Tongcheng medical insurance reimbursement for medical treatment in different places

1. General clinic

Insured employees themselves can enjoy the general outpatient security treatment within the policy scope of Anqing City (currently designated medical institutions above the first level); Those who have successfully gone through the filing procedures of "resettling retirees in different places", "long-term residents in different places" and "permanent residents in different places" can enjoy the general outpatient security treatment at the filing place (currently designated medical institutions above the first level). The minimum payment standard is 800 yuan, and the annual payment limit is 2000 yuan. On-the-job employees pay 60% in the first-class designated medical institutions, 55% in the second-class designated medical institutions and 50% in the third-class designated medical institutions. The contribution rate of retired employees is 5% higher than that of on-the-job employees.

2. Chronic disease clinic

(1) The outpatient expenses for chronic diseases in the designated medical institutions for chronic diseases in Anqing City can be declared immediately with the ID card or social security card. (2) Outpatient expenses of chronic diseases occurred in designated medical institutions for chronic diseases outside Anqing City, can be declared immediately by social security card or medical insurance electronic certificate after handling medical treatment in different places. (3) In principle, the outpatient expenses of chronic diseases treated in designated medical institutions outside the province can be settled directly in medical institutions with social security cards or medical insurance electronic certificate, but in actual operation, some medical institutions have not opened the outpatient direct settlement business, so the insured employees need to consult whether the medical insurance office of the medical institution has opened the outpatient direct settlement business. (4) Outpatient expenses for chronic diseases that have not been settled immediately outside Anqing are reimbursed at the medical insurance window on the first floor of the government service center. When reimbursing, it is necessary to provide a copy of the social security card of the insured employees, drugs (or special drugs) necessary for the treatment of chronic diseases, invoices for examination and treatment items (attached list) (list of drugs for chronic diseases and diagnosis and treatment items uniformly stipulated by provinces and cities), outpatient medical records and other materials.

Special reminder: The drugs necessary for patients to treat chronic diseases, the compliance medical expenses of examination and treatment items (the list of drugs and treatment items for chronic diseases stipulated by provinces and cities) are included in the scope of reimbursement, and other invoices, such as medical inspection centers, medical imaging centers, commercial retail pharmacies (except dual-channel drugs), village clinics, handwritten invoices, expired invoices and other medical insurance reimbursed invoices, are not compensated.

Second, hospitalization reimbursement

1. Report to the hospital for hospitalization immediately.

In Anqing City, patients are hospitalized in designated medical institutions in various counties. Patients with social security cards or medical insurance electronic certificate go through the immediate settlement procedures at the hospital settlement window, and there is no need to go to the medical insurance window for reimbursement.

After hospitalization in Anqing city and designated medical institutions outside Anqing city, after referral registration, you can apply for reimbursement directly at the window of designated hospitals nationwide with your social security card.

In addition to emergency, the insured person who is hospitalized in a non-designated medical insurance hospital does not enjoy medical insurance reimbursement.

Special reminder: Pay attention to the official account of "Anqing Medical Insurance" WeChat or download the know-it-all APP, and enter the "Tongcheng Medical Insurance Online Service Hall" for online referral and filing. If you are seeking medical treatment outside the province, you can file it through the national medical insurance service platform.

2. Sporadic reimbursement (patients who are not reimbursed immediately due to special reasons such as network)

(1) General hospitalization. Provide a copy of the insured patient's social security card, hospitalization invoice, expense list, original discharge summary (all need to be stamped) and other materials, and submit the reimbursement to the medical insurance window of the government service center (or to the town and street medical insurance office where the account is located), and the reimbursement will be directly remitted to the provided social security card bank account.

