Year-old residents (men over 60 years old, women over 55 years old and above) are eligible for financial subsidies.

Medical insurance benefits

(1) General outpatient services

For general outpatient medical care for urban residents, the first consultation system at designated community health service institutions is implemented. Insured residents choose a community health service institution designated by comprehensive medical insurance as their first medical institution. Fixed-amount subsidies are provided for outpatient medical expenses. Ordinary outpatient medical expenses incurred by insured residents at designated community health service institutions that are within the payment scope of basic medical insurance will be paid by the basic medical insurance co-ordinating fund at a rate of 30%. In one year, the total reimbursement amount will not exceed 30%. If the amount exceeds 30 yuan, the registered first-diagnosis designated medical institution will first pay in advance, and the medical insurance agency will pay it from the pooling fund every quarter. General outpatient management measures will be formulated separately.

(2) Emergency outpatient clinic

The longest emergency observation time for insured residents shall not exceed 3 days. If one of the following conditions is met, the medical expenses during the emergency observation period shall be as follows: Settlement of hospitalization medical expenses. If it is lower than the minimum payment standard, the subsidy can be based on the general outpatient standard. When reimbursing medical expenses incurred in outpatient emergencies, valid certificates such as emergency department certificates, original invoices, outpatient medical records, and prescriptions should be provided.

1. Those with body temperature (underarm) above 39°C;

2. Various acute bleeding;

3. Various acute inflammations accompanied by high fever (T38°C or above);

4. Shock caused by various reasons;

5. Various acute accidental injuries (excluding injuries caused by traffic accidents and fights);

6. Various acute accidental poisonings;

7. Acute heart failure, myocardial infarction, arrhythmia;

8. Acute abdomen;

9. Acute urinary tract disease, anuria, hematuria, acute renal failure;

10. Hypertensive encephalopathy, cerebrovascular accident;

11. Coma, convulsions, Epileptic seizures;

12. Acute allergic diseases.

(3) Hospitalization

If urban residents are hospitalized due to illness and meet the medical insurance hospitalization disease catalog, they must present the admission notice issued by the designated medical institution and the "Urban Residents Basic Medical Insurance Card" 》Go to the medical insurance office or hospitalization department of any comprehensive designated hospital to complete relevant procedures. If the condition is stable and requires long-term hospitalization, with the approval of the medical insurance agency, the patient can be transferred to a designated community medical institution to continue treatment.

(4) Referral and transfer

1. Principles of referral and transfer

Referral and transfer generally follow the following principles: first within the city and then outside the city, and transfer step by step For diagnosis, common diseases and frequently-occurring diseases are admitted to the community; urban hospitals can refer each other, but they are not allowed to be transferred to non-comprehensive designated hospitals in the city; transfers are not allowed outside the city to hospitals that have not been approved by the local government as comprehensive designated hospitals for medical insurance.

2. Transfer within the city

If urban residents really need to be transferred to another hospital for treatment, the transferring medical institution must fill out the "Jining Basic Medical Insurance Referral Approval Form" and report it to the medical institution. Insurance agency registration. Transfers between designated medical institutions in the city are regarded as one hospitalization, and the deductibles are calculated together. If the deductibles of the transferring hospital are higher than those of the transferring hospital, the difference should be paid.

3. Transfer from outside the city

If critical and difficult diseases that cannot be diagnosed and treated due to technical and equipment conditions in the coordinating area really need to be transferred to a hospital, they will be transferred to a tertiary hospital or a municipal specialist hospital. Fill out the "Jining Basic Medical Insurance Referral Approval Form" and the social medical insurance agency will review and approve it. A transfer from outside the city is regarded as a hospitalization, and the minimum payment standard is based on that of a tertiary hospital. Expenses that are within the scope of medical insurance payment will be reimbursed according to the prescribed proportion after the individual bears 10%. After the patient is discharged from the hospital, he or she will be sent to the transferring hospital for review and reimbursement based on the transfer approval form, discharge diagnosis, detailed list of expenses, copies of hospitalization medical records and valid expense receipts. The transferred hospital shall upload details of medical expenses in accordance with relevant regulations and hospitalization management methods, and settle and reimburse the insured residents. The medical insurance agency shall review the fees payable for out-of-city referrals and transfers to designated hospitals every month and then allocate them to designated hospitals. For those who are transferred outside the city, after the diagnosis is clear or the condition is stable, those who have treatment conditions in this city should return to this city for treatment. The maximum time for referral to another hospital shall not exceed two months. If treatment is really needed after the expiration of the period, the patient must go to the social medical insurance agency to apply for extension of treatment procedures.

