First, outpatient expenses.
(1) Reimbursement scope: general outpatient and emergency expenses incurred by the insured in designated medical insurance hospitals or specialized hospitals, traditional Chinese medicine hospitals and 3A hospitals (Friendship, Xuanwu, Guang 'anmen Traditional Chinese Medicine, Tongren, Sheikh, Third Hospital of Beijing Medical University, Peking University People, Peking University One, Jishuitan, Chaoyang, Gong Jian and Liangxiang).
(2) Reimbursement ratio: the total emergency expenses of general outpatient clinics in a natural year exceed 2,000 yuan, 50% of which are paid by some large medical mutual funds with a price of more than 2,000 yuan, and 50% are paid by individuals themselves. The retirees have accumulated more than 1.300 yuan, and the part that exceeds 1.300 yuan is covered by the large medical mutual aid fund over 70 years old, with 70% paid by individuals, 30% paid by individuals, 80% paid by the large medical mutual aid fund over 70 years old and 20% paid by individuals. The maximum payment limit in a natural year is 20000 yuan.
(3) Medical management: individual cash payment for general outpatient and emergency expenses, and the medical expenses incurred shall conform to the scope of the three major medical insurance catalogues. When purchasing drugs, special prescriptions should be issued in designated hospitals and stamped with the special seal for medical insurance outsourcing, and then drugs should be purchased in designated pharmacies.
(4) Reimbursement process: If the cumulative Qifubiaozhun exceeds the minimum Qifubiaozhun in a natural year, the insured shall submit the documents to the unit or social security office, which will enter the documents into the enterprise version and declare the electronic information and documents to the medical insurance center. The medical insurance center will complete the examination, settlement and payment within 15 working days.
(5) Application materials: general outpatient and emergency receipts, medical insurance prescriptions (dual-price prescriptions), and details of examination and treatment expenses.
(VI) Date of declaration: every month1-20th, the expenses of the current month will be declared next month, and the expenses of the current year will be declared again before1October 20th, 65438+.
Second, the hospitalization expenses
(1) Reimbursement scope: hospitalization expenses incurred by the insured in designated hospitals or specialized hospitals, Chinese medicine hospitals and 3A hospitals selected by the individual.
(2) Reimbursement ratio: The minimum threshold for the first hospitalization in a natural year is 1.300 yuan, and 650 yuan every time thereafter. The payment ratio is divided into three grades. Take a tertiary hospital as an example. The floating standards are: 30,000 yuan, 85% on the job, 9 1% for retirement, 90% for 30,000-40,000, 94% for retirement, more than 40,000, 95% for employment and 97% for retirement. 90 days of general hospitalization is a settlement cycle. Psychiatric hospitalization for 360 days is a settlement cycle, and the floating standard is halved. In a natural year, the overall fund pays a maximum of 70,000 yuan. The maximum hospitalization amount is 654.38+10,000 yuan, and the hospitalization ratio is 70%.
(3) Medical management: Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays in full, the individual only needs to pay part of the hospitalization prepayment to go through the hospitalization procedures. The medical expenses incurred should conform to the scope of the three major catalogues of medical insurance.
(IV) Reimbursement process: When leaving the hospital, the hospital and the individual will settle the self-funded and self-funded amount, and the reimbursement amount of the overall fund will be settled by the hospital and the district medical insurance center.
Third, outpatient special diseases
(1) Reimbursement scope: outpatient medical expenses incurred by the insured after going through the examination and approval procedures for special diseases due to radiotherapy and chemotherapy for malignant tumors, renal dialysis and taking anti-rejection drugs after renal transplantation.
(2) Reimbursement ratio: Reimbursement ratio is the same as hospitalization. The settlement period of outpatient special diseases is 360 days.
(3) Medical management: the insured can only choose one hospital as the designated hospital for special diseases. Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays the full amount, the individual only needs to pay the personal out-of-pocket expenses and the self-funded part, and the reimbursement amount of the overall fund is settled by the hospital and the district medical insurance center.
(4) Reimbursement process: the insured submits the documents to the unit or social security office, and the unit declares the documents to the medical insurance center. The medical insurance center completed the audit, settlement and payment on the same day.
Fourth, the scope of medical insurance reimbursement in Beijing
(a) western medicine and Chinese patent medicine, in accordance with the municipal health bureau "on the issuance of the notice" (Beijing word [1997]No. 15) and "closed liver implementation supplementary opinions" (Beijing word [1998] No.2) file execution.
The expenses marked "part to be borne by individuals" in drugs shall be borne by individuals first, and the rest shall be included in the payment scope of the basic medical insurance fund.
(2) Hospital preparations; According to the Notice on Implementation issued by the Municipal Health Bureau (J.Z. [1999] No.2).
(three) the scope of payment and use of Chinese herbal pieces
1. Chinese herbal pieces that need to be borne by individuals shall be implemented according to the first article of the Notice of the Municipal Health Bureau (No.267 [77] of Beijing Municipality).
2. The single use of Chinese herbal pieces and the rational use of compound prescription due to illness (not exceeding the normal dosage) shall be handled according to Article 2 of the Notice on Inspection (No.267 [77] of Beijing Municipal Health Bureau).
3. The expenses for the rational use of the above-mentioned 1 and 2 kinds of Chinese herbal pieces during the rescue of critically ill patients shall be included in the payment scope of the basic medical insurance fund.
