Anhui Province Employee Medical Insurance Outpatient Reimbursement Policy

Outpatient reimbursement policy. Within a calendar year, the ordinary outpatient expenses incurred by insured employees within the scope of the policy within the overall planning area are guaranteed in accordance with regulations.

The unit payment will no longer be transferred to the personal account. The detailed rules make it clear that the personal account counting method is reformed. The personal accounts of employees in the province's employee medical insurance are counted from the basic medical insurance premiums paid by individuals. The counting standard is in principle controlled at 2 of the individual's insurance payment base; the personal accounts of retirees are in principle The overall fund will be allocated according to a fixed amount, and the allocated amount will be gradually adjusted to about 2% of the average level of basic pensions in the year when the overall planning area implements reforms in accordance with these measures. All basic medical insurance premiums paid by the unit shall be included in the overall fund.

1. Minimum payment standard: The minimum payment standard for ordinary outpatient expenses under employee medical insurance is 800 yuan.

2. Reimbursement ratio: First-level designated medical institutions (including unclassified township hospitals and community health service centers) pay a payment ratio of 60%, second-level designated medical institutions pay a payment ratio of 55%, and third-level designated medical institutions pay a payment ratio of 55%. Scale 50.

3. Preferential policy: The reimbursement ratio for retired employees is 5 percentage points higher than that for active employees by hospital level.

4. Annual reimbursement limit: The overall fund payment limit for employees’ general outpatient expenses within a calendar year is 2,000 yuan. Payment limits are not carried forward or accumulated to the next year.

5. Benefit algorithm: General outpatient fee payment amount = (general outpatient fee within the scope of the policy - individual prepayment - minimum payment standard) × corresponding level of medical institution payment ratio.

6. Situations that are not reimbursed: outpatient expenses incurred when employees stopped paying or failed to pay basic medical insurance premiums as required; outpatient expenses incurred while employees were hospitalized; inpatient and outpatient chronic expenses that have been included in employee medical insurance Outpatient expenses within the scope of payment for special diseases, etc.; outpatient expenses remaining out of pocket after being paid according to employee medical insurance inpatient and outpatient chronic disease protection policies; other medical expenses that do not comply with employee medical insurance policies. The financial security benefits of employee medical insurance outpatient clinics are only available to the employee himself and cannot be used among family members.

Legal basis:

"The People's Government of Anhui Province on Issuing the Implementation Measures for the Establishment and Improvement of the Outpatient Financial Security Mechanism of Basic Medical Insurance for Employees in Anhui Province" "The Establishment and Improvement of Basic Medical Insurance for Employees in Anhui Province" Notice on the Implementation Rules of the Financial Security Mechanism for Insurance Outpatient Clinics"

Article 1 is to further improve the employee basic medical insurance (hereinafter referred to as employee medical insurance) system with mutual assistance, financial support and responsibility. To better solve the problem of outpatient security for employees covered by employee medical insurance and effectively reduce the burden of medical expenses, according to the "Notice of the General Office of the People's Government of Anhui Province on Issuing the Implementation Measures for the Establishment and Improvement of the Outpatient Economic Security Mechanism of Basic Medical Insurance for Employees in Anhui Province" ( According to the requirements of Anhui Government Office Secretary [2021] No. 112), these detailed rules are formulated based on the actual conditions of our province.

Article 2: These measures apply to the management of medical expenses incurred by Anhui Provincial employee medical insurance participants (including provincial employee medical insurance participants, hereinafter referred to as employees) during general outpatient treatment.

Article 3: The medical security administrative department is responsible for the policy formulation, organization, implementation, supervision and management of employee medical insurance outpatient security. The medical security agency is responsible for fund raising, management, benefit review, and payment. The financial department shall, in accordance with the social insurance fund financial system, do a good job in the fund's special financial account management, financial supervision and other related work.

Article 4 For employees who participate in employee medical insurance with the employer, and for employees who are flexibly employed and participate in employee medical insurance through a combination of overall funds and personal accounts, the personal account shall be included in the basic medical insurance premium paid by the individual. , the inclusion standard is 2 of the individual’s insured payment base. Those who participate in employee medical insurance through a single pooled fund model do not need to set up personal accounts.

All employee medical premiums paid by the unit shall be included in the overall fund. For those with flexible employment who participate in employee medical insurance through a combination of a unified fund and individual accounts, all personal contributions will be included in the overall fund except for the personal account; for those who participate in employee medical insurance through a separate pooled model, all personal payments will be included in the overall plan fund.

Article 5: For retired employees who participate in employee medical insurance through the combination of overall funds and personal accounts, their personal accounts will be transferred from the overall fund according to a fixed amount. Starting from July 1, 2022, 70 yuan per month will be credited to the personal account, and will be adjusted in accordance with national regulations in the future.

Article 6: In case of any of the following circumstances, the personal account shall be stopped from being debited:

(1) Current employees stop paying or fail to pay employee medical insurance premiums as required;

(2) Death of an employee (including active and retired).