One-year reimbursement limit for serious illness outpatient service in Qingdao

1. How does the Measures for Social Medical Insurance in Qingdao stipulate the implementation time and scope of application?

The Measures of Qingdao Municipality on Social Medical Insurance has been implemented since 20 15 10, and employees' medical insurance and residents' medical insurance participants have enjoyed medical insurance-related benefits according to the new policy since 20 15 10. These Measures are applicable to all insured persons in the six districts of Shinan, Shibei, Licang, Laoshan, Chengyang and Huangdao, and in Jimo, Jiaozhou, Pingdu and Laixi.

2. What is the annual maximum amount of social medical insurance for employees and social medical insurance for residents?

The annual maximum payment limits of basic medical insurance for employees and residents are 200,000 yuan and 6,543.8+0.8 million yuan respectively; After being reimbursed by the basic medical insurance, if the expenses borne by individuals within the overall scope are relatively large, they shall be reimbursed by the serious illness medical insurance according to the regulations, with the annual maximum payment limit of 600,000 yuan; Medical assistance for serious illness will be given to the large medical expenses and special drugs and materials expenses borne by individuals outside the overall planning scope, with the annual maximum assistance of more than 654.38+10,000 yuan. With the combination of the three treatments, the annual maximum guarantee amount of employees' medical insurance participants reaches more than 900,000 yuan, which is 654.38+10,000 yuan higher than the current one; The number of residents participating in medical insurance reached more than 880,000 yuan, which was 654.38+10,000 yuan higher than the original urban residents' medical insurance and 400,000 yuan higher than the original new rural cooperative medical system.

3. What is the minimum payment standard of social medical insurance in our city?

The qifubiaozhun for social medical insurance insured persons to treat serious illness in the first, second and third level hospitals is 200 yuan, 500 yuan and 800 yuan respectively. The first hospitalization will be paid in full, the second hospitalization will be paid in half, and the third and above hospitalization will be paid at 100 yuan. Insured outpatient treatment of serious illness, in a year to bear a Qifubiaozhun.

4. How is the hospitalization treatment for employees insured by medical insurance stipulated?

The proportion of medical expenses paid by the insured workers within the scope of overall planning above the Qifubiaozhun in the first, second and third-level designated medical institutions is less than 40,000 yuan, which is 90%, 88% and 86% before retirement and 95%, 94% and 93% after retirement. For those who have accumulated more than 40,000 yuan a year, the unified payment ratio is 95% before retirement and 97% after retirement.

5. How is the hospitalization treatment for residents participating in medical insurance stipulated?

For the medical expenses incurred by residents' medical insurance participants in the first, second and third-level designated medical institutions and above the Qifubiaozhun as a whole, the proportion of primary payment paid by adult residents is 85%, 80% and 70% respectively; The adult residents who pay the second grade are 80%, 70% and 55% respectively; Students and children are 90%, 85% and 80% respectively. Adult residents were hospitalized in the streets and town health centers (community health service centers) where the basic drug system was implemented, and the payment ratio increased by 5 percentage points.

6. Can I reimburse maternity medical expenses for participating in medical insurance?

In view of the fact that there is no maternity insurance system arrangement for flexible employees and residents' medical insurance participants at present, the medical expenses for hospitalization and childbirth that meet the family planning policy in designated medical care shall be paid by the basic medical insurance pooling fund according to regulations.

7. How is the outpatient treatment for serious illness of employees insured by medical insurance stipulated?

Medical insurance for employees insured in designated medical institutions Qifubiaozhun above the overall payment scope of outpatient medical expenses for serious illness, in the first, second and third designated medical institutions reimbursement ratio were 90%, 88%, 86%, more than 50% of the disease limit standard; 92% of the patients visited the designated medical institutions in the community, and 70% of them exceeded the disease limit standard.

