How to reimburse children’s medical insurance in Beijing?

Beijing Medical Insurance’s specific reimbursement conditions and procedures

1. Outpatient expenses

(1) Reimbursement scope: insured persons receive medical insurance in designated hospitals of their personal choice Or general outpatient services that occur in specialized hospitals, traditional Chinese medicine hospitals and Class A hospitals (Youyi, Xuanwu, Guang'anmen Traditional Chinese Medicine, Tongren, Xiehe, Peking University Third Hospital, Peking University People's Hospital, Peking University First, Jishuitan, Chaoyang, Jiangong, Liangxiang) Emergency room expenses.

(2) Reimbursement ratio: If the total outpatient and emergency expenses incurred by employees in a calendar year exceed 2,000 yuan, the medical mutual aid fund will pay 50% of the large amount of more than 2,000 yuan, and the individual will pay 50%. For retirees whose total accumulated income exceeds 1,300 yuan, the large-amount medical mutual aid fund over 1,300 yuan for those over 70 years of age pays 70% and the individual pays 30%. The large-amount medical mutual aid fund for those over 70 years old pays 80% and the individual pays 20% out of pocket. The maximum payment limit within a calendar year is 20,000 yuan.

(3) Medical treatment management: General outpatient and emergency medical expenses must be paid in personal cash. The medical expenses incurred must comply with the scope of the three major catalogs of medical insurance. When outsourcing drugs, special prescriptions must be issued in designated hospitals and Stamp the special seal for medical insurance outsourcing, and then go to a designated pharmacy to purchase medicines.

(4) Reimbursement process: If the minimum payment standard is exceeded in a calendar year, the insured will submit the documents to the unit or social security office. The unit or social security office will enter the documents into the enterprise version and declare the electronic information and documents Go to the health insurance center. The medical insurance center completes the review, settlement, and payment within 15 working days.

(5) Application materials: general outpatient and emergency department receipts, medical insurance prescriptions (double price for prescriptions), detailed examination and treatment costs.

(6) Declaration date: 1st to 20th of each month. Fees for the current month must be declared the following month. Fees for the current year must be declared again before January 20th of the year.

2. Hospitalization expenses

(1) Scope of reimbursement: hospitalization expenses incurred by insured persons in medical insurance designated hospitals or specialized hospitals, traditional Chinese medicine hospitals and Class A hospitals selected by individuals.

(2) Reimbursement ratio: The minimum payment standard for the first hospitalization within a calendar year is 1,300 yuan, and 650 yuan each time thereafter. The payment ratio is divided into three levels. Taking a tertiary hospital as an example, the rising standard is: 30,000 yuan, 85% in employment, 91% in retirement, 90% in employment between 30,000 and 40,000 yuan, 94% in retirement, and 95% in employment above 40,000 yuan. Retirement 97%. A billing cycle is generally 90 days for hospitalization. 360 days for psychiatric hospitalization constitute a settlement cycle, and the fluctuation standard is halved. The maximum overall fund payment within a calendar year is RMB 70,000. The maximum payment for major hospitalization is 100,000 yuan, and the payment ratio for major hospitalization is 70%.

(3) Medical treatment management: Please use the "Beijing Medical Insurance Manual" when seeking medical treatment. If the unit pays the fee in full, the individual only needs to pay part of the hospitalization prepayment to go through the hospitalization procedures. The medical expenses incurred must comply with the scope of the three major catalogs of medical insurance.

(4) Reimbursement process: The hospital and the individual settle the self-pay and self-pay portion when discharged, and the overall fund reimbursement amount is settled by the hospital and the district medical insurance center.

3. Outpatient special diseases

(1) Reimbursement scope: Insured persons who take anti-rejection drugs after malignant tumors, radiotherapy and chemotherapy, renal dialysis, and kidney transplantation Outpatient medical expenses incurred after the special disease approval procedures are within the scope of outpatient special disease medication.

(2) Reimbursement ratio: The reimbursement ratio is the same as hospitalization. The billing cycle for outpatient special diseases is 360 days.