(2) Accidental injury hospitalization. In principle, if you are hospitalized in a designated medical institution in Anqing City, you can go through the formalities related to accidental injury in the hospital and report it immediately in the hospital. At present, it can't be reported directly outside Anqing city. If the report is not completed immediately, a copy of the social security card of the insured patient and the original stamped hospitalization invoice shall be provided (if the original hospitalization invoice cannot be provided due to the advance payment of third-party institutions such as commercial insurance, A copy of the hospitalization invoice and a statement stamped by a third party are required), the original stamped hospitalization expense list, the copy of the medical record (or admission record), the original stamped discharge summary, the ID card and copy of the insured (if there is an agent, the ID card and copy of the agent should be provided), and the Anqing Medical Insurance Accidental Injury Questionnaire (agent version) (stamped after investigation and verification by the village (neighborhood Committee) and the town (street)), Accidental injury If the insured bears all or part of the responsibility and applies for payment of medical insurance benefits for accidental injury, it is necessary to provide the original letter of responsibility confirmation from the traffic safety management department and the judgment and ruling of the people's court; If it is determined that the third-party responsible person fails to pay or cannot pay in full, it shall provide relevant materials issued by the judicial organ. Reimbursement time: If the insured has an accidental injury and fails to apply for treatment and payment within 1 year from the date of the accident, the medical insurance agency will no longer accept it. If the application is postponed due to force majeure such as case litigation, unless the relevant department can provide proof.

Special reminder:

1 The maximum payment limit of employee's basic medical insurance is 300,000 yuan/year, of which the overall fund limit is 654.38+10,000 yuan/year, and the large medical assistance fund limit is 200,000 yuan/year;

2. Guaranteed reimbursement for compliance medical expenses incurred in general hospitalization: 45% for medical institutions in the province and 40% for medical institutions outside the province;

Except for resettlement in different places, 2000 yuan was hospitalized outside Anqing in the first year, and 200 yuan was hospitalized twice or more in the year, which was lower than the first time.

Insured employees should deduct deductible for each hospitalization. Since May 1 day, 2022, patients with leukemia, malignant tumor (radiotherapy and chemotherapy, targeted therapy, immunotherapy), cerebral palsy rehabilitation, chronic renal failure (uremia) and mental disorder (severe illness) really need to be hospitalized for many times in the same hospital for different courses of treatment, only for the first time in the insured year.

Third, critical illness insurance.

The treatment standard of serious illness insurance for urban workers is: the part paid by individuals within the scope of serious illness insurance policy (the total amount of expenses within the scope of policy-the payment amount of basic medical insurance-the total amount of various deductible lines), minus the part of the deductible line of serious illness insurance of more than 20,000 yuan, 0 to 20,000 yuan (inclusive), and 50% will be reimbursed; 2 to 65438+ ten thousand yuan (inclusive), 60% reimbursement; 10 to 200,000 yuan (inclusive), with 70% reimbursement; More than 200 thousand yuan, according to 80% reimbursement; Employees' critical illness insurance is not capped. Note: For those who meet the requirements of serious illness insurance, one-stop settlement and payment can be made in the system.

Fourth, medical assistance.

Medical assistance is mainly aimed at special groups, such as poor people, low-income people, people returning to poverty, and people being monitored. The compliance medical expenses incurred by the designated medical institutions in Tongcheng City or referred to other places for medical treatment according to regulations are paid by basic medical insurance and serious illness insurance. , according to the policies and regulations to help. At the same time, for the above-mentioned four categories of people who are referred for medical treatment in the province, after being paid by the three guarantees system, individuals who pay more than 1 10,000 yuan within the policy scope can also enjoy secondary assistance. Stabilize the poor population and ordinary insured workers, and seriously ill patients whose total family income is lower than the standard of rural low-income families and meet the conditions for property verification of low-income families within one year can enjoy medical assistance according to their applications.

V. Long-term insurance

Long-term care insurance for urban workers (hereinafter referred to as long-term care insurance) is aimed at those who participate in the basic medical insurance for urban workers in Tongcheng. Those who participate in the basic medical insurance for urban workers shall participate in the long-term care insurance for urban workers simultaneously. Long-term care insurance covers the insured who is in a state of severe (moderate) disability for a long time. (1) Bid treatment. I or my agent carry the applicant's ID card, valid diagnosis certificate and complete medical records. Apply to the service window of the agency, fill in the "Anqing Mayor Insurance Treatment Qualification Application Form" and sign it for confirmation. You can also apply through online channels such as Anqing Medical Insurance WeChat official account, Know-it-all APP and official website of Anqing Medical Insurance Bureau. (2) Welfare payment standard. If the disability assessment level of the assessed object reaches the prescribed treatment enjoyment level, it will start to enjoy long-term insurance benefits from the day after the conclusion of disability assessment is publicized. According to the different grades of the disabled, the types of treatment are mainly divided into four categories: first, nursing in medical institutions, severe 60 yuan/day (moderate 40 yuan/day); Second, nursing in old-age care institutions, severe 50 yuan/day (moderate 30 yuan/day); Third, living allowance for the aged at home, 15 yuan/day (moderate 10 yuan/day); Fourth, home care service. On the basis of on-site subsidies, domestic companies provide nursing services for 30 on-site nursing projects. Long-term insurance fund subsidies 70%, the maximum monthly severe cases do not exceed 500 yuan (the maximum monthly moderate cases do not exceed 300 yuan).

