How to apply for resident medical insurance in Xixiangtang, Nanning City?

There are two ways to apply for social security:

(—) To pay in the name of an individual, you need to apply at the Social Security Bureau where the household registration is located. The procedures include: personal ID card and two recent one-inch photos without a hat. , premium, application form, etc. And it can only apply for two types of pension and medical insurance.

1. The amount to be paid is calculated based on the local average wage last year, and it is not the same every year.

For example, if the average salary in place A is 20,000 yuan, then the pension insurance payment is 20,000*20%=about 4,000/year, and the medical care payment is 20,000*10%=about 2,000/year.

2. In addition, the minimum and maximum levels are also stipulated. The payment for the lowest level shall not be less than 60% of the average monthly salary of employees in the society, and the payment for the highest level shall be 300% of the average monthly salary of employees. Generally, the lowest grade is the most common.

3. In addition, the minimum payment period for pension insurance is 180 months or 15 years, and medical insurance needs to be paid for at least 25/30 years. When you reach retirement age, you can apply for pension benefits and medical reimbursement (as long as you renew This is usually possible).

(2) Or purchase social security as an employer.

In addition, if you are applying for social security, it is better to use the second payment method through the employer, because the employer will bear a large part of the cost for us, thereby reducing our own payment pressure.

Nanning Urban Employees Basic Medical Insurance Measures

Chapter 1 General Provisions

Article 1 is to establish a complete basic medical insurance system to effectively protect the majority of employees To provide basic medical needs and safeguard the legitimate rights and interests of employees, in accordance with the "Social Insurance Law of the People's Republic of China", "Interim Regulations on the Collection and Payment of Social Insurance Premiums", and "Decision of the State Council on Establishing a Basic Medical Insurance System for Urban Employees" (State Council [1998] No. 44) and the "Notice of the Guangxi Zhuang Autonomous Region on the Implementation of Municipal-level Coordination of Basic Medical Insurance for Urban Employees" (Guizhengfa [2010] No. 30) and other relevant regulations, these measures are formulated based on the actual situation of our city.

Article 2 The basic medical insurance system for urban employees adheres to the policy of “wide coverage, basic protection, multi-level and sustainable”; adheres to the principle of reasonably determining the level of basic medical security based on the level of economic and social development; adheres to the principle of The principle of combining the basic medical insurance pooling fund and personal accounts; adhering to the principle of territorial management; adhering to the principle that all urban employers and their employees should participate in the urban employee basic medical insurance, and the basic medical insurance premiums are paid jointly by the employer and employees *** ; Adhere to the principle of fund expenditures determined by revenue, balance revenue and expenditure, with a slight surplus; adhere to the principle of overall planning and coordination, and do a good job in connecting basic policies, standards and management measures between various medical security systems.

Article 3: The basic medical insurance for urban employees in Nanning City shall be coordinated at the municipal level. Municipal and county social insurance administrative departments are responsible for the basic medical insurance for urban employees within their respective administrative regions.

Chapter 2 Insurance Scope

Article 4: Within the administrative area of ??Nanning City, various urban enterprises and their employees, state agencies and their staff, public institutions and their employees, Social groups and their full-time personnel, private non-enterprise units and their employees, as well as urban individual industrial and commercial households with employees and their employees should participate in the urban employee basic medical insurance.

In the administrative area of ??Nanning City, workers who have established labor relations with state agencies, institutions, and social groups must participate in the basic medical insurance for urban employees.

Individual industrial and commercial households without employees, urban part-time employees who have not participated in the urban employee basic medical insurance in their employer, and other urban flexible employment personnel (hereinafter collectively referred to as "flexible employment personnel") can participate in urban employee basic medical insurance. Basic medical insurance for employees.

Chapter 3 Insurance Registration and Payment

Article 5 If the employer encounters the following circumstances, it shall go to the social insurance agency to handle social insurance registration, change or payment according to regulations. Procedures for cancellation of registration and addition, deletion and change.

(1) A newly established unit shall apply for social insurance registration procedures with a business license, registration certificate or unit seal and other materials within 30 days from the date of establishment.

