What expenses can be claimed for hospital visits?

What medical expenses can be claimed?

Outpatient expenses are basically not reported, and inpatient treatment expenses are partially reported

Basic medical insurance drugs are divided into Category A catalog drugs and Category B catalog drugs. Class A drugs are fully reimbursed, and Class B drugs are partially reimbursed on a proportional basis. Some medical treatments and services are also partially reimbursed. You must ask clearly when seeking medical treatment!

1. What are Category A drugs? How to pay?

Drugs in the "Category A Catalog" are drugs that are necessary for clinical treatment, are widely used, have good curative effects and are low-priced among similar drugs. Expenses incurred for the use of Category A listed drugs shall be paid by the unified fund in accordance with the provisions of basic medical insurance.

2. What are Category B drugs? How to pay?

"Category B" drugs are drugs that can be used for clinical treatment, have good curative effects, and are slightly more expensive than those in Category A among similar drugs. The insured person will first pay a certain proportion of the expenses incurred when using Category B drugs, and the rest will be paid by the overall fund in accordance with regulations.

3. How to pay for traditional Chinese medicine pieces and hospital preparations?

(1) The expenses incurred in using traditional Chinese medicine pieces, except for some pieces that are not covered by the "Shandong Province Basic Medical Insurance Drug Catalog", will be paid according to the provisions of the basic medical insurance.

(2) If each hospital preparation has been approved by the municipal labor and social security department to be included in the scope of basic medical insurance, the expenses that should be borne by the individual will first be borne by the insured in proportion.

(3) For drugs with prescribed limited use, payment shall be made according to the prescribed usage limit.

4. What are the drugs that insured persons pay for themselves?

(1) Drugs that mainly serve as nutritional supplements.

(2) Some animals and animal organs, and dried (fruit) fruits that can be used as medicine.

(3) Various wine preparations made from Chinese medicinal materials and Chinese medicinal pieces.

(4) Fruit preparations and oral effervescent preparations among various types of medicines.

(5) Blood products and protein products (except for special indications and first aid and rescue).

(6) Other drugs that are not covered by the basic medical insurance fund stipulated by the Ministry of Labor and Social Security and the province.

5. How is the out-of-pocket ratio stipulated for diagnosis and treatment items for which the basic medical insurance fund pays part of the cost?

(1) Diagnostic and treatment equipment and medical materials

A. Application of x-ray computed tomography equipment (CT), cardiac and angiography x-ray machines (including digital subtraction Equipment), magnetic resonance imaging device (MRI), single photon emission computerized scanning device (CPECT), color Doppler, medical linear accelerator for examination and treatment items, the individual is responsible for 10%.

B. Stereotactic radiation device (γ-knife, x-knife) (limited to the treatment of central nervous system diseases), the individual pays 40% out of pocket.

C. For extracorporeal vibration lithotripsy and hyperbaric oxygen therapy, the individual pays 15% out of pocket.

D. For pacemakers, human joints, intraocular lenses, artificial larynxes, and vascular stents (the installation of the above imported artificial organs will be settled at the highest price of similar types of domestically produced artificial organs), the individual must pay 10%.

E. For disposable medical materials that can be individually charged more than 100 yuan as stipulated by the provincial price department, individuals must pay 15%.

(2) Treatment items

A. Hemodialysis and peritoneal dialysis, the individual pays 5% out of pocket.

B. Kidney, heart valve, cornea, skin, blood vessel, bone, and bone marrow transplant, the individual pays 10% out of pocket.

C. For cardiac laser drilling, microwave knife treatment, and fast neutron treatment projects, individuals pay 15% out of pocket.

D. Anti-tumor cellular immunotherapy, the individual pays 40% out of pocket.

(3) If the conditions for diagnosis and treatment are met, the individual will pay 50% of the cost of remote consultation via the Internet.

6. How is the out-of-pocket ratio of medical service facilities for which the basic medical insurance fund pays part of the cost?

First, the scope of medical service facilities for which the basic medical insurance fund pays

(1) Basic hospital bed fees

(2) Door (emergency) Simple bed fee for diagnosis and treatment

Second, the proportion of out-of-pocket expenses for medical service facilities where the basic medical insurance fund pays part of the fee

(1) Care unit fees (CCU, ICU), individual self-payment Pay 10%.

(2) Individuals pay 10% of the laminar flow ward bed fee.

Third, the scope of medical service facilities that are not covered by the basic medical insurance fund

(1) Medical (referral) transportation fees and emergency ambulance fees;

(2) Air conditioning fees, television fees, heating fees, telephone fees, food humidifier fees, maternal hygiene fees, electric stove fees, microwave oven fees, refrigerators and damage to public property compensation fees, etc.;

( 3) Accompanying fees, nursing fees, cleaning fees, outpatient medicine decoction fees, medicine introduction fees, Chinese herbal medicine processing fees, and corpse storage fees;

(4) Meal and nutrition fees;

(5) Books, newspapers, cultural and entertainment activities and other special living service expenses.

