First, how to choose the first hospital?
Insured residents can choose one from the list of first-visit designated hospitals determined by residents' medical insurance as the first-visit designated hospital when seeking medical treatment. The first-time designated hospital can be re-selected once a year, but it will not be adjusted every medical year.
Second, how do residents seek medical treatment after insurance?
(1) Normal medical treatment in the first-visit hospital: When insured residents seek medical treatment due to illness, they should first go to the first-visit hospital of their choice (except emergency) and bring their own Medical Insurance Manual for Urban Residents. When the balance of the outpatient account of the first-visit hospital is insufficient, it can be paid in cash. When hospitalization or referral is needed, I will bring my Medical Manual to the medical department of the first-visit hospital to go through the relevant procedures, and I will be hospitalized normally according to the relevant regulations of residents' medical insurance.
(two) the normal medical treatment in the referral hospital:
Due to the limitation of the medical service level of the first-visit hospital, if it is necessary to transfer to the referral hospital for the treatment of difficult diseases, the insured residents should issue a referral approval form for urban residents in the first-visit hospital, carry the referral approval form to the medical insurance department of the referral hospital for referral hospitalization procedures, and be hospitalized normally according to the relevant provisions of residents' medical insurance, and discharge settlement.
Residents' medical insurance hospitalization expenses are settled by the standard system of hospitalization deductible line, and the standard of hospitalization deductible line is adjusted at 20 10 as follows: first-class hospitals: 350 yuan (adults) and 200 yuan (minors, college students); Secondary hospitals: 550 yuan/time (adults) and 400 yuan/time (minors and college students); Tertiary hospitals: 750 yuan (adults) and 600 yuan (minors and college students). Qifubiaozhun shall be borne by the insured residents themselves. If they are referred for hospitalization in the city, only one Qifubiaozhun will be charged for one hospitalization.
The hospitalization expenses are within the scope of the overall fund payment, above the deductible and below the maximum payment limit. The proportion of the overall fund payment is 60% in the first-class hospital, 55% in the second-class hospital and 50% in the third-class hospital, and the maximum payment limit of the overall fund is adjusted to 40,000 yuan/year 20 10.
(3) transfer to other places for medical treatment:
Insured residents who have difficulty in the first referral hospital in the overall planning area due to difficult diseases can be transferred to the top three hospitals in Beijing, Shanghai and Tianjin. The procedure of off-site referral is step by step referral, that is, the first-time hospital is transferred to the designated hospital for referral. If it is difficult to be treated in the designated referral hospital, the referral hospital will issue the Approval Form for Referral of Urban Residents and directly transfer it to the designated hospitals of basic medical insurance in Beijing, Shanghai and Tianjin for medical treatment.
The scope of referral hospitals is: specialist hospitals are responsible for the referral of diseases belonging to specialties, and general hospitals are responsible for the referral.
After the insured residents are referred for treatment, they shall go through the reimbursement procedures in the medical insurance department of the referral hospital with the referral approval form, hospitalization medical records, formal invoices, discharge certificates and detailed list of expenses. The hospitalization expenses are within the scope of the overall fund payment, above the deductible line and below the maximum payment limit, and the reimbursement ratio of the overall fund is 45%.
(4) emergency hospitalization:
Insured residents can be hospitalized in the emergency department of non-first-visit hospitals according to the principle of seeking medical treatment nearby. Emergency hospitalization expenses (excluding emergency outpatient service) will be reimbursed to the medical insurance department of the first-visit hospital of your choice with hospitalization records, formal invoices, discharge certificates and expense details after discharge.
Emergency hospitalization expenses belong to the scope of overall fund payment, above the deductible and below the maximum payment limit, and the proportion of overall fund payment is 50%.
(five) outpatient chronic diseases:
Insured residents who have been insured for one year and continue to pay fees in the second year can enjoy the reimbursement treatment of chronic diseases in outpatient department, which is divided into quarterly reimbursement and quota reimbursement.
1. Diseases reimbursed quarterly: hemodialysis after renal failure, taking domestic anti-rejection drugs after organ transplantation, radiotherapy for malignant tumors, chemotherapy and pulmonary heart disease.
(1) Insured residents who need outpatient dialysis due to renal failure should fill in the Identification Form of Chronic Diseases in Outpatient Department of Basic Medical Insurance for Urban Residents in Taiyuan City, go to the designated dialysis hospital for identification, and be examined and registered by the medical insurance department of the hospital. Meet the conditions, can be in the designated dialysis hospital outpatient dialysis.