(2) When the social insurance registration information such as name, address, legal representative or person in charge, account opening bank and account number of the insured unit changes, relevant certification materials shall be provided within 30 days from the date of change. Go to the social insurance agency to go through the change procedures.

(3) When an insured unit undergoes division, merger, termination, restructuring, bankruptcy, etc., it shall, within 30 days from the date of occurrence, go to the place of original registration with the relevant legal documents and the approval of the competent department. The social insurance agency handles the registration change or cancellation procedures.

(4) The insured unit shall complete the social insurance registration procedures for its employees with the social insurance agency within 30 days from the date of employment.

(5) The insured unit recruits new personnel, or due to employee job transfers, resignations, voluntary resignations, as well as employees who terminate or terminate the labor relationship with the unit due to various reasons, employees retire, etc. If the number of people changes, you should go to the social insurance agency with relevant materials before the 10th of each month to go through the procedures for increasing or decreasing the number of people paying premiums in that month.

Article 6: Persons with flexible employment who want to participate in the basic medical insurance for urban employees should go to the social insurance agency with relevant materials to apply for individual insurance registration according to regulations.

Article 7 The insured unit shall use the average monthly salary of the unit’s employees in the previous year as the payment base, and the unit and the individual shall pay the basic medical insurance premiums simultaneously in accordance with the following regulations:

(1) The insured unit shall pay basic medical insurance premiums at 8% of the total average monthly salary of its employees in the previous year.

(2) Active employees shall pay 2% of their average monthly salary in the previous year for basic medical insurance premiums. The basic medical insurance premiums payable by individual employees shall be withheld and paid by the insured units.

(3) If the salary of an active employee in the previous year was lower than 60% of the average salary of urban employees in the district in the previous year, 60% of the average salary of urban employees in the district in the previous year shall be calculated and paid; if it exceeds the previous year If the average salary of on-the-job employees in urban units in the region is 300%, 300% of the average salary of on-the-job employees in urban units in the region in the previous year will be calculated and paid.

(4) For individuals who participate in the basic medical insurance for urban employees and have paid for the specified number of years when they reach the statutory retirement age, after completing the change procedures from in-service to retirement, the participating units and individuals will no longer be covered by the insurance starting from the month following the change. Pay basic medical insurance premiums and enjoy the unified basic medical insurance retirement benefits along with the unit as a whole.

Article 8 For flexible employment personnel, 60% of the average salary of urban employees in the region in the previous year shall be the payment base, and basic medical insurance premiums shall be paid at a rate of 8% (the payment rate shall be determined by the payment rate of the insured unit). Adjustment).

Article 9: The social insurance agency shall determine the amount of basic medical insurance premiums payable by the insured units for that month before the 20th of each month, and collect them according to the prescribed payment method.

Article 10: Insured units shall pay basic medical insurance premiums in full in accordance with regulations every month. If the following circumstances occur, the following provisions shall apply:

(1) If the insured unit is temporarily unable to pay due to financial difficulties, it shall submit a request to the municipal (county) social insurance administrative department within the prescribed payment time. Upon written application, upon review and approval, payment can be deferred in part or in full, and the deferment period is up to 90 days. During the deferral period, late payment fees will be waived. Those who fail to pay or top up the basic medical insurance premiums within the prescribed time limit will be suspended from the basic medical insurance pooling fund payment benefits.

(2) When an employer goes bankrupt, closes, auctions, cancels or cancels, merges, splits, transfers or restructures in accordance with the law, it must pay off the basic medical insurance premiums payable in accordance with current relevant regulations. The basic medical insurance premiums payable according to current relevant regulations shall be included in the overall planning of restructuring costs.