(four) the scope of payment of chemotherapy drugs for malignant tumor outpatient service
When the insured carries out radiotherapy and chemotherapy for malignant tumors in the outpatient department, the following drugs can be included in the payment scope of the basic medical insurance fund:
1. tumor drug therapy
In addition to cantharidin tablets, immune ribonucleic acid injection and thymosin injection, there are 59 kinds of Chinese and western medicines "Eleventh Class Tumor Drugs" within the scope of reimbursement of free medical care and labor insurance medical care in Beijing.
2. Leukopoiesis promoting drugs
Granulocyte colony stimulating factor [special] injection (imported), reserpine tablets, shark liver alcohol tablets, inosine tablets injection.
3. Anti-infective drugs
There are "antibiotics" (45 kinds) and "antifungal drugs" (5 kinds) among the "Class I anti-infective drugs" within the scope of reimbursement for free medical care and labor insurance medical drugs in Beijing. ***50 drugs.
(five) the scope of anti-rejection drugs in renal transplant clinics
Cyclosporine, prednisone, dexamethasone, methylprednisolone and azathioprine.
Two, the basic medical insurance service facilities and standards
(1) ordinary bed fee
Ordinary bed fees are included in the basic medical insurance fund payment scope. The wards that have not been completely renovated are 16 yuan/bed day; After the overall transformation, every bed in the ward will be 24 yuan; If the actual cost is lower than the above standard, it shall be paid according to the actual cost.
(two) emergency observation room, rescue ward, blood ward bed fees included in the scope of payment, the implementation of the Municipal Price Bureau approved charges.
(three) bone marrow transplantation, chemotherapy for hematological diseases need to live in laminar flow ward due to illness, which can be included in the scope of payment.
(four) to strengthen the ward construction, according to the Municipal Health Bureau "ICU admission standards" (Beijing [1996] No.8) file execution.
(five) the community health service center (station) to establish a therapeutic family bed construction fees, bed inspection fees included in the scope of payment.
(six) heating costs during hospitalization; By the insured units in accordance with the relevant provisions to be paid.
Three, the basic medical insurance treatment project
(1) The maximum cost of artificial organs installed in human body included in the payment scope is as follows:
1. Pacemaker: single cavity 14000 yuan/set, double cavity 18000 yuan/set, temporarily 6000 yuan/set;
2. Heart valves: 7,000 yuan for each set of biomembrane and 8,000 yuan for each set of mechanical membrane;
3. Each intraocular lens is 668 yuan;
4. Artificial joint: 4,500 yuan for each set of artificial hip joint, 5,000 yuan for each set of artificial knee joint and 3,300 yuan for each set of artificial femoral head;
5. The highest payment standard for installing other artificial organs in the body is 18000 yuan;
If the above actual charges are lower than the above standards, they shall be paid according to the actual charges.
(two) organ transplantation and tissue transplantation are included in the scope of payment, and the cost standards are as follows:
1. The scope of payment shall be implemented according to Article 3 of the Notice of the Municipal Labor and Social Security Bureau on Further Deepening the Reform of Free Medical Care (No.86 [2000] of Beijing Labor and Social Security Bureau);
2. The hospitalization expenses for organ transplantation and tissue transplantation shall be borne by the individual first, and the rest shall be included in the scope of payment.
(three) large medical equipment and medical materials
The reimbursement scope and use of large-scale medical equipment shall be implemented according to Articles 1 to 6 of the Interim Provisions of the Municipal Health Bureau on the Reimbursement Scope of Large-scale Medical Equipment and Expensive Medical Materials for Free Medical Care (Beijing [1998] 14).
The expenses for examination and treatment (including those items that are approved to be included in the reimbursement scope of personal examination and treatment expenses and above 200 yuan) by using the equipment in Article 2 of the above-mentioned documents (included in the reimbursement scope of large-scale medical equipment) shall be borne by the individual first, and the rest expenses shall be included in the payment scope of the basic medical insurance fund.
(4) Community health service center (station)
The scope and standard of payment of medical expenses in community health service centers (stations) shall be implemented according to the Notice of the Municipal Labor and Social Security Bureau on Issues Related to the Management of Community Health Services for Free Medical Care and Serious Illness Medical Insurance (No.2000106 issued by Beijing Labor and Social Security Bureau).
(5) Others
X-ray computed tomography and magnetic resonance imaging (1. X-ray computed tomography and magnetic resonance imaging) shall be implemented in accordance with the document "X-ray computed tomography technology and magnetic resonance imaging specification" issued by the Municipal Health Bureau (J.W.G. Zi [1996] No.9).
2. Hyperbaric oxygen therapy, according to the municipal health bureau "hyperbaric oxygen therapy medical reimbursement scope" (Beijing word [1996] No.7) file execution;
3 polio sequelae correction surgery fees included in the basic medical insurance fund payment.
(six) related expenses not included in the scope of payment of the basic medical insurance fund:
The basic medical insurance fund does not pay the project, according to the Municipal Health Bureau "on the issuance of the notice" (90) execution. 100) Annex Article 4 of the Measures for the Administration of Public Medical Care in Beijing and Article 2 of the Notice of the Municipal Labor and Social Security Bureau on Strengthening the Management of Public Medical Care and Serious Illness Medical Insurance (No.90 [2000] of Beijing Labor and Social Security Bureau) shall be implemented.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.