Article 23
For farmers participating in the new rural cooperative medical system, the outpatient compensation fee shall be included in the outpatient family account according to the standard of 18 yuan per person per year, and it shall be used as a lump sum. The amount of compensation for outpatient medical expenses per household shall not exceed the total amount of family account, and the balance at the end of the year can be carried forward to the next year, but it shall not offset the expenses that individuals should pay in the cooperative medical fund in the next year.
Article 24
Farmers who participate in the new rural cooperative medical system are hospitalized due to illness, and they can get compensation for expenses including medicines, beds, examination, nursing, treatment, surgery, infusion, blood transfusion, oxygen delivery, routine imaging examination and routine laboratory tests (blood, urine and stool routine) during hospitalization.
The compensation for hospitalization medical expenses shall be set up with deductible line and capping line. The deductible standard is: 80 yuan, a town-level designated medical institution, the Municipal Hospital of Traditional Chinese Medicine 100 yuan, the Municipal Maternal and Child Health Hospital 150 yuan, and 500 yuan, a designated medical institution outside the city. The capping line is 50,000 yuan, that is, the total accumulated compensation of the new rural cooperative medical fund for each person's hospitalization medical expenses per year does not exceed 50,000 yuan. The medical expenses for each hospitalization of farmers participating in the new rural cooperative medical system shall be borne by individuals below the deductible line, and the medical expenses above the deductible line shall be compensated by the new rural cooperative medical system hospitalization fund in proportion:
(a) in the town-level designated medical institutions for hospitalization, medical expenses partially compensated above 80 yuan.
80%;
(two) hospitalized in the city hospital of traditional Chinese medicine, medical expenses in 100 yuan above the part of the compensation of 70%;
(3) Hospitalization in the Municipal Maternal and Child Health Hospital, and the medical expenses above 150 yuan will be compensated by 65%;
(4) Hospitalization in the First Hospital, the Second Hospital, the Third Hospital, Taikang Hospital, Cheng Nan Health Center, Health School Affiliated Hospital, and Aipu Eye Hospital, and 60% of the medical expenses above 200 yuan will be compensated;
(five) hospitalization in medical institutions outside the city, medical expenses in 50 1 yuan to 5000 yuan (including 5000 yuan) part of the compensation 40%; Part of the compensation of more than 5000 yuan is 45%.
The pregnant women who participate in the new rural cooperative medical system will be compensated to 350 yuan for their delivery in hospital.
If the participating farmers are hospitalized after emergency rescue in the outpatient clinic due to dangerous, urgent and serious diseases. , the outpatient emergency rescue expenses will be reimbursed in the hospitalization expenses; If the participating farmers suffer from the same disease and are continuously transferred for treatment within one year, only the deductible line of the highest-level hospital will be calculated; Rural five-guarantee households, low-income households and entitled groups cancel the hospitalization deductible standard.
Article 25
Measures for compensation of new rural cooperative medical system:
(a) the medical expenses incurred by farmers participating in the new rural cooperative medical system in designated village clinics and health centers shall be deducted directly from the outpatient family account of cooperative medical certificate by medical service institutions; In the municipal designated medical institutions for outpatient treatment, medical practitioners should hold the invoice of outpatient medical expenses to the designated village clinic where the household registration is located for compensation procedures.
(II) The medical expenses incurred by the farmers participating in the new rural cooperative medical system in the designated medical institutions in this Municipality shall be compensated immediately by the medical service institutions when the medical patients leave the hospital, and the compensation part shall be paid in advance by the medical service institutions, and the medical patients only need to pay the self-funded part after compensation when they leave the hospital.
(III) If the participating farmers in the area around the city, Beishi and Development Zone are hospitalized in local health centers, the reimbursement policy shall be implemented in the relevant reimbursement policies of township health centers.
(IV) The medical expenses incurred in transferring to the designated medical institutions above the city with the approval of the Municipal Joint Management Office shall be paid in advance by the medical practitioners, and the compensation procedures shall be handled in the town joint management office where the household registration is located within 30 days after discharge with the certificate of transfer and a copy of the medical records of the medical institution, the diagnosis certificate, the summary of discharge medical records, the list of medical expenses, the original invoice of medical expenses, the certificate of new rural cooperative medical care in Zaoyang City, the ID card or the household registration book.