From the establishment of the coordinated regional basic medical insurance system for employees, employers and employees must participate in the basic medical insurance for employees in accordance with regulations, and must make up for the years they should be insured but have not been insured. According to the current policy, when retirees in the co-ordination area, or when they transition from working to retirement, the cumulative payment of basic medical insurance does not reach the minimum payment years (including the deemed payment years and the actual payment years) in the co-ordination area, the employer shall be deemed as bankrupt. , closure, auction, cancellation or cancellation, merger, division, transfer and restructuring, 60% of the average salary of employees in urban units in the region in the previous year shall be the payment base and the prescribed payment ratio shall be paid to make up the basic medical care for the missing number of years. Only the insured retirees can enjoy the unified basic medical insurance retirement benefits.

(3) If the employer fails to declare the amount of basic medical insurance premiums it should pay as required, the social insurance agency may determine the payment base based on 110% of the unit’s payment base in the previous year. ; After the payment unit completes the declaration procedures, the social insurance agency will settle the payment in accordance with regulations.

(4) Employers who want to make back payment of basic medical insurance premiums for the current year or previous years must apply for back payment procedures with valid arbitration or litigation legal documents and other relevant supporting materials.

Article 11 People with flexible employment who participate in urban employee basic medical insurance can choose to pay basic medical insurance premiums for one year or half a year. If you choose to pay annually, the normal payment time is from July to September each year; if you choose to pay semi-annually, the normal payment time is from July to September each year. To pay the premiums from July to December of the current year, January of each year Pay premiums from January to June of the current year in March.

Flexible employment personnel are subject to a waiting period for collective fund payment. The waiting period for first-time insurance is 3 months from the month of payment; if payment is not made within the prescribed time, a back-payment can be made, and the waiting period is calculated from the month of payment. 3 months from now, and starting from the next month after the expiration of the waiting period, you can enjoy the payment benefits from the urban employee basic medical insurance co-ordination fund; if the employees of the insured unit leave the unit to participate in the urban employee basic medical insurance for flexible employment and the payment is interrupted, the renewal period 3 months starting from the first month of interruption. When the insurance is renewed, the basic medical insurance premiums during the interruption period can be repaid; if no repayment is made or the repayment is not made within the renewal period, the waiting period for the unified fund payment after the renewal of the insurance will be treated as the first insurance.

If a person with flexible employment terminates the basic medical insurance relationship in the year of payment, or changes to be an employee of the insured unit, the basic medical insurance premiums paid by the individual for the remaining months of the year will be included in his or her basic medical insurance premiums. Medical insurance personal account.

Article 12: The payment period for urban employee basic medical insurance includes the actual payment period and the deemed payment period.

Before the establishment of the basic medical insurance system for urban employees in this coordinating area, during the period of working in state-owned enterprises, collective enterprises at or above the county level, government agencies and institutions, the continuous length of service or work that can be calculated in accordance with relevant national and autonomous region policies The number of years shall be deemed as the payment period.

Article 13 For employees participating in the basic medical insurance for urban employees, when going through retirement procedures or applying for basic pension insurance benefits in accordance with national and autonomous region regulations, the cumulative payment years for men must be 25 years or more and for women 20 years or more. Years, and the actual payment years in this co-ordination area are 5 years or more, the insured units and individuals will no longer pay basic medical insurance premiums starting from the month following their retirement or the month they enjoy basic pensions, and the individuals will enjoy the unified provisions with the unit as a whole Basic medical insurance retirement benefits.

After the basic medical insurance system for urban employees in the coordinated area is established, employers and employees should participate in the insurance and pay premiums in accordance with the law. The years after the establishment of the urban employee basic medical insurance system are all the years that should be insured. Employers and employees must make up contributions for the years that should be insured but are not actually insured.

After the employer pays the urban employee basic medical insurance premiums for its employees in accordance with the law, if the employee does not reach the payment period specified in the preceding paragraph when he retires, the individual may make up a one-time payment or pay the basic medical insurance for the short period year by year. After paying the fee, you can enjoy basic medical insurance retirement benefits. The standard for one-time supplementary payment of basic medical insurance premiums shall be based on the payment ratio specified at the time of supplementary payment and 60% of the average salary of on-the-job employees in urban units in the region in the previous year as the payment base.

