I. Reimbursement rate

Proportion of reimbursement for medical expenses of urban workers:

Proportion of hospitalization reimbursement:

Qifubiaozhun:

First hospitalization: Grade I: 100 yuan; Technical secondary school 300 yuan; Three-level 880 yuan.

Second hospitalization: level 1: 30 yuan; Technical secondary school 90 yuan; Three-level 264 yuan.

Level 3 and above hospitalization: level 1: 0 yuan; Middle school 0 yuan; Three-level 0 yuan.

Note: Qifubiaozhun over 70 years old is halved.

Payment part:

1, Class B drugs, special inspection and special treatment: Class B drugs 3%, special inspection and special treatment10%;

Disposable medical materials and artificial organs over 2,200 yuan: 10% made in China and 20% imported;

3. Out-of-range drugs used for rescue: 40%.

Total compensation part:

Overall self-payment part = [total hospitalization expenses-(Qifubiaozhun+first self-payment part+full self-payment part) ]× self-payment ratio.

On-the-job employees: Grade 1 9%, Grade 2 12%, Grade 315%;

Retired employees: 5% for Grade I, 8% for Grade II and11%for Grade III;

Outpatient reimbursement ratio:

1, general outpatient service

Personal full payment

2, outpatient special examination, special treatment

The individual pays 30% of the examination and treatment expenses, and the basic medical expenses are reimbursed as a whole by 70%.

Note: Special examination and treatment are required in the outpatient department of the second-class hospital or above.

3. Chronic disease outpatient service

In a natural year, regardless of hospital level, the first Qifubiaozhun is 550 yuan. After exceeding the Qifubiaozhun, 80% will be paid by the overall fund and 20% by the individual;

Note: the maximum payment limit of the overall fund in each natural year is 2000 yuan (limited to drug expenses). If two or more "special chronic diseases" are identified through inspection, the maximum payment limit will be raised to 3,000 yuan, and the drug expenses exceeding the maximum payment limit will not be reimbursed.

4, special disease outpatient service

Patients with "special diseases" identified by the audit shall be reimbursed for outpatient expenses according to hospitalization within a natural year.

Proportion of reimbursement for medical expenses of urban and rural residents:

Hospitalization:

1, the deductible line of medical institutions of level I and below is 100 yuan, and the reimbursement rate is 85%;

2. The Qifubiaozhun for secondary medical institutions is 300 yuan, and the reimbursement rate is 75%;

3, tertiary hospitals Qifubiaozhun for 600 yuan, reimbursement rate of 60%;

Outpatient medical treatment:

The outpatient medical expenses and hospitalization medical expenses incurred by the insured in the designated primary medical service institutions shall be reimbursed by the overall fund by 50%, and the maximum payment limit shall be 400 yuan within a natural year;

Second, the scope of reimbursement

Urban and rural medical insurance expenses will not be reimbursed:

(1) Define the medical expenses paid by the industrial injury insurance fund;

(2) Traffic accidents (except the relevant escape certificate issued by the public security traffic management department), accidents, medical accidents, etc. This is obviously the responsibility of a third party;

(3) It should be borne by public health;

(4) Going abroad for medical treatment;

(5) Other expenses that shall not be paid according to laws and regulations.

Third, the reimbursement conditions

Individuals begin to enjoy medical insurance benefits after six months of continuous payment for the first time.

Fourth, reimbursement materials

1, outpatient medical records

2, discharge summary

3. Disease certificate

4, hospitalization fee receipt (invoice)

5. List of hospitalization expenses

6. Medical insurance IC card (insured students without a card must provide medical insurance payment receipt and their ID card or household registration book)

7. For reimbursement of hospitalization expenses in different places, provide the original and photocopy of the certificate of the unit (community neighborhood committee/school) or the Registration Form for Persons Living in Different Places or Going Abroad in Kunming to Choose Designated Medical Institutions in Different Places.

8. For special reasons, if you can't settle the card directly in the designated hospital, provide relevant certificates and explanations for medical treatment.

9. If an agent is entrusted, the applicant's power of attorney and the original and photocopy of the agent's ID card (original inspection) shall be provided.

10, insured residents must provide a two-way referral form when referring to the hospital for medical treatment.