8. How is the treatment of serious illness outpatient service for residents' medical insurance participants stipulated?

Residents' medical insurance participants are reimbursed 80%, 70% and 65% respectively in the first, second and third level designated medical institutions, 75%, 65% and 55% respectively in the second grade, and 90%, 85% and 80% respectively for students and children. The payment proportion of community designated medical institutions shall be implemented according to the first-class hospitals. The proportion of reimbursement for essential drugs for adult residents in designated medical institutions in the community increased by 10 percentage point. The part exceeding the disease limit standard will not be reimbursed.

Compared with the original system, there are mainly the following changes: First, the scope and quota standards of outpatient serious diseases are unified, the scope of diseases among rural residents is expanded to 53, and the payment standards and quotas are correspondingly improved, which generally benefits rural residents. Second, in order to encourage the use of essential drugs and reduce the burden on the insured, the proportion of reimbursement for the use of essential drugs by adult residents in designated medical institutions in the community will be increased by 10 percentage point, and at the same time, the treatment of serious illness by rural residents in outpatient clinics in township hospitals will not be reduced, and urban adult residents will also benefit generally.

9. What medical expenses can be included in the payment scope of medical insurance for serious illness?

After the hospitalization and outpatient medical expenses incurred by social medical insurance participants in designated medical institutions are paid by the basic medical insurance pooling fund according to regulations, the following expenses borne by individuals are included in the payment scope of the serious medical insurance fund: (1) Medical expenses that meet the overall payment scope and exceed the maximum payment limit of the basic medical insurance pooling fund; (2) Medical expenses that meet the scope of overall payment and are borne by individuals according to Qifubiaozhun and out-of-pocket ratio; (3) Medical expenses borne by individuals according to their own proportion before Class B drugs, medical service items and medical service facilities are included in the scope of overall payment.

10, how is the medical insurance treatment for critical illness stipulated?

Social medical insurance insured in designated medical institutions in the hospitalization and outpatient medical expenses for serious illness, after the payment of basic medical insurance, can be included in the scope of payment of serious illness medical insurance according to regulations:

(1) Over-limit subsidy. Medical expenses exceeding the maximum payment limit of the basic medical insurance pooling fund shall be subsidized by 90% for employees; 80% of first-year residents, 80% of students and children, and 70% of second-year residents. The maximum subsidy for one year is 400,000 yuan.

(2) Large subsidies. Within one year, the employee subsidy will be 75% for the part exceeding the Qifubiaozhun of medical insurance for serious illness (specific standards will be formulated and announced separately); 60% subsidy for residents, students and children; Residents' second-grade subsidy is 50%. Among the medical insurance participants, the deductible standard of medical insurance for uremia dialysis treatment and organ transplantation anti-rejection treatment participants is 3,000 yuan, and 75% of the employees above the deductible standard are subsidized; 70% subsidy for residents, students and children; The second-grade subsidy for residents is 60%. The maximum payment for a year is 200,000.

1 1. What medical expenses can be included in the scope of medical assistance for serious illness?

While enjoying the basic medical insurance benefits and serious illness medical insurance benefits, social medical insurance participants should include the following serious illness medical expenses incurred in the inpatient and outpatient departments of designated medical institutions into the payment scope of the serious illness medical assistance fund: (1) Medical expenses incurred by eligible insured persons using special drugs and materials; (2) Medical expenses necessary for treatment beyond the basic medical insurance drug list, medical service items and medical service facilities list; (3) Medical expenses necessary for treatment above the maximum expenses stipulated in the basic medical insurance drug list, medical service items and medical service facilities list.

12, how is the medical assistance for the seriously ill insured in social medical insurance stipulated?

Workers' medical insurance insured and residents' medical insurance insured shall implement unified medical assistance treatment for serious illness. The insured person's hospitalization and outpatient medical expenses for serious illness in designated medical institutions, on the basis of enjoying the basic medical insurance benefits and serious illness medical insurance benefits, can be included in the scope of payment of serious illness medical assistance fund according to regulations:

(a) medical expenses incurred by eligible insured persons using special drugs and materials, 70% assistance.

