From June 65438+1 October1day, provincial and Changsha-Zhuzhou-Xiangtan medical insurance general clinics can be included in the scope of medical insurance reimbursement (other areas in the province are being opened one after another). After the official implementation of this policy, many patients will ask the staff every day when they are in hospital for treatment or settlement: Can this be reimbursed? How much can I reimburse? Can outpatient examinations and prescriptions be reimbursed? I am a soldier's family member. Should I bear the expenses below the deductible?
Today, we invite the Medical Insurance Management Section of Hunan Armed Police Corps Hospital to interpret the economic policy of medical insurance outpatient service for everyone. Let's have a look!
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1. What is the general outpatient co-ordination of employee medical insurance?
answer
The outpatient medical expenses incurred by the insured in the designated medical institutions for outpatient co-ordination shall be paid by the employee medical insurance co-ordination fund according to regulations, so as to reduce the outpatient medical burden of the insured.
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2. What is the policy basis?
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Guiding Opinions of General Office of the State Council on Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance (Guo Ban Fa [202 1] 14) and Implementation Opinions of General Office of Hunan Provincial People's Government on Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance (Zheng Xiang Ban Fa [2022] 12),
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3. Who is the employee medical insurance outpatient co-ordination policy applicable to?
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Applicable to medical insurance for employees at the same level in Hunan Province, Changsha City (Neiwu District, Wangcheng District, Liuyang City, Changsha County and Ningxiang City), Zhuzhou City and Xiangtan City. Including flexible employees and retirees (must be in a state of non-stop insurance and non-stop insurance).
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4. How to realize outpatient reimbursement?
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Outpatient payment, inform the settlement window staff to use outpatient co-ordination for reimbursement, and show medical insurance electronic certificate, ID card or social security card (one of three choices) for reimbursement and pay the self-funded part.
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Is there an upper limit for the reimbursement of outpatient co-ordination
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Yes Every year, 65438+1 October1to 65438+February 3 1 is the year of treatment enjoyment. At present, it is stipulated that the maximum annual reimbursement amount for employees within one year is 1500 yuan, and the maximum annual reimbursement amount for retirees is 2,000 yuan. Qifubiaozhun (Qifubiaozhun) 300 yuan/year (Qifubiaozhun for tertiary hospitals).
(Note: The military can further reduce or exempt (spouse)/give preferential treatment (parents) if the overall outpatient expenses of the military exceed the ceiling line.
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6. Can the total expenses be reimbursed if they fail to reach the threshold?
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It can't be reimbursed, but it can be included in this expense.
The amount of the reimbursable part is accumulated to the threshold fee until it reaches 300 yuan (the minimum threshold for a tertiary hospital).
If the total outpatient expenses are in 200 yuan and the out-of-pocket ratio is 20% (that is, 40 yuan), then the cumulative threshold fee is 160 yuan (200-40= 160 yuan).
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7. Do I have to pay more than 300 yuan for each outpatient service?
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No, as long as the accumulated threshold fee reaches more than 300 yuan in one year, the threshold fee will not be needed after seeing the outpatient service, and it will be reimbursed directly in proportion.
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8. Can I be reimbursed as long as I have a check-up in the hospital outpatient department and prescribe a medicine?
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You can't. Only in the national and provincial basic medical insurance drug list, medical service items list and medical consumables list can be reimbursed, and those beyond the scope of basic medical insurance reimbursement will not be reimbursed.
Reimbursement amount = (outpatient medical expenses-Class B self-payment-out-of-catalog self-payment-deductible line 300)X60%.
For example, the total outpatient medical expenses of a patient are within 500 yuan, including Class A 200 yuan, Class B 200 yuan, out-of-catalog (Class C) expenses 100 yuan, and the out-of-pocket proportion of Class B is 10%, that is, 200 X 10% =20 20 yuan. Then the actual reimbursement amount for this outpatient service is (500-20- 100-300)X 60% =48 yuan, and the reimbursement amount for medical insurance is (500-20- 100-300)X 40% =32 yuan, so the patient should pay 300+20+for this outpatient service.
If the patient belongs to a military family, the military can further reduce (spouse)/give preferential treatment to 20 yuan, who pays the proportional amount for Class B, and 32 yuan (20+32=52 yuan), who is not reimbursed for medical insurance.
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9. Do patients who are insured in other provinces also have to bear the expenses below the deductible?
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Not necessarily, according to the medical insurance policy of the patient's insured place. In areas where outpatient co-ordination has been implemented in the insured area, after the outpatient emergency expenses are settled by medical insurance, individuals are required to bear the expenses below the deductible and completely at their own expense; If there is no outpatient deductible policy in the insured area, individuals do not need to bear the expenses below the deductible.
(Note: Patients insured from other provinces need to be filed in different places when they come to our hospital for medical treatment! )
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10. Can nucleic acid testing and physical examination be reimbursed?
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I can't. Medical insurance is not reimbursed: it should be paid from the industrial injury insurance fund; Should be borne by a third party; Should be borne by public health; Go abroad for medical treatment; Outpatient nucleic acid testing costs; Fitness, health care consumption, physical examination, cosmetic surgery, etc. ; Other expenses not paid by the medical insurance fund stipulated by the state; Expenses below the deductible line, above the capping line and outside the medical insurance catalogue.
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1 1. How to reimburse emergency expenses?
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If emergency rescue requires hospitalization within 72 hours, the emergency rescue medical expenses and hospitalization expenses shall be calculated together; Emergency rescue of death, with reference to hospitalization policy reimbursement; Other emergency expenses are reimbursed according to the general outpatient co-ordination standard.
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12. how long can the insured enjoy the overall treatment of the staff outpatient service after hospitalization?
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During the hospitalization of the insured, they do not enjoy the overall treatment of the staff outpatient service. From the next day after discharge, you can enjoy the overall treatment of staff outpatient service without waiting period.
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13. Can outpatient medical expenses be reimbursed repeatedly?
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I can't. The insured can't enjoy general outpatient co-ordination or outpatient reimbursement for chronic diseases and special diseases during hospitalization; Medical expenses have been reimbursed for the "dual-channel" management of drug treatment and outpatient treatment for chronic diseases and special diseases, but not for the general outpatient department.
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14. Can pharmacies reimburse drugs?
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Yes, the insured person can go to the designated retail pharmacy with the prescription of the outpatient doctor of the designated medical institution or the electronic circulation prescription of the medical insurance doctor.
Dispensing expenses shall be reimbursed according to the standards of the designated medical institutions that issue prescriptions.
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15. When will it be implemented?
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It will be implemented from June 5438+1 October 1 in 2022, and the policy transition period is June 65438+1October/to June 65438+February 3 1. During the transition period, personal accounts will be credited in the same way. From June 65438+ 10/day, 2023, personal accounts will be included in the new method.