1. The liquidation scope of the new rural cooperative medical system refers to the medical expenses, inspection expenses, inspection expenses, operation expenses, treatment expenses and nursing expenses incurred by the insured in the outpatient department of the designated hospital due to illness during the overall planning period, which meet the liquidation scope of the medical insurance for urban employees (i.e. effective medical expenses).
Second, the payment of the new rural cooperative medical fund has set a threshold and a maximum payment limit. The annual payment standard of hospitalization medical expenses in our hospital is 1 1,000 yuan, and the hospitalization expenses below the annual payment standard are paid by individuals. If the payment standard is reached in the same unified period, the hospitalization expenses for more than two hospitalizations can be accumulated and settled. The hospitalization expenses exceeding the initial payment standard shall be calculated by stages and settled cumulatively, and the maximum amount per person per year shall be 50,000 yuan.
Segmentation standard and liquidation proportion of new rural cooperative medical system in Kecheng District.
100 1 yuan-5,000 yuan, with 30% liquidation.
50,065,438+0 yuan-65,438+00,000 yuan, 35% liquidation.
1000 1 yuan-25,000 yuan, with 45% settlement.
2500 1 yuan, 50% liquidation.
Qujiang district new rural cooperative medical system liquidation amount segmentation standard, liquidation ratio, etc.
65,438+0,000 yuan-65,438+0,000 yuan, with 30% settlement.
1 0,000 yuan-20,000 yuan, 35% liquidation.
More than 20 thousand yuan, 40% liquidation.
Three, the specific outpatient treatment costs of special diseases can be regarded as the settlement of hospitalization expenses, once every three months. The liquidation standard is the same as the general hospitalization effective medical expenses.
Qujiang district new rural cooperative medical care fund pays for special diseases
(1) Treatment of Malignant Tumors
(2) Hemodialysis and peritoneal dialysis for chronic renal failure.
(3) Anti-rejection therapy of organ transplantation
(4) Aplastic anemia
(5) Psychiatric treatment
(6) Systemic lupus erythematosus (one of the complications of heart, lung, kidney, liver and nervous system).
The special diseases paid by the new rural cooperative medical fund in Kecheng District are as follows
(1) Chemotherapy and radiotherapy for malignant tumor
(2) Hemodialysis and peritoneal dialysis for severe uremia.
(3) Anti-rejection therapy after tissue or organ transplantation
(4) Schizophrenia with mental retardation
(5) Systemic lupus erythematosus (one of the complications of heart, lung, kidney, liver and nervous system)
(6) Aplastic anemia
(7) Anticoagulation after cardiac surgery.
Specific outpatient treatment of special diseases includes necessary supportive treatment and symptomatic treatment of systemic and local reactions during treatment, while general adjuvant treatment is not included in the liquidation scope.
Four, the following circumstances are not included in the liquidation scope of the new rural cooperative medical system:
(1) Outpatient medical expenses of designated hospitals in non-co-ordination areas (except outpatient treatment expenses for special diseases), and expenses incurred from purchasing drugs without going to see a doctor according to regulations.
(2) the cost of family planning measures and medical expenses in violation of the family planning policy.
(3) Dental implants, orthodontics, ophthalmoscopy, hearing AIDS, artificial organs, beauty treatment, plastic surgery, rehabilitation (Qigong, massage, physical therapy, magnetic therapy, etc. ) and various escort fees, consulting fees, other miscellaneous expenses during hospitalization, etc.
(4) If a third party is responsible, the medical expenses incurred due to personal injury, such as traffic accidents, medical accidents and industrial accidents, shall be borne by the third party according to law.
(5) Medical expenses for suicide, self-mutilation, drug abuse, drug abuse, quarrel and other illegal acts. And deliberately hurting their families.
(6) Medical expenses incurred abroad or in Hongkong, Macau and Taiwan Province Province.
(7) Drugs and articles not settled according to the medical insurance system for urban workers.
(8) Other non-liquidation expenses decided by the district medical management.