(two) the medical expenses necessary for the treatment outside the scope of overall planning, the annual cumulative part of more than 50 thousand yuan is 60%. Enjoy special care, subsistence allowances, subsistence allowances for the insured in marginal families, and there is no threshold for large-scale assistance. The maximum annual compensation for large-scale assistance is 654.38+10,000 yuan.

(three) eligible low-income family insured persons can also enjoy special medical assistance in accordance with the provisions of the civil affairs department.

13. After the overall planning of urban and rural areas, are the catalogues of medical treatment and drug purchase reimbursement consistent between employees and residents?

After the overall planning of urban and rural medical insurance, employees and residents will uniformly implement the three catalogues of medical insurance drugs, medical service items and medical service facilities. The scope of reimbursement for rural residents has been further expanded, and the number of reimbursement for drugs alone has expanded from more than 900 to more than 2,400.

14. Are there any special provisions for the medical insurance treatment of the only child?

Family planning policy is the basic national policy of our country. In order to better implement the family planning policy, the basic medical insurance fund will increase the emergency expenses for the only child's hospitalization, outpatient serious illness and accidental injury by 5 percentage points on the basis of the prescribed proportion of students and children.

15. What is the waiting period for social medical insurance for employees?

There is a waiting period for employees' social medical insurance. Those who meet the conditions for participating in social medical insurance for employees should pay the insurance premium in time within 3 months. Continuous payment for less than 6 months, only enjoy the basic medical insurance personal account treatment; After 6 months of continuous payment, employees enjoy social medical insurance benefits according to regulations. Employees who have been insured for more than three months shall be recalculated when they are insured again.

16. Who can exempt employees from the waiting period for medical insurance benefits?

Full-time fresh graduates of various schools who participated in the social medical insurance for employees in the year of employment, demobilized military cadres and demobilized veterans who participated in the social medical insurance for employees within one year after their transfer or demobilization, and other personnel who meet the policy requirements, shall enjoy the social medical insurance benefits for employees according to regulations from the next month of payment.

17. How to calculate the medical year of social medical insurance participants?

The medical year of social medical insurance participants is uniformly adjusted to be calculated according to the natural year, and the medical year of each participant is the same, that is, from 65438+ 10/to 65438+February 3 1.

18. What medical expenses are not paid by the basic medical insurance fund?

The medical expenses not paid by the basic medical insurance fund include the following categories: (1) expenses other than the "three catalogues"; (2) Expenses exceeding the maximum expense limit of basic medical insurance; (three) the expenses borne by the individual before the class B drugs and diagnosis and treatment projects in the "Three Catalogues" enter the overall planning; (four) the expenses borne by the individual according to the Qifubiaozhun; (five) after entering the scope of overall payment, the expenses shall be borne by themselves according to the grading ratio; (six) medical expenses that meet the overall payment standards and exceed the maximum payment limit of basic medical insurance. The expenses of (1) and (2) for hospitalization and outpatient treatment of serious illness of the insured person shall be included in the scope of medical assistance for serious illness according to regulations; (three), (four), (five) and (six) expenses, according to the provisions into the serious illness in medical insurance coverage.

19. What are the "three catalogues" of basic medical insurance?

After enrollment, not all medical expenses can be included in the scope of overall payment, but there is a basic norm in medication, diagnosis and treatment, service facilities and so on. That is, the basic medical insurance "drug list", "diagnosis and treatment project list" and "medical service facilities scope", referred to as the "three directories" of medical insurance. The expenses beyond the scope of the insured's "three directories" are not included in the overall reimbursement. Drugs and articles listed in the "Three Catalogues" are managed in two categories: A and B. Among them, drugs and articles in category A can directly enter the scope of overall payment, and drugs and articles in category B can only enter the scope of overall payment after a certain proportion is borne by individuals.

20. Can all the expenses incurred by using the drugs in the drug list be reimbursed?

I can't. The expenses incurred in the use of "Class A drugs" in the Drug Catalogue shall not be borne by individuals before being included in the medical insurance reimbursement; The expenses incurred in the use of Class B drugs shall be borne by individuals in accordance with the provisions of "self-payment ratio" and "maximum expense limit" before being included in the medical insurance reimbursement.