Article 14 When flexible employment personnel reach the legal retirement age or enjoy basic pension insurance benefits, and apply for retirement or enjoy basic pension in accordance with national and autonomous region regulations, the cumulative payment years must be 25 years for men and 25 years for women. Those who have served for 20 years or more, and have been paying continuously for 15 years or more in this co-ordination area, will enjoy basic medical insurance retirement benefits.

If flexible employment personnel do not meet the payment period requirements specified in the preceding paragraph when they retire, they can enjoy basic medical insurance retirement benefits after the individual pays a one-time supplementary payment or pays the medical insurance premium year by year for the insufficient period. The one-time supplementary payment of medical insurance premiums shall be based on the payment ratio specified at the time of supplementary payment and 60% of the average salary of on-the-job employees in urban units in the region in the previous year as the payment base. Regarding the payment period requirements for self-employed personnel of closed, bankrupt, or restructured state-owned enterprises to enjoy basic medical insurance retirement benefits, those provisions shall prevail if there are other provisions.

Article 15: The basic medical insurance premiums that retirees pay in one go or year by year in accordance with Articles 13 and 14 of these regulations shall be included in the unified management of the basic medical insurance pooling fund. The one-time supplementary basic medical insurance premium will be transferred into the personal account at a rate of 23.33%.

Article 16 The adjustment of the basic medical insurance payment ratio for urban employees shall be made by the municipal social insurance administrative department based on the level of economic development and fund revenue and expenditure, together with the municipal finance department, and shall be implemented after being submitted to the municipal people's government for approval. .

Chapter 4 Personal Accounts and Overall Funds

Article 17 The urban employee basic medical insurance personal account (hereinafter referred to as the "personal account") is mainly used to pay for medical expenses incurred by designated medical institutions. Outpatient medical expenses and hospitalization expenses that comply with the drug catalog, diagnosis and treatment items, and medical service facility scope and payment standards of Nanning City's urban basic medical insurance (hereinafter referred to as the "Three Basic Catalogs"), and the portion of hospitalization expenses paid by individuals in prescribed proportions, as well as retail sales at designated points Drug purchase costs at pharmacies.

The specific transfer ratio of personal accounts is as follows:

(1) All personal contributions of employees of participating units are transferred to their personal accounts. Among the basic medical insurance premiums paid by the unit, those who are 45 years old For employees who are below the age of 46 years old (including the original number) and before retirement, 1% of the personal payment base of the insured employees will be transferred into their personal accounts. Personal Account.

(2) The basic medical insurance premium payment base for flexible employment personnel shall be transferred to their personal accounts according to the following proportions according to different age groups: 1 for persons under 45 years old (inclusive) %, 1.4% for those aged 46 and above (inclusive) and reaching the age of applying for basic pension.

(3) Retirees who enjoy basic medical insurance retirement benefits according to regulations shall have 3.8% of their average retirement payment or average pension in the previous year transferred into their personal accounts.

Personal accounts accrue interest in accordance with regulations, and the principal and interest belong to the insured individual and can be carried forward. After the death of the insured person, the balance of his personal account will be paid to his designated beneficiary or legal heir in one lump sum.

Article 18: The urban employee basic medical insurance co-ordination fund is mainly used to pay for some medical expenses such as hospitalization, specific outpatient items, special examinations and special treatments that comply with the "Three Basic Catalogs".

Article 19 The basic medical insurance card is the settlement voucher for insured persons to use their personal accounts and overall funds. When registering for insurance, insured persons shall apply for a basic medical insurance card in accordance with regulations. . When purchasing medicines, you should take the initiative to show your basic medical insurance card and make settlement in a timely manner. If the basic medical insurance card of an insured individual is lost or damaged, he should promptly go to the designated location to handle the procedures for reporting the loss and replacing the card.

If the state and autonomous regions have new regulations on the issuance and use of basic medical insurance cards, those regulations shall prevail.

