Scope and standard of compensation
1, outpatient compensation:
(1) village clinics and village center clinics are reimbursed 60%, and the prescription drug fee limit for each visit 10 yuan, and the prescription drug fee limit for temporary rehydration for doctors in health centers is 50 yuan.
(2) Reimbursement for medical treatment in town health centers is 40%. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 100 yuan.
(3) The reimbursement for medical treatment in secondary hospitals is 30%, and the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 200 yuan.
(4) 20% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan.
(5) The prescription attached to the invoice of traditional Chinese medicine is limited to 1 yuan.
(6) The annual compensation limit for rural cooperative medical clinics is 5,000 yuan.
2, hospitalization compensation
(1) Reimbursement scope:
A. Drug expenses: auxiliary examination: the expenses for ECG, X-ray fluoroscopy, radiography, laboratory tests, physical therapy, acupuncture, CT and nuclear magnetic resonance are limited to 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan).
B, the elderly over 60 years old are hospitalized in Xingta Town Health Center, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan.
(2) Reimbursement ratio: town hospitals reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.
3. Compensation for serious illness
(1) town risk fund compensation: all inpatients who participate in the cooperative medical system whose medical expenses exceed 5,000 yuan at one time or for the whole year shall be compensated by stages, that is, 500 1- 10000 yuan is 65%,10001-/.
The annual compensation limit of town-level cooperative medical system hospitalization, uremia outpatient hemodialysis and tumor outpatient radiotherapy and chemotherapy is 1. 1 ten thousand yuan.
Not covered by reimbursement
1. Medical treatment at one's own expense (no designated hospital or referral form), drugs purchased at one's own expense, drugs that cannot be reimbursed according to the regulations of public medical care and medical expenses that do not meet the requirements of family planning;
2, outpatient treatment fees, visits, hospitalization fees, meals, escort fees, nutrition fees, blood transfusion fees (except for family blood storage, according to the relevant provisions of reimbursement), heating and cooling fees, ambulance fees, allowances and other expenses;
3. Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents;
4. Orthopedics, cosmetic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc. ;
5, within the scope of reimbursement, beyond the limit.
Scope of compensation:
(1) Pay the hospitalization expenses of patients due to illness. It mainly includes: medical expenses, operation expenses, materials expenses, hospitalization expenses, treatment expenses, laboratory expenses, inspection expenses, etc.
(2) Pay for outpatient treatment of chronic diseases. Chronic diseases mainly refer to hypertension (phase II), heart disease complicated with cardiac insufficiency, cerebral hemorrhage and cerebral infarction recovery, rheumatoid arthritis, chronic active hepatitis, chronic obstructive emphysema and cor pulmonale, epilepsy, hepatolenticular degeneration, decompensated cirrhosis, diabetes mellitus with ineffective diet control, chronic nephritis, Parkinson's disease, systemic lupus erythematosus, disc herniation, chronic pelvic inflammatory disease and adnexitis, and others audited by the Expert Committee on Chronic Diseases of the New Rural Cooperative Medical System and the District Management Center. Extra-large outpatient expenses such as radiotherapy and chemotherapy for malignant tumor, dialysis treatment for chronic renal insufficiency, aplastic anemia, leukemia, hemophilia, schizophrenia, organ transplantation and anti-rejection treatment are included in hospitalization compensation.
Participating farmers suffering from the above-mentioned chronic diseases shall apply by themselves, based on the diagnostic proof materials of the second-class first-class hospitals, identified by the expert committee of chronic diseases of the new rural cooperative medical system in the district, submitted to the district joint management center for examination and approval, and receive a chronic disease outpatient certificate, which shall be audited by the district joint management center at the beginning of each year.
(3) Pay special inspection fee when the patient is hospitalized due to illness. Mainly refers to CT, cardiac and angiographic X-ray machine, electronic gastroscope, color Doppler instrument, hyperbaric oxygen chamber, extracorporeal shock wave lithotripsy, hemodialysis, organ transplantation and other high-cost medical projects. Patients who need to check the above items shall apply to the designated hospitals and report to the district management center for examination and approval.
(4) Meet the fertility conditions, and give birth in hospitals above the second level, designated medical institutions and designated delivery points.
(5) there is no other responsible party for the accidental injury (excluding unpaid items) that farmers have in the process of production, life and study; If there is any responsibility of the other party, it shall be borne by the other party. Accidental injury compensation can only be paid after it has been publicized for more than 1 month within a certain range, and there is no objection or report, or after investigation and confirmation.
(6) The participating farmers were hospitalized immediately after the outpatient examination, and the outpatient examination expenses closely related to hospitalization were included in the hospitalization medical expenses. During hospitalization, the application is made by the hospital under the jurisdiction due to illness, and after the examination and approval by the district joint management center, the examination expenses are calculated according to the compensation ratio corresponding to the examination hospital level and included in the compensation scope.
(7) The hospitalization expenses of newborns who were not born at the time of fund-raising and did not attend hospitalization with their parents within 7 days after delivery (perinatal period) due to maternal complications and diseases caused by complications. It is suggested that pregnant women who are about to give birth or are expected to give birth in the coming year should pay the alloy for their unborn children in advance.