(3) Medical treatment management: Insured persons can only choose one hospital as the designated hospital for special diseases. Please use the "Beijing Medical Insurance Manual" when seeking medical treatment. If the unit pays the fee in full, the individual only needs to pay the personal out-of-pocket and self-pay portion, and the reimbursement amount from the overall fund will be settled by the hospital and the district medical insurance center.

(4) Reimbursement process: The insured person submits the documents to the unit or social insurance office, and the unit reports the documents to the medical insurance center. The Medical Insurance Center completed the review, settlement, and payment work on the same day

IV. Scope of Beijing Medical Insurance Reimbursement

(1) Western medicines and Chinese patent medicines, in accordance with the Municipal Health Bureau's "About the Publicly Funded Medical Treatment in Beijing" "Notice on the Reimbursement Scope of Medical and Labor Insurance Medical Drugs" (Jingwei Gongzi [1997] No. 15) and "Supplementary Opinions on the Implementation of the "Reimbursement Scope of Publicly Funded Medical and Labor Insurance Medical Drugs in Beijing" (Jingwei Gongzi [1998] No. 2) file execution.

For the cost of drugs that is stated as “partially borne by the individual,” the individual must first bear 10%, and the remaining costs will be included in the payment scope of the basic medical insurance fund.

(2) Hospital preparations: According to the Municipal Health Bureau's "Notice on Implementing the Reimbursement Scope of Hospital Preparations for Publicly Funded Medical and Labor Insurance Medical Care in Beijing" (Jingwei Gongzi [1999] No. 2).

(3) Payment scope and use of traditional Chinese medicine pieces

1. Traditional Chinese medicine pieces that need to be paid by the individual shall be covered by the Municipal Health Bureau's "About Inspection and Issuance" Article 1 of the document "Regulations on the Scope of Self-paid Drugs" (Jingweicai Zi [77] No. 267) will be implemented.

2. Traditional Chinese medicine pieces that are used alone or used reasonably in compound recipes due to medical conditions (no more than normal dosage), according to the Municipal Health Bureau's "About Inspection and Issuance" < Beijing Municipal Medical Personnel Enjoying Publicly Funded Medical Care and Labor Insurance Article 2 of the document "Regulations on the Scope of Self-paid Drugs" (Jingwei Cai Zi [77] No. 267) will be implemented.

3. The cost of reasonable use of the traditional Chinese medicine pieces in items 1 and 2 above during the rescue period of critically ill patients is included in the payment scope of the basic medical insurance fund.

(4) Scope of payment for outpatient radiotherapy and chemotherapy drugs for malignant tumors

When insured persons undergo outpatient radiotherapy and chemotherapy treatment for malignant tumors, the following drugs can be included in the basic medical insurance overall fund payment Scope:

1. Tumor drugs

The "Eleventh Category Tumor Drugs" of Chinese and Western medicines in the "Beijing Publicly Funded Medical and Labor Insurance Medical Drug Reimbursement Scope" exclude cantharidin tablets, In addition to three drugs, immune ribonucleic acid injection and thymosin injection, there are 59 other types of tumor drugs.

2. Leukocyte production-stimulating drugs

4 types of drugs: granulocyte colony-stimulating factor [special] injection (imported), Lixuesheng tablets, shark liver alcohol tablets, and inosine tablets injection .

3. Anti-infective drugs

"Antibiotics" (45 types) and "Antifungals" (5 types). ***50 kinds of medicines.

(5) Scope of anti-rejection drugs in kidney transplant clinic

Cyclosporine, prednisone, dexamethasone, methylprednisolone, azathioprine*** 5 kinds.

2. Scope and standards of basic medical insurance service facilities

(1) Ordinary bed fees

Ordinary bed fees are included in the payment scope of the basic medical insurance pooling fund. The ward without overall renovation is 16 yuan per bed day; the ward with overall renovation is 24 yuan per bed day; if the actual charges are lower than the above standards, the actual charges will be paid.

(2) The bed fees for the emergency observation room, emergency ward, and blood ward are included in the payment scope, and the charging standards approved by the Municipal Price Bureau shall be followed.