(5) Failing to go through the examination and approval procedures for hospitalization outside the city, being hospitalized in designated medical institutions outside the new rural cooperative medical system in our city, and being hospitalized in different places during the period of going out to work, staying temporarily or visiting relatives, the medical expenses shall be compensated according to 70% of the reimbursement ratio of the corresponding medical institutions as stipulated in Article 24.
(six) to participate in the new rural cooperative medical system for farmers to go out to work, stay, visit relatives during illness and need hospitalization, in principle, back to the designated medical institutions in this city for hospitalization and compensation; Medical expenses incurred due to hospitalization in different places shall be compensated according to the fourth and fifth provisions of article twenty-fifth.
(seven) the designated medical institutions shall fill in the list of medical expenses for the inpatients of farmers who participate in the new rural cooperative medical system, and the list shall be signed and approved by the patients themselves or their families. Where the medical expenses are not signed by the patient himself or his family, the cooperative medical fund will not compensate, and the patient has the right to refuse to pay.
(VIII) Designated medical institutions shall, after paying compensation fees for farmers participating in the new rural cooperative medical system, report the reimbursement data to the Municipal Joint Management Office on a regular basis every month in accordance with the provisions of the Municipal Joint Management Office, and after being audited by the Municipal Joint Management Office and reported to the Municipal Finance Bureau for review, allocate the compensation funds paid by the designated medical institutions to the designated medical institutions.
Article 26
The following expenses are not included in the scope of compensation for the new rural cooperative medical system:
(a) the cost of using standard drugs other than the Catalogue of Essential Drugs for New Rural Cooperative Medical System in Zaoyang City; Costs of imported drugs and materials;
(two) medical expenses caused by fighting injury, suicide, self-mutilation, taking poison, alcoholism, work-related injuries, work-related injuries, motor vehicle traffic accidents, etc. ; Expenses arising from illegal crimes;
(3) Medical expenses incurred by dentures, dentures, non-functional cosmetic surgery, cosmetology, physiotherapy, medicated bath, non-therapeutic orthopedic surgery, weight loss, vision correction, artificial eye installation, prosthesis, organ source transplantation (tribute or donation), family planning (such as premarital examination, curettage, ligation, fallopian tube recanalization, etc.). ) and occupational diseases;
(four) the medical expenses that have been identified as medical accidents or medical malpractice disputes have not been identified;
(five) medical expenses due to irresistible natural disasters, major epidemics and group poisoning incidents;
(6) Transportation expenses, first aid expenses, expert consultation fees at higher levels, home visits, telephone fees, heating fees, air conditioning fees, electric fans, TV monitoring fees, and compensation fees for public property damage; Rehabilitation appliances;
(seven) all kinds of epidemic prevention, health care, genetic diagnosis and treatment, AIDS examination and treatment, sexual function diagnosis and treatment, sexually transmitted diseases and family beds;
(8) Ward fees, escort fees, nursing fees, laundry fees, decoction fees and meals (including nutritious meals and medicated meals) other than ordinary wards;
(9) Self-purchased drugs and medical examination expenses, examination and treatment expenses unrelated to diseases (excluding exclusive diagnosis and examination expenses), drug expenses inconsistent with prescription drugs, expenses violating the medical service price policy, etc. ;
(ten) hospitalization expenses belonging to medical insurance for urban workers and medical insurance for urban residents;
(eleven) in violation of other relevant provisions.
Article 27
During hospitalization, large-scale examinations and treatments such as CT, color B-ultrasound, and magnetic resonance vibration that really need to be diagnosed and treated shall be subject to the prior approval system, and the expenses within 200 yuan shall be included in the compensation scope according to the facts; More than 200 yuan, according to 200 yuan included in the scope of reimbursement. The interlocking nails, dynamic condyles and dynamic hips used in orthopedic surgery are less than 2,000 yuan each time, the internal fixation materials for skull or spine surgery and hip replacement are less than 3,000 yuan each time, and the internal fixation materials for other parts of orthopedics are less than 1000 yuan each time, which are actually included in the reimbursement scope, and the excess parts will not be reimbursed. The expenses of intraocular lens implantation in ophthalmic surgery within 400 yuan are actually included in the scope of reimbursement, and the excess part will not be reimbursed.
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