(three) in any of the following circumstances, the application for severe disability assessment will not be accepted. 1. Failing to pay long-term care insurance premium or medical insurance premium as required; 2 for various reasons to stop enjoying the basic medical insurance benefits; 3. The patient is hospitalized or his condition is unstable; 4. Less than 6 months from the date of the last appraisal conclusion. Special reminder: 1. The insured who needs long-term care can apply for long-term care insurance only after his condition is stable for not less than 6 months, and it must be assessed according to the degree of fault; 2. Long-term care insurance benefits enjoy the same starting and ending time as medical insurance; 3. Enjoy long-term care insurance benefits must reach the degree of severe (moderate) disability.

Six, chronic disease declaration and identification

To declare chronic diseases online through Tongcheng Medical Insurance Online Service Hall, you need to upload the following materials: 1. The patient's second-generation resident ID card or social security card. 2. Original outpatient medical records, inspection reports and disease diagnosis certificates issued by secondary and above medical institutions within one year (inpatients provide discharge summary, disease diagnosis certificates of secondary and above medical institutions and related medical records).

Special reminder: inform the applicant of the results of chronic diseases by SMS (please fill in the applicant's mobile phone number accurately) or inquire about the results of chronic diseases online through the service platform of Anhui Medical Insurance Company.

Chronic diseases:

Common chronic diseases (50 groups): hypertension, hypertension with complications, cardiac insufficiency, coronary heart disease, stroke, chronic obstructive pulmonary disease, diabetes, insulin therapy for diabetes, hyperthyroidism, hypothyroidism, epilepsy, rheumatoid arthritis, myasthenia gravis, tuberculosis, idiopathic thrombocytopenic purpura, systemic sclerosis, advanced schistosomiasis, vitiligo, AIDS, Behcet's disease and rigidity. Amyotrophic lateral sclerosis, bronchial asthma, polymyositis, dermatomyositis, Sjogren's syndrome, polyarteritis nodosa, hemophilia, outpatient treatment of malignant tumor, autoimmune liver disease, Alzheimer's disease (Alzheimer's disease), glaucoma, myeloproliferative diseases, congenital immunodeficiency, cerebral palsy, Pradeville syndrome, Parkinson's disease, Niemanpique's disease, growth hormone deficiency, ANCA-related vasculitis, etc. Moderate and severe psoriasis, chronic hepatitis B, chronic hepatitis C (non-1b type), chronic hepatitis C (1b type), drug-resistant tuberculosis, severe atopic dermatitis, nephrotic syndrome and chronic nephropathy.

Special chronic diseases (Group 22): heart valve replacement, stent implantation, coronary artery bypass grafting, hepatolenticular degeneration, mental disorder, multiple sclerosis, idiopathic pulmonary fibrosis, cirrhosis, systemic lupus erythematosus, myelodysplastic syndrome, acromegaly, macular eye disease, pulmonary hypertension, aplastic anemia, hemophilia, leukemia, malignant tumor (radiotherapy and chemotherapy, targeted therapy).

Seven, the relevant provisions of Tongcheng hospital referral.

In addition to resettlement in different places, if you fail to go through the referral procedures and go to Anqing municipal medical institutions for medical treatment, the reimbursement ratio (including the guarantee ratio) will be reduced by 5 percentage points; The reimbursement rate (including the guarantee rate) for medical treatment outside Anqing City decreased by 10 percentage point. Refer to the following announcement for the filing regulations.