Article 20 If the following situations occur to the insured persons, they shall go through the transfer and continuation procedures of the medical insurance relationship in accordance with the regulations:

(1) Employees of the insured units, due to various reasons For those who are employed across coordinating areas, the insured unit shall go to the social insurance agency to handle the transfer procedures for the basic medical insurance relationship. Insured persons with flexible employment should go to the social insurance agency to apply for the transfer procedures of the basic medical insurance relationship. The balance of the personal account of the insured person's basic medical insurance is transferred with him/her.

(2) For persons who transfer to our city from outside the coordinating area to participate in insurance, the receiving unit shall go to the social insurance agency to handle the medical insurance renewal procedures for them in accordance with regulations; individuals who do not have a receiving unit shall Within 3 months after terminating the original basic medical insurance relationship, go through the registration procedures with the social insurance agency and participate in the urban employee basic medical insurance as required.

Chapter 5 Medical Insurance Benefit Settlement

Article 21: Basic medical insurance benefits for urban employees include benefits for general outpatient services, hospitalization, specific outpatient services, special examinations, special treatments, etc.

Article 22 Urban Employee Basic Medical Insurance medical treatment and referral shall be handled according to the following prescribed procedures:

(1) Medical expenses incurred by insured persons in designated medical institutions and designated For drug purchase costs at retail pharmacies, a basic medical insurance card must be held before the basic medical insurance fund can be used for settlement.

(2) Specific outpatient items, special examinations, special treatments, etc. must be submitted to municipal and county social insurance agencies for approval in accordance with regulations.

(3) Those who are transferred to a hospital for treatment outside the coordinated area should go to the designated designated medical institutions, social insurance agencies and social insurance administrative departments to complete relevant transfer procedures according to procedures.

(4) If the insured person lives or works outside the coordinating area for more than 3 months (including 3 months), he must first go to the social insurance agency in the coordinating area to complete the registration procedures for living in another place.

(5) If an insured person suffers a sudden illness within 3 months outside the coordinating area due to visiting relatives, business trips, studies, etc. and needs to seek medical treatment at a local designated medical institution, he should report to the coordinating regional social insurance agency Filing.

Article 23 The outpatient medical expenses incurred by insured persons at designated medical institutions and the drug purchase expenses at designated retail pharmacies shall be paid by the insured individuals themselves according to the policy. If they can be settled using personal accounts, Use a basic medical insurance card to settle the bill, or pay in cash; according to regulations, the portion that should be paid by the overall fund will be advanced by designated medical institutions and designated retail pharmacies. Social insurance agencies make direct settlements with designated medical institutions and designated retail pharmacies on a monthly basis.

Article 24 The hospitalization expenses of the Urban Employee Basic Medical Insurance shall be settled according to the following provisions:

(1) Calculation of the number of hospitalizations

Insured persons receive medical treatment at designated points For each inpatient treatment that the institution handles for admission and discharge procedures, the number of hospitalizations is counted as one. Among them:

1. If the insured person is directly hospitalized after treatment in the emergency observation room, his or her first hospitalization will be calculated from the date of admission to the observation room;

2. Insured person If a person needs to be hospitalized continuously for a long time based on his or her condition, the number of hospitalizations will be calculated every 3 months. If the number of hospitalizations is less than 3 months, it will be calculated as one hospitalization.

3. If the hospitalization spans multiple medical insurance years, the year in which the personal out-of-pocket ratio is calculated will be based on the hospitalization expenses incurred in the year of discharge.

(2) A minimum payment standard is set for hospitalization, and expenses up to and including the minimum payment standard are paid by the individual. During the medical insurance year, each time an insured person is hospitalized, the individual will pay out of pocket according to the level of the medical institution and the overall fund minimum standard. The specific standards are as follows:

For patients who are hospitalized for the first time during the year, the minimum payment standards for hospitalization individual out-of-pocket funds in third-level, second-level, and first-level medical institutions are 700 yuan, 600 yuan, and 300 yuan respectively;< /p>

For hospitalization for the second time and above, the minimum payment standards for hospitalization individual out-of-pocket pooling funds in third-level, second-level, and first-level medical institutions are 400 yuan, 200 yuan, and 100 yuan respectively.

