The reimbursement ratio of Wuhan residents’ medical insurance in 2022 can be roughly divided into five categories:
1. For general outpatient clinics, the residents’ medical insurance fund payment ratio is 50%;
2 , high blood pressure, and diabetes outpatient medication are guaranteed, and the payment ratio of the overall coordination fund within the scope is 50%;
3. For outpatient treatment of severe (chronic) diseases, the payment ratio of the basic medical insurance fund is 50%; payment for phenylketonuria The proportion is 70%;
4. Hospitalization;
5. Critical illness insurance, within an insurance year, the personal burden amount that meets the coverage of critical illness insurance is calculated cumulatively.
The reimbursement ratios of various types are different, and the specific reimbursement ratios are as shown below.
1. Hospitalization medical insurance reimbursement ratio
Insured persons who are hospitalized in designated medical institutions must first pay the standard expenses. The portion of medical expenses that meet the medical insurance regulations above the minimum payment standard and below the maximum payment limit will be shared proportionally between the overall fund and the individual. Except for community health service centers, the minimum payment standard for hospitalization pool funds for two or more hospitalizations in one insurance year is reduced by half. Within an insurance year, the maximum payment limit is 240,000 yuan.
1. Employee hospitalization:
The payment ratio of the overall fund of third-level medical institutions is 86%, and the individual payment ratio is 14%;
The overall fund payment ratio of secondary medical institutions The payment ratio is 89%, and the individual self-pay ratio is 11%;
The payment ratio of the first-level medical institution's overall fund is 92%, and the individual self-pay ratio is 8%;
The community health service center overall fund The payment ratio is 92%, and the personal payment ratio is 8%.
2. Retirees:
The personal self-payment ratio is 80% of the employee’s personal self-payment ratio.
2. Medical insurance reimbursement ratio for outpatient severe (chronic) diseases
1. Chronic renal failure requiring renal dialysis treatment, anti-rejection after kidney transplantation, and anti-rejection after liver transplantation Reimbursement ratio: 87% for employees and 90% for retirees;
2. Malignant tumors (including leukemia), radiotherapy and chemotherapy, and grade 3 hypertension (with one of the complications of heart, brain, kidney, or aorta) ), diabetes (one of the complications of infection, heart, kidney, eyes, nerves, and blood vessels), severe mental illness (including schizophrenia, mood disorders, and organic brain disorders) reimbursement ratio: 80% for employees, 85% of retirees;
3. Chronic renal failure (chronic kidney disease stage 4 and above), antiviral treatment for hepatitis B, antiviral treatment for hepatitis C, chronic severe hepatitis, and liver cirrhosis ( Decompensated stage), chronic obstructive pulmonary disease (GOLD level 3 and above), chronic corpus pulmonale (decompensated stage of lung and heart function), hyperthyroidism (thyrotoxic heart disease occurs) ), severe aplastic anemia, hemophilia, systemic lupus erythematosus, rheumatoid arthritis (X-ray examination of joint disease stage III and above), systemic sclerosis (reaching the sclerosis stage or atrophy stage of skin lesions) , ankylosing spondylitis (with "radiological sacroiliitis"), Parkinson's disease, Parkinson's syndrome, vascular interventional surgery, heart valve replacement surgery, autism (autism spectrum disorder), cerebral palsy , mental retardation (combined with psychiatric symptoms), myasthenia gravis (moderate systemic type and above), sequelae of cerebrovascular disease (confirmed by imaging and severe neurological deficit), epilepsy, coronary heart disease (heart failure reaching difficult The reimbursement ratio for patients with refractory end-stage heart failure), after surgical treatment of coronary heart disease, and rheumatic heart disease (with heart failure reaching the stage of refractory end-stage heart failure): 60% for employees and 65% for retirees.
3. Large-amount medical insurance reimbursement ratio
In one insurance year, hospitalization, outpatient emergency rescue and outpatient treatment of employees and retirees comply with the "About Adjustment of Basic Medical Insurance Outpatient Treatment of Severe Disease ( "Notice on Policies on Chronic) Diseases" (Wu Ren She Fa [2017] No. 46) (the severe (chronic) diseases listed above), the medical expenses that comply with the provisions of the employee basic medical insurance policy are more than 240,000 yuan ( For the part excluding RMB 240,000), the insurer pays 98%, and the insured person pays 2% out of pocket.
For the portion above 100,000 yuan (excluding 100,000 yuan) to 200,000 yuan (inclusive of 200,000 yuan), the insured’s personal out-of-pocket ratio is 4%;
20 For the portion from RMB 10,000 (excluding RMB 200,000) to RMB 240,000 (including RMB 240,000), the insured person shall pay 2% out of pocket, and the remainder shall be paid by the Basic Medical Insurance Co-ordinating Fund and the Large-amount Medical Insurance Fund according to relevant regulations. Policy mandates burdens.
Legal basis:
"Social Insurance Law of the People's Republic of China"
Article 28 In line with the basic medical insurance drug catalog, diagnosis and treatment items, Standards of medical service facilities and medical expenses for emergency and rescue services shall be paid from the basic medical insurance fund in accordance with national regulations.
Article 29: The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit.
The social insurance administrative department and the health administrative department should establish a settlement system for medical expenses in other places to facilitate insured persons to enjoy basic medical insurance benefits