies in the jurisdiction should verify the identity of the heir (payee), the heir (payee) and the termination of medical insurance personnel;

3, the termination of medical insurance personnel "death certificate" (copy) or proof of going abroad to settle down, out of the city;

4. A copy of the payee's bank account information (the payee needs to open an account in Hankou Bank); If you use a social security card financial account (Hankou Bank), you must open a card at the bank counter to activate the account.

Sixteen, how to handle the relocation?

Retirees who are resettled in different places can go through the formalities of medical insurance resettlement in different places. Applicants need to apply in writing, fill in the Registration Form for Medical Treatment of Urban Workers in Different Places in Wuhan, and go to the social security agencies in their respective jurisdictions for handling. Copy of transfer certificate or residence permit or temporary residence permit 1 copy, 2 copies of ID card and 2 copies of postal savings bank card or passbook shall be provided when handling.

XVII. Treatment of relocated personnel

Personal accounts for the placement of retirees should be entrusted to the bank for payment or issued by the unit.

The medical expenses for emergency outpatient rescue, hospitalization and partial outpatient treatment of severe (chronic) diseases in the designated hospitals in the resettlement place shall be paid in advance by myself, and within one month after the end of the treatment, the unit to which I belong shall submit my copy of medical records, detailed list of medical expenses and other expense vouchers to the medical insurance agencies in the jurisdiction for review, and the municipal medical insurance center shall allocate them to the account within 15 working days from the date of receiving the complete reimbursement materials submitted by the social security department.

I'm here to sort out the information about these problems, hoping to help you. The laws in China are gradually improving, and we look forward to helping more people.