If an insured person is hospitalized multiple times during the year, and the medical expenses for the first hospitalization are lower than the prescribed deductible standard for the first hospitalization, the difference will be carried forward to the next hospitalization and accumulated with the prescribed deductible standard for the second hospitalization. Settlement.

(3) The above threshold payment standard shall be paid by the basic medical insurance co-ordinating fund and individuals in proportion. The standards are as follows:

Inpatient treatment in non-designated medical institutions due to acute and critical illness in the coordinating area , upon approval to transfer hospitalization treatment outside the coordinating area, and other in-place hospitalization medical expenses that meet the regulations, the individual out-of-pocket proportion will be increased by 5 percentage points, and the co-ordinating fund payment proportion will be reduced by 5 percentage points accordingly.

(4) The maximum standard for the urban employee basic medical insurance pooling fund to pay for ordinary beds is 25 yuan/bed·day; the maximum standard for paying intensive care unit bed fees is 30 yuan/bed·day. If the actual amount of bed fees is lower than the above standards, the actual settlement will be made.

Article 25: Specific outpatient items and medical expense settlement of urban employee basic medical insurance.

(1) Types and scope of specific outpatient items

1. Outpatient and emergency observation: mainly including acute severe trauma, brain trauma, fractures, dislocations, lacerations, burns, acute Abdominal pain, sudden high fever, acute bleeding, vomiting blood, signs of internal bleeding, diarrhea, severe dehydration, shock, convulsions or unconsciousness, and foreign bodies in the ear, nasal passages, pharynx, eyes, trachea, bronchi and esophagus, Those with acute eye pain, redness and swelling or sudden visual impairment, difficulty breathing, those with sudden onset, severe symptoms, and rapid deterioration after onset, poisoning, drowning, electric shock, acute anuria, acute allergic disease, suspected severe infectious disease, and Other diseases that are considered life-threatening by the attending physician or above and require emergency treatment.

2. Family hospital bed: The treatment scope mainly includes the sequelae of cerebrovascular accidents, advanced malignant tumors, chronic obstructive pulmonary disease, senile brain atrophy, fracture recovery period, cardiac insufficiency caused by chronic cardiovascular diseases, various Patients with limited mobility such as urinary retention due to various reasons such as indwelling urinary catheter, chronic failure, chronic uremia, etc.

3. Scope of serious diseases in the outpatient clinic:

(1) Various malignant tumors: ① non-radiotherapy and chemotherapy, ② radiotherapy and chemotherapy; ⑵ anti-rejection treatment after organ transplantation; ⑶ Chronic renal insufficiency: ① non-dialysis treatment, ② dialysis treatment; ⑷ chronic obstructive pulmonary disease; ⑸ chronic congestive heart failure; ⑹ chronic active hepatitis consolidation phase; ⑺ liver cirrhosis; ⑻ diabetes; ⑼ coronary heart disease; ⑽ mental illness ( (limited to schizophrenia, paranoid disorder); ⑾ active stage of tuberculosis; ⑿ hemophilia; ⒀ psoriasis; ⒁ hypertension (high-risk group); ⒂ hyperthyroidism; ⒃ sequelae of cerebrovascular disease; ⒄ Parkinson's syndrome ; ⒅ systemic lupus erythematosus; ⒆ aplastic anemia; ⒇ thalassemia major and intermedia; (21) rheumatoid arthritis.

(2) Payment ratio for specific outpatient items

After approval, specific outpatient items will be paid by the overall fund and insured individuals in proportion. The standards are as follows:

1. Outpatient and Emergency Observation: The payment method for medical expenses incurred by insured persons each time they stay for observation in the emergency observation room of a designated medical institution is the same as the payment method for inpatient medical expenses.

2. Family hospital beds: For active employees, 20% will be paid by individuals within 2 months and 80% will be paid by the overall fund; from the third month onwards, 30% will be paid by individuals and 70% will be paid by the overall fund. For retirees, within 2 months, 10% will be paid by individuals and 90% will be paid by the collective fund; from the third month onwards, 15% will be paid by individuals and 85% will be paid by the collective fund.