If you still don’t understand the above explanation, let me give you an example:

Example 1: Xiao Wang is an employee of a certain unit and has participated in the city’s basic medical insurance. Due to illness She was admitted to a certain Grade II A hospital, and the medical expenses were 9,760 yuan. Among them, the expenses outside the three major catalogs are 200 yuan, and the expenses for Class B drugs are 2,000 yuan (the self-pay ratio is 15%). How much is Xiao Wang’s personal medical expenses and overall payment?

Analysis:

1. Deduct personal expenses before payment from the overall fund:

Expenses outside the catalog: 200 yuan

B Personal responsibility for similar drugs: 2000×15%=300 (yuan)

Total deducted expenses: 20300=500 (yuan)

2. The expenses that fall within the scope of overall payment are: : 9760-500=9260 (yuan)

3. Personal expenses within the payment range of the overall fund:

(1) Minimum payment standard: Xiao Wang lives in a secondary medical institution , the minimum payment standard is 9% of the social average salary of 10,000 yuan in the previous year, that is: 10,000×9%=900 (yuan)

(2) Xiao Wang is an active employee, and the minimum payment standard is less than 10,000 yuan The individual is responsible for 15%, that is: (9260-900) × 15% = 1254 (yuan)

(3) The total personal expenses within the scope of the overall fund payment:

901254 =2154 (yuan)

4. Xiao Wang’s personal expenses are: the personal expenses deducted before the overall fund payment plus the personal expenses within the payment range of the overall fund, that is: 502154=2654

Xiao Wang should pay 2654 yuan for his own medical expenses, and the overall fund will pay:

9760-2654=7160 (yuan)

Example 2: Lao Wang is a retired employee of a certain unit. I participated in our city's basic medical insurance and large medical expense relief. This year I was admitted to a tertiary-level cancer hospital in our city due to cancer. The total cost was 78,000 yuan, of which 6,500 yuan was spent on anti-tumor cellular immunotherapy ( The self-pay ratio is 40%), Class B drugs are 4,000 yuan (the self-pay ratio is 15%), self-pay drugs are 4,000 yuan, air-conditioning fees are 350 yuan, and Chinese herbal medicine processing fees are 200 yuan. How much yuan will the overall fund pay? How much should Lao Wang pay for his own medical expenses?

Analysis:

1. Deduct personal expenses before payment from the overall fund:

Private medicines at your own expense: 4,000 (yuan)

The air-conditioning fee and Chinese herbal medicine processing fee are borne by the individual, that is: 35200=550 (yuan)

Anti-tumor cellular immunotherapy is at your own expense: 6500×40%=2600 (yuan)

Personal responsibility for Class B drugs: 4000×15%=600 (yuan)

Total deducted expenses: 40055260600=7750 (yuan)

2. Enter the overall fund And the expenses within the payment range of large-amount relief funds are:

78000-7750=70250 (yuan)

3. Personal expenses within the payment range of the overall fund:

(1) Minimum payment standard: Lao Wang lives in a third-level medical institution, and the minimum payment standard is 12% of the average social salary of 10,000 yuan in the previous year, that is: 10,000×12%=1,200 (yuan)

(2) Lao Wang is a retired employee, and the minimum payment standard is 12% of the personal responsibility within 10,000 yuan, that is: (10,000-1,200) × 12% = 1,056 (yuan)

(3) Maximum payment limit It is 4 times the social average salary of 10,000 yuan in the previous year, that is, 40,000 yuan. If the salary is more than 10,000 yuan and less than 40,000 yuan, the personal responsibility is 9%. The personal responsibility in this paragraph is: (40,000-10,000) × 9% = 2,700 (yuan)

(4) Total personal expenses within the scope of payment from the overall planning fund: 1201056+2700=4956 (yuan)

4. Individual expenses within the scope of payment of large-amount relief funds:

The individual is responsible for 10% of the payment range of large-amount relief funds. The expenses within the payment range of Lao Wang's large-amount relief funds are 70250-40000=30250 yuan. The personal responsibility for this section is: 30250×10%=3025 (yuan)

5. The total of Lao Wang’s personal expenses:

The personal expenses deducted before the overall fund payment + the personal expenses within the scope of the overall fund payment + the personal expenses within the scope of large-amount relief payments, that is ：

7754956+3025=15731 (yuan)

Lao Wang should bear 15731 yuan for medical expenses

Coordinated fund and large relief fund payment: 78000 -15731=62269 (yuan)

Example 3: Patient Zhang San is an employee of a certain unit and has participated in the city’s basic medical insurance and large medical expense assistance. Last year, I was hospitalized for surgery due to cancer. This year, I had outpatient surgery followed by radiotherapy and chemotherapy. The annual medical expenses were ***51,200 yuan.

The unit owed basic medical insurance premiums in March and made up the payment in May. According to the policy, basic medical insurance benefits will resume from the month after the arrears are paid, including 200 yuan in medical expenses in April and 100 yuan in five-part medical expenses. The cost of treating chronic appendicitis is 1,000 yuan, the cost outside the catalog is 900 yuan, the cost of radiotherapy is 32,000 yuan (including 1,200 yuan for linear accelerated fixed irradiation, and the borne proportion is 10%), and the cost of chemotherapy is 17,000 yuan (of which 13,000 yuan is used for Class B drugs, and the borne proportion is 10%) 15%), how much yuan should the medical insurance agency pay? How much does Zhang San need to pay for his own medical expenses?