(2) Those who take domestic anti-rejection drugs in the outpatient department for a long time after organ transplantation should fill out the application appraisal form for specific diseases in the insurance outpatient department of Taiyuan grass-roots hospital and go to the Second People's Hospital of Shanxi Province for appraisal. Eligible patients can enjoy the treatment of taking domestic anti-rejection drugs in outpatient department.
(3) The differentiation and treatment of pulmonary heart disease and malignant tumor that need radiotherapy or chemotherapy in outpatient department are in the first-visit hospital. If the first-visit hospital has difficulties in treatment, it will be transferred from the first-visit hospital to the referral hospital, fill in the application appraisal form for specific diseases in the basic medical insurance outpatient department of Taiyuan City, and go through the checkout formalities at the first-visit hospital every quarter.
(4) The chronic outpatient diseases of the insured residents shall be reimbursed quarterly, and the medical expenses shall be paid within three categories. In a medical year, the individual shall bear the expenses above Qifubiaozhun and below the maximum payment limit, 20% of which shall be paid by himself (category B projects will no longer pay the personal payment), and 80% shall be paid by the overall fund.
(5) List of inpatient dialysis hospitals: Second People's Hospital of Shanxi Province, Traditional Chinese Medicine Hospital of Shanxi Province, Taiyuan General Hospital, Second People's Hospital of Taiyuan City, Shanxi Coal Central Hospital, Eighth People's Hospital of Taiyuan City and Seventh People's Hospital.
2. Outpatient chronic diseases reimbursed according to the quota: type III hypertension (extremely high risk), coronary heart disease complicated with acute myocardial infarction, neurological deficit caused by cerebrovascular sequelae, diabetes complicated with heart disease, diabetes complicated with retinopathy, diabetes complicated with nephropathy, and diabetes complicated with acrogangrene.
(1) The materials required for its identification and the quota standard for its enjoyment:
The corresponding situation that the material required for the maximum payment limit of medical insurance is the name of the disease
Hypertension grade Ⅲ, extremely high-risk cardiopulmonary insufficiency grade Ⅲ (cardiac color Doppler EF
renal failure
(SCR 442 ~ 707μ mol/L) in-patient medical records
Renal function examination 80 yuan/month
Coronary heart disease complicated with acute myocardial infarction complicated with cardiac function Ⅲ
(heart color Doppler ef
Inpatient medical records
100 yuan/month
Hospitalized medical records after coronary stent implantation
100 yuan/month
After coronary artery bypass grafting 100 yuan/month
Cerebrovascular sequelae
Treatment of neurological deficit The score of neurological deficit caused by cerebrovascular disease is greater than 16.
80 yuan/month
Diabetes mellitus complicated with heart disease and myocardial infarction (cardiac color Doppler ef
Diabetic retinopathy complicated with fundus fluorescein angiography is consistent with the hospitalization records of diabetic retinopathy (stage ⅳ)
Fundus fluorescein angiography 100 yuan/month
Diabetic Nephropathy Over Stage ⅳ Diabetic Nephropathy Hospitalized Medical Records
24-hour urine protein quantitative test report > 0.5g (last month) 100 yuan/month.
Diabetes complicated with acromegaly Diabetic foot and acromegaly open skin lesions invade deep muscle tissue, accompanied by cellulitis and skin necrosis. Hospitalization medical record 100 yuan/month.
Remarks: Hospitalization medical records: ① All positive indicators should be included.
(2) The inpatient medical records of general hospitals above Grade II A six months ago.
(2) Insured residents hold the personal basic medical insurance diagnosis and treatment manual, and bring the required materials (see the attached table) to the medical insurance department of the selected first-visit hospital for preliminary examination before the end of each year 10 (the first-visit hospital must be the first-visit hospital selected by patients in the following year), and fill in the outpatient chronic disease approval form.
(3) The Hospital Insurance Department will report the list of qualified personnel in the preliminary examination to an urban agency before1/month 10 every year, and the Taiyuan Medical Insurance Center and the urban agency will organize expert review, and the information of eligible insured personnel will be publicized in urban agencies and hospitals for the first time. Those who have no objection after publicity will enjoy the treatment of the following year 1 month.
(4) In accordance with the provisions, issue the Medical Certificate for Specific Diseases in the Outpatient Department of Basic Medical Insurance for Urban Residents in Taiyuan City.
(5) Outpatients with chronic diseases go to the first-visit hospital for outpatient treatment of chronic diseases with the Medical Certificate of Special Diseases in the Basic Medical Insurance for Urban Residents in Taiyuan.