3. Outpatient serious illness: Insured persons submit an application for outpatient serious illness in accordance with regulations. After review and approval, they will enjoy outpatient serious illness medical treatment from the date of application from designated medical institutions (secondary and above):

(1) Various malignant tumor chemotherapy, radiotherapy, approved anti-rejection treatment after organ transplantation and severe uremic dialysis: 15% is paid individually by current employees and 8% is paid individually by retirees, which are paid separately by the overall fund 85% and 92%.

(2) Except for chemotherapy, radiotherapy for malignant tumors, anti-rejection treatment after organ transplantation and dialysis for severe uremia, the cumulative cost of restricted drugs used in one month exceeds 300 yuan/month. , active employees pay 20% individually and the overall fund pays 80%; retirees pay 10% individually and the overall fund pays 90%.

(3) The outpatient serious illness overall payment benefit is valid for one year, and the outpatient serious illness treatment card is subject to a one-year review system.

Article 26: Scope of special examinations and special treatment items of urban employees’ basic medical insurance.

(1) Special examinations mainly include: application of χ-ray computed tomography device [CT], stereotactic radiation device [γ-knife, χ-knife], cardiac and angiography χ-ray machine [ Medical examination items carried out by large-scale medical equipment such as digital subtraction equipment], magnetic resonance imaging equipment [MRI], single photon emission electronic computer scanning equipment [SPECT], and medical linear accelerators, and the individual cost exceeds 200 yuan/time Medical examination items.

(2) Special treatments mainly include:

1. Extracorporeal vibration lithotripsy, hyperbaric oxygen therapy, medical linear accelerator therapy, intensive care and rescue CCU, ICU ward treatment ;

2. Kidney transplantation, heart valve transplantation, corneal transplantation, skin transplantation, blood vessel transplantation, bone transplantation, bone marrow transplantation, islet transplantation;

3. Pacemaker, artificial Replacement and installation of artificial organs in the body such as joints, intraocular lens, artificial larynx, artificial hip joint, cardiac bypass surgery, and cardiac catheter balloon dilatation;

4. Hemodialysis, peritoneal dialysis;

5. Cardiac laser drilling, anti-tumor cell immunotherapy, interventional therapy and fast neutron treatment projects;

6. Treatment projects with a single cost exceeding 200 yuan/time.

Article 27 The expenses for special examinations and special treatments for insured persons due to outpatient or hospitalization shall be directly paid by the individual and the unified fund within the maximum payment limit of the unified fund. The standards are as follows: Working individuals pay 30% out of pocket and the pooled fund pays 70%; retired individuals pay 15% out of pocket and the pooled fund pays 85%. For special examinations and special treatments approved to be transferred outside the coordinated area, the payment ratio of the unified fund will be reduced by 5%.

Expenses incurred for the use of artificial organs and implanted materials in special treatments due to illness needs, after approval by the social insurance agency, will be directly borne by the individual within the maximum payment limit of the overall fund. For medical materials with a single cost of more than 200 yuan (excluding materials implanted in the body), after approval by the municipal social insurance agency, the overall fund will be settled according to the payment ratio specified in special examinations and special treatments.

For approved diagnosis and treatment projects with a single cost of 5,000 yuan or more, the basic medical insurance co-ordinating fund will pay 50%.

Article 28: Specific management measures for specific outpatient items, special examinations, and special treatments shall be formulated separately by the municipal social insurance agency.

Article 29: The medical blood used by insured persons under the following circumstances may be included in the scope of payment of part of the expenses by the overall fund:

(1) Acute massive bleeding (including intraoperative bleeding) ), blood for emergency rescue in hemorrhagic shock and other critical illnesses;

(2) Necessary blood treatment for large-area burns;

(3) Hemophilia and other platelet dysfunction caused by Bleeding requires component blood transfusion for treatment;

(4) Bleeding or severe infection due to bone marrow suppression or failure caused by thrombocytopenia and granulocytopenia caused by disease, chemotherapy, and radiotherapy requires component blood transfusion;

< p>(5) Blood treatment for bleeding caused by other blood component defects (congenital or acquired deficiency of FⅡ, FⅤ, FⅦ, FⅩ, FⅪ and FⅧ factors);

(6) Due to diseases and other reasons Blood transfusion treatment is necessary for bone marrow hematopoietic dysfunction or severe anemia.