(3) The expenses for bone marrow transplantation and hematological disease chemotherapy that require hospitalization in a laminar flow ward due to illness can be included in the scope of payment.

(4) Enhanced wards shall be implemented in accordance with the Municipal Health Bureau's "Enhanced Ward (ICU) Admission Standards" (Jingwei Gong [1996] No. 8).

(5) The bed construction fees and bed checking fees for therapeutic family hospital beds established by community health service centers (stations) are included in the scope of payment.

(6) Heating expenses during hospitalization; the unit where the insured person works shall pay according to relevant regulations.

3. Basic medical insurance diagnosis and treatment items

(1) For artificial organs installed in the body, the maximum cost standard included in the payment scope is as follows:

1. Heart Pacemaker: 14,000 yuan per set for single chamber, 18,000 yuan per set for dual chamber, 6,000 yuan per set for temporary;

2. Heart valve: 7,000 yuan per set for biofilm, 7,000 yuan per set for mechanical membrane 8,000 yuan;

3. Intraocular lenses are 668 yuan each;

4. Artificial joints: artificial hip joints are 4,500 yuan per set, artificial knee joints are 5,000 yuan per set, and artificial femoral heads are 3,300 yuan per set;

5. The maximum payment standard for installing other artificial organs in the body is 18,000 yuan;

If the actual charges are lower than the above standards, the actual charges will be paid.

(2) Organ transplantation and tissue transplantation are included in the payment scope and fee standards as follows:

1. The payment scope is in accordance with the Municipal Labor and Social Security Bureau's "Notice on Issues Concerning Further Deepening the Reform of Publicly Funded Medical Care" "(Jinglao She Yifa [2000] No. 86) is implemented;

2. For hospital medical expenses for organ transplantation and tissue transplantation, individuals must first bear 2%, and the remaining expenses will be included Payment range.

(3) Large medical equipment and medical materials

The scope and use of reimbursement for large medical equipment shall be determined in accordance with the Municipal Health Bureau's "Interim Regulations on the Scope of Publicly Funded Medical Reimbursement for Large Medical Equipment and Valuable Medical Materials" Articles 1 to 6 of the document "Regulations" (Jingwei Gong [1998] No. 14) will be implemented.

Due to the needs of the condition, the expenses for examination and treatment using the equipment in Article 2 of the above-mentioned document (included in the "Reimbursement Scope of Large Medical Equipment") (including the expenses for single examination and treatment approved to be included in the reimbursement scope) are For items costing more than 200 yuan), individuals must first bear 8% of the cost and then the remaining costs will be included in the payment scope of the basic medical insurance fund.

(4) Community Health Service Centers (Stations)

The scope and standards of medical expense payment for community health service centers (stations) are based on the Municipal Labor and Social Security Bureau’s "About Publicly Funded Medical Treatment and Serious Disease Medical Treatment" "Notice on Issues Related to the Management of Insurance Community Health Services" (Jinglao Shefa [2000] No. 106) document implementation.

(5) Others

1. "Imaging Specifications" (Jingwei Gongzi [1996] No. 9) document execution;

2. Hyperbaric oxygen therapy, according to the Municipal Health Bureau's "Hyperbaric Oxygen Therapy Publicly Funded Medical Reimbursement Scope" (Jingwei Gongzi [1996] ] No. 7) document execution;

3. The cost of corrective surgery for sequelae of poliomyelitis is included in the payment scope of the basic medical insurance fund.

(6) Relevant expenses that are not included in the payment scope of the basic medical insurance fund:

Items that are not covered by the basic medical insurance fund shall be paid according to the Municipal Health Bureau's "About the Public Expenditure of Beijing Municipality" Article 4 of the annex "Measures for the Management of Publicly Funded Medical Care in Beijing" ([90] Jingwei Gongzi No. 100) and the Municipal Labor and Social Security Bureau's "Relevant Issues on Strengthening the Management of Publicly Funded Medical Care and Critical Illness Medical Insurance" Implementation of Article 2 of the Notice" (Jinglao She Yifa [2000] No. 90).

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