(6) Insured patients who enjoy the outpatient chronic disease quota payment can purchase medicines with prescriptions issued by doctors in the first-visit designated hospitals, and the patients pay 20% of the personal part, and the proportion of self-payment will no longer be deducted for the second-class items. The remaining expenses shall be settled quarterly by urban agencies and designated first-visit hospitals.
(7) Outpatient chronic diseases are paid in the form of subsidies every year, which are adjusted year by year according to the fund balance.
(8) The insured can enjoy outpatient chronic disease treatment in the quarter of death, and stop enjoying outpatient chronic disease treatment from the quarter of death.
(9) Patients with pulmonary heart disease and advanced postoperative chemotherapy of malignant tumor should be treated in the first hospital in principle. In principle, patients with difficulties in hospitalization can be transferred from the first-visit hospital to the referral hospital for treatment, and the reimbursement method is deductible once a year. After the end of each quarter, bring the Approval Form for Chronic Diseases in Outpatient Department and the Application Form for Reimbursement of Medical Expenses, invoices, diagnosis certificates and other related materials to the first-visit hospital for reimbursement. Basic medical expenses in medical insurance coverage, the individual pays 20% (not deducted for Class B items first), and the overall fund pays 80%.
(10) Outpatients with chronic diseases cannot change hospitals within one year.
(1 1) Outpatient chronic diseases are identified once a year.
(12) The amount of outpatient chronic disease subsidy is included in the overall maximum payment limit.
(6) Family sickbed:
(1) Insured residents can apply for family beds in the first-visit hospital due to sequelae of cerebrovascular accident, advanced malignant tumor and fracture traction.
(2) Handling formalities: fill in the application form for family sickbed, bring the diagnosis proposal, pathological examination report or CT and X-ray report, and go through the examination and approval formalities in the medical insurance department of the hospital. Each course of treatment shall not exceed two months. If it is necessary to continue treatment after the time limit, the relevant procedures shall be re-handled. You must be hospitalized in a designated hospital at the same time during your family bed, and you can't prescribe drugs unrelated to your illness. The reimbursement method and proportion of family bed expenses are the same as hospitalization.
(seven) maternity expenses reimbursement:
For insured residents who have paid for more than two years continuously, the maternity hospitalization expenses that meet the requirements of the national, provincial and municipal family planning policies during the insured period will be paid by the overall fund limit, and the limit standard will be adjusted from 20 10 to 1200 yuan (including prenatal examination expenses 100 yuan).
Medical expenses incurred by insured residents during hospitalization and delivery (natural delivery, midwifery and cesarean section). Within nine months from the date of settlement, take the medical manual, birth certificate of family planning and its copy, one-child certificate and its copy, hospital baby birth certificate and its copy, discharge certificate, formal invoice, expense details and other materials to the selected first-visit hospital for settlement.
Three, the use of outpatient medical insurance fund for insured residents
(1) In 2009, newly insured urban residents established outpatient medical pooling fund according to 40 yuan/year for adults and 20 yuan/year for minors; Urban residents who have been insured in 2008 will continue to be insured in 2009, and the outpatient medical co-ordination fund will be established according to 80 yuan, an adult, and 40 yuan, a minor. The outpatient medical co-ordination fund is only used in the first-visit hospitals (preschool children should also be used in the first-visit hospitals of non-provincial and municipal maternal and child health hospitals).
(2) Insured residents can use the outpatient medical co-ordination fund to pay the outpatient or hospitalization expenses of the first-visit hospital or hospitalization settlement I choose, and the insufficient part of the individual outpatient medical co-ordination fund will be paid by the insured residents in cash.
(3) When the insured residents use the outpatient medical pooling fund, the first-visit hospital should issue a statement for the insured residents and guide them to sign it.
(4) if there is a balance in the outpatient medical co-ordination fund of the insured during the year, the balance will be transferred to the next year to continue to be used (except for not continuing to participate in the insurance or dying in the next year).
Four, college students residents medical insurance special provisions
1. The medical year of the insured college students is a natural year, that is, every year 10/to February 1 to 3 1.
2. New college students who participate in the medical insurance for residents in this co-ordination area can be counted as a medical year from June 5438+00 to June 5438+02 in the first year of insurance, but they do not enjoy the outpatient medical co-ordination account.
3. Insured college students can arbitrarily choose a designated hospital for the first visit of residents as the first visit hospital (not limited by the school hospital). Hospitalization, emergency treatment, accidental injuries, chronic diseases and maternity expenses are all implemented according to the relevant policies of residents' medical insurance.
4. The medical expenses incurred by the insured college students in their place of residence due to illness and holidays shall be paid by themselves first, and then reimbursed to the first-visit hospital in the normal way after returning to school.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.