For medical blood expenses within the prescribed range (excluding reimbursable expenses for unpaid blood donation), within the maximum payment limit of the overall fund, 30% will be directly paid by the individual himself, and 70% will be paid by the overall fund.

Article 30: The insured person’s medical expenses that meet the regulations incurred in another place should be paid in advance by the individual. After the treatment is completed, the relevant materials should be brought to the social insurance agency to handle the reimbursement procedures.

Article 31 If an insured person incurs medical expenses and is unable to settle them with a medical insurance card at a designated medical institution due to special reasons, he or she shall maintain a medical insurance card within 6 months from the date of discharge (outpatient settlement). Relevant materials must be submitted to the municipal social insurance agency for reimbursement procedures. Overdue applications will not be accepted.

Article 32: The maximum payment limit of the basic medical insurance pooling fund for urban employees is 6 times the average salary of on-the-job employees in urban units in the region in the previous year. After the insured persons pay the premium, they will enjoy the maximum payment limit of the urban employee basic medical insurance pooling fund in accordance with the following provisions:

(1) After the employees of the insured units pay the premium, their benefits within the maximum payment limit of the basic medical insurance pooling fund shall be calculated on an annual basis. calculate.

(2) After flexible employment personnel pay, the maximum payment limit of their collective fund shall be calculated based on annual accumulation. At the end of medical treatment, it shall be settled based on the number of payment months, and at the end of the year, it shall be settled based on actual settlement. If the annual payment is for 12 consecutive months, each person can enjoy the maximum payment limit in full according to the payment regulations; if the payment is less than 6 months, the payment is 30%; if the payment is 6 months but less than 12 months, the payment is 70%.

Article 33: The Urban Employees Basic Medical Insurance Co-ordination Fund will not pay for medical expenses incurred in the following scopes:

(1) Medical expenses incurred in non-designated medical institutions (due to emergencies) Except for critically ill patients who are hospitalized in the emergency department of non-designated medical institutions);

(2) Injuries caused by traffic accidents, medical accidents or other liability accidents;

(3) Due to personal drug abuse , fights, violations of laws and regulations, etc. causing injuries;

(4) Treatment due to suicide, self-mutilation, alcoholism, drug addiction, etc.;

(5) Undertaken by the coordinator without approval Seeking medical treatment outside the region;

(6) Seeking medical treatment overseas (including Hong Kong, Macao and Taiwan);

(7) Paying from the work-related injury insurance fund;

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(8) Should be borne by public health;

(9) Other items and expenses that are not payable according to relevant documents of the state and autonomous regions.

Chapter 6 Medical Insurance Service Management

Article 34: Designated medical institutions and designated retail pharmacies for basic medical insurance for urban employees shall implement designated qualification management. The municipal social insurance administrative department is responsible for the review and management of designated qualifications of medical institutions and retail pharmacies, and publishes the list of designated medical institutions and designated retail pharmacies to the public in accordance with regulations, and accepts social supervision.

Article 35 Social insurance agencies sign service agreements with designated service agencies based on the needs of management services, clarify the responsibilities, rights and obligations of both parties, and conscientiously perform the agreement. Any violation of the agreement shall be borne in accordance with the law. Liability for breach of contract.

Article 36 The municipal social insurance administrative department shall standardize the settlement relationship between social insurance agencies and designated service agencies in accordance with the principle of "determining expenditures based on revenue and balancing revenue and expenditure" of the urban employee basic medical insurance fund. , formulate fee settlement methods including settlement methods and standards, settlement scope and procedures, review methods and management measures.

Article 37: Designated service institutions and individuals who have made outstanding contributions to the basic medical insurance for urban employees shall be commended and rewarded in appropriate ways.