(5) Medical treatment in other places

1. Urban residents who live away from home for a long time should choose a local medical insurance designated hospital as their designated hospital, and the township where they are insured and registered (Subdistrict Office) handling personnel should fill in the "Jining City Basic Medical Insurance Resettlement Personnel Medical Registration Form" and report it to the social medical insurance agency for record. When insured residents are hospitalized, they should go to the selected hospital for medical treatment and report to the medical insurance agency within 5 days after admission. After discharge, they should bring the hospital's valid medical documents, a copy of the hospitalization medical record and a detailed list of medical expenses to the medical insurance agency. to reimburse. If transfer is required for treatment, the selected medical institution shall issue a transfer certificate and submit it to the medical insurance agency for approval.

2. If an insured person suffers an emergency, critical or serious illness due to reasons such as going out or visiting relatives and needs to be hospitalized or observed in the emergency department of a local hospital, the patient must report to the social medical insurance agency within 3 days after admission. . Valid medical expense documents, emergency certificates, outpatient medical records, inpatient medical records and a detailed list of medical expenses must be provided when reimbursing. The medical expenses will be reimbursed according to the prescribed proportion after first paying 5% out of pocket.

(6) Outpatient treatment of special diseases

1. Scope of diseases

Special diseases are divided into two categories: Category A and Category B. Insured residents who apply for special disease outpatient treatment must comply with the diseases specified in the special disease outpatient treatment catalog. Category A diseases include: (1) uremia; (2) organ transplantation; (3) malignant tumors. Category B diseases include: (1) Type I and II diabetes (combined infection or one of heart, kidney, liver, or neurological complications); (2) Stage III hypertension; (3) Coronary heart disease; (4) Cerebral hemorrhage and cerebral infarction (recovery stage); (5) Cor pulmonale (with right heart failure); (6) Bronchial asthma; (7) Rheumatoid arthritis (active stage); (8) Chronic hepatitis (high ALT) More than 2 times the normal value); (9) Psoriasis; (10) Permanent hypothyroidism; (11) Rheumatic heart disease; (12) Prostatic hyperplasia; (13) Myasthenia gravis; (14) Parkinson's disease syndrome; (15) peptic ulcer; (16) hyperthyroidism; (17) femoral head necrosis; (18) cervical and lumbar spondylosis; (19) peripheral vascular disease; (20) mental illness; (21) aplastic Anemia; (22) Systemic lupus erythematosus; (23) Tuberculosis.

2. Identification time and required materials

Type A diseases are identified at any time, and Type B diseases are identified on the 10th to 15th of the first month of each quarter. If an insured resident suffers from two or more special diseases, he or she can apply at the same time; when applying, the insured resident's ID card, "Basic Medical Insurance Card", and "Jining Basic Medical Insurance Special Disease Outpatient Treatment Approval" should be presented. Form" and copies of inpatient medical records, diagnostic certificates, pathology reports, inspection report forms and other relevant materials issued by second-level hospitals or above, go to the municipal special disease management center for identification. The appraisal standards shall be implemented in accordance with the relevant provisions of the basic medical insurance for urban employees.

3. Medical treatment

Insured residents who are identified as suffering from special diseases can seek medical treatment at any of the comprehensive designated hospitals determined by the Municipal Labor and Social Security Bureau according to their own wishes. Choose a hospital as your designated hospital for outpatient treatment and change it within one year. If the designated hospital really needs to be referred for medical treatment or go out to purchase medicine due to medical conditions, the designated hospital must fill out the "Jining Basic Medical Insurance Special Disease Outpatient Referral Approval Form" and submit it to the social medical insurance agency for approval. Outpatient medical expenses for special diseases are reviewed and settled on a calendar year basis. Persons identified as outpatient treatment for special diseases must strictly follow the provisions of the basic medical insurance to seek medical treatment and purchase drugs. Medical expenses and diagnosis and treatment incurred in designated hospitals for non-special diseases are not special. Medical expenses for approved diseases will not be reimbursed by the unified fund.

4. Payment method

The minimum payment standard for outpatient special diseases is 900 yuan. For medical expenses above the minimum standard, adult residents pay 50%; minor residents pay 60% % is paid.

(7) Each year, 50% of the balance of the Urban Resident Basic Medical Insurance Fund will be withdrawn to subsidize urban residents’ medical expenses or establish large-scale medical assistance. The withdrawal proportion will be adjusted in a timely manner according to the operation of the fund. Specific measures shall be formulated separately by the medical insurance agency and submitted to the competent department for approval.

(8) Expenses not covered by the medical insurance fund

1. Medical expenses incurred in non-designated medical institutions (except emergency cases);

2. Medical expenses incurred during the period of interruption of payment;

3. Outpatient medical expenses incurred due to accidental injuries (except students);

4. Incurrences of illegal crimes, fights, alcoholism, drug abuse, etc. Medical expenses;

5. Medical expenses incurred for suicide or self-mutilation (non-mental illness);

6. Medical expenses incurred during going abroad and arriving in Hong Kong, Macao and Taiwan;

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7. Childbirth and related expenses;

8. Medical expenses incurred in traffic accidents, medical accidents and other liability accidents;

9. Lifestyle plastic surgery and plastic surgery ;

10. Other medical expenses that do not meet the payment regulations of basic medical insurance