Analysis:

1. Deduct the personal self-responsibility before payment from the overall fund:

Expenses during the gray list period: 20100=300 (yuan)

Chronic appendicitis, out-of-catalogue cost: 100900=1900 (yuan)

Linear accelerated fixed irradiation: 1200×10%=120 (yuan)

Personal responsibility for Class B drugs: 13000×15%=1950 (yuan)

Total deducted expenses: 30190121950=4270 (yuan)

2. Enter the overall fund The expenses within the payment range of large-amount relief funds are:

51200-4270=46930 (yuan)

3. Personal expenses within the payment range of the overall fund:

(1) Minimum payment standard: Zhang San is an outpatient patient, and the minimum payment standard is 6% of the social average salary of 10,000 yuan in the previous year, that is: 10,000×6%=600 (yuan)

( 2) Zhang San is an active employee, and the minimum payment standard is 15% of the amount above 10,000 yuan, that is: (10,000-600) × 15% = 1,410 (yuan)

(3) The maximum payment limit is The social average salary of the previous year is 4 times 10,000 yuan, that is, 40,000 yuan. Individuals who are above the maximum payment limit of 10,000 yuan are responsible for 12%. The personal responsibility for this paragraph is: (40,000-10,000) × 12% = 3,600 (yuan)

< p>(4) Total personal expenses within the scope of payment from the overall planning fund:

601413600=5610 (yuan)

4. Individuals within the scope of large-amount relief payments Expenses:

The expenses within the payment range of large-amount relief funds are: 46930-40000=6930 (yuan)

Individuals are responsible for 10% of the large-amount relief funds, that is: 6930× 10%=693 (yuan)

5. The total self-pay expenses of Zhang and the three persons:

The personal self-pay part deducted before the payment of the overall fund + the personal self-pay part within the payment scope of the overall fund + the large amount The amount of assistance payment range is the personal responsibility, that is:

427561693=10573 (yuan)

Answer: Zhang San needs to bear the medical expenses: 10573 (yuan)

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The medical insurance agency should pay 51200-10573=40627 (yuan).

What should I do when I reach retirement age?

According to regulations, retirees do not pay basic medical insurance premiums. As long as their unit participates in basic medical insurance and pays in full, their retirees can enjoy the benefits, otherwise they will not.

Under the same circumstances, the personal account of retirees is 2.5 percentage points higher than that of retirement, and medical expenses are reported 3 percentage points more. However, individuals have to pay a large monthly relief fund of 4 yuan.

1. What are the minimum payment years for insured persons?

When the insured person reaches the retirement age, the cumulative minimum payment period for enjoying the basic medical insurance benefits for retirees is: 30 years for men and 25 years for women.

If the minimum payment period has not been reached, the employer and the insured shall use the average monthly salary of employees in the city in the previous year at the time of retirement procedures as the base, and after making up the basic medical insurance premiums for the missing months in one go, Only then can you enjoy the basic medical insurance benefits for retirees. Before it is replenished, the personal account funds can continue to be used, but basic medical insurance benefits are suspended.

The back-paid basic medical insurance premiums will be transferred to personal accounts in accordance with relevant regulations.

Before an employer participates in the basic medical insurance, its employees who meet the continuous service length, working years or basic pension insurance payment years stipulated by the state will be calculated as the minimum payment years for the basic medical insurance.

2. When will the insured begin to enjoy the basic medical insurance benefits for retirees?

Personnel who have reached the normal retirement age (including delayed retirement) and have gone through retirement procedures and meet the minimum payment period for basic medical insurance will enjoy the benefits of basic medical insurance for retirees starting from the month after they are approved to retire.

Those who have been approved to go through the deferred withdrawal procedures will enjoy the basic medical insurance benefits for active employees during the deferred period.

3. What should retired employees of bankrupt enterprises do?

According to Lu Zhengfa <1999> Document No. 94, the medical expenses of retirees of bankrupt enterprises shall be paid according to the average amount of medical expenses of retirees in the city for ten years in the previous year. After that, medical expenses shall be handled by medical insurance The agency is responsible.

4. What should we do if the number of retirees in participating units increases abnormally and exceeds 30% of the number of employees?

When there is an abnormal large increase in the number of retirees in the insured unit, exceeding more than 30% of the number of employees, 10% of the city’s per capita medical expenses for retirees in the previous year will be paid for each additional person. After paying the basic medical insurance premium for 2 years, you can enjoy the basic medical insurance benefits.

5. What to do with special groups?

Special personnel refer to retired personnel, old Red Army soldiers, disabled revolutionary servicemen of Class B or above, and personnel who participated in revolutionary work before the founding of the People's Republic of China and enjoy retirement benefits based on 100% of their original salary. These personnel do not participate in basic medical care. For insurance, special policies are implemented for special personnel, and their medical benefits remain unchanged. Medical expenses are settled through the original financing channels, are specially raised, and are separately accounted and managed by the medical insurance agency.