2 1. How to understand the "restricted scope of use" in the "Drug Catalogue" and how to choose drugs?

There are some expensive drugs in the drug list, which are easy to be abused, and only necessary for several diseases according to the condition, and the curative effect is exact. Other diseases can be used or not according to the condition, and there are similar alternative drugs in the catalogue. Therefore, according to the condition, curative effect and other factors, the scope of medication is limited to one or several diseases, and the medication for other diseases is at the individual's own expense or increases the proportion of personal burden. These regulations are clearly marked in the "Drug List".

For example, "Angong Niuhuang Pill" is limited to "high fever, unconsciousness, rescuing patients", and other diseases are treated at their own expense or selected from the "Drug List".

22. How to understand the "maximum expense limit" in the Drug Catalogue and how to choose drugs?

There are some similar drugs in the Drug Catalogue, which have similar curative effects, but the prices are quite different. In order to reduce the tendency of abusing high-priced drugs, a "maximum expense limit" has been set for more expensive drugs, and the expenses above the limit are borne by individuals. Clinicians and insured persons can choose to use according to the specific conditions such as the condition and the patient's economic affordability.

23. What are the main drugs that are not included in the basic medical insurance drug list?

(a) drugs that mainly play a nourishing role;

(two) some animals and animal organs, dried fruits (water) that can be used as medicine;

(three) all kinds of wine preparations processed with Chinese herbal medicines and Chinese herbal pieces;

(4) Fruity preparations and oral effervescent agents in various medicines;

(5) Blood products (except for specified special indications) and protein products;

(six) other drugs that are not paid by the basic medical insurance fund as stipulated by the human resources and social security departments.

24. What are the main contents of the scope of diagnosis and treatment projects and medical service facilities?

The scope of diagnosis and treatment projects and medical service facilities mainly includes the name of the project, the level of the project, the proportion of conceit, the charging standard, the pricing unit, the maximum cost limit, and the restricted use scope. Among them, the meanings of item grade, self-sufficiency rate, maximum expense limit and restricted use range are consistent with the drug list. The charging standard and pricing unit belong to the price charging policy and are the charging standards determined by the price department.

25. What are the main diagnosis and treatment projects that are not listed in the catalogue of basic medical insurance diagnosis and treatment projects?

(1) Service items: registration fee, out-of-hospital consultation fee, medical record fee, etc. Special medical services such as visiting fees, urgent fees for examination and treatment, additional fees for roll call surgery, high-quality and good-price fees, and self-invited special care.

(2) Non-disease treatment projects: various beauty and bodybuilding projects, as well as non-functional plastic surgery and orthopedic surgery; All kinds of weight loss, weight gain and height increase projects; Various health checks; All kinds of medical consultation and medical appraisal.

(3) Diagnosis and treatment equipment and medical materials: inspection and treatment items carried out by using large-scale medical equipment such as positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic apparatus; Rehabilitation appliances such as glasses, dentures, artificial eyes, artificial limbs and hearing AIDS; All kinds of self-use health care, massage, examination and treatment equipment; Disposable medical materials that cannot be charged separately as stipulated by the price department.

(4) Treatment items: organ sources or tissue sources of various organ or tissue transplants; Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow; Orthopedic surgery for myopia; Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.

(5) Others: diagnosis and treatment of various infertility (pregnancy) and sexual dysfunction; Various scientific research and clinical verification diagnosis and treatment projects.

26, which medical service facilities are not included in the basic medical insurance social pooling payment scope?

According to national regulations, the basic medical insurance does not pay for life service items and service facilities, mainly including: outpatient transportation expenses and first aid expenses; Air conditioning fee, TV fee, telephone fee, baby incubator fee, food incubator fee, electric stove fee, refrigerator fee and compensation for public property damage; Escort fee, nursing fee, washing fee and outpatient decocting fee; Meal expenses; Hospitality and other special living service expenses.