I. Insurance and Payment

1, insurance scope and object

The basic medical insurance for urban workers in Taizhou covers all employees of urban enterprises, state organs, institutions, social organizations, private non-enterprise units and flexible employees in urban areas (including municipalities directly under the Central Government, Jiaojiang, Huangyan and luqiao district). If the above-mentioned objects should participate in the basic old-age insurance, they must first participate in the basic old-age insurance when participating in the basic medical insurance.

2, payment standard 3, quasi and treatment category

The payment standard of medical insurance in each settlement year (July 1 day to the end of June of the following year) is based on the monthly payment time, and the average monthly salary of employees in the whole province in the previous year is the payment base. All kinds of insurance are collected according to the corresponding proportion, which is published in June each year and adjusted in July.

Subsidies for civil servants in basic medical insurance of unit nature

critical illness insurance

Insurance type

Unit, individual, unit and individual adjustment

organ

undertaking

Career 8%2%/442

Enterprise 5%//442

Individual /5%//82

Note: 1. Major diseases are operated by commercial insurance, and the compensation ratio is 0.6%-0.7%. The settlement year in 2006 is tentatively set as 10 yuan, with 40% for each unit and individual and 20% for the overall fund. 2. Taizhou College enjoys civil servant subsidy insurance.

Different payments correspond to different treatment categories: enterprise basic medical care (hospitalization co-ordination payment), enterprise basic medical care (outpatient personal account payment, hospitalization co-ordination payment), and civil servant Medicaid treatment (outpatient and hospitalization subsidies).

3. How do new employees apply for medical insurance?

(1) The new teaching and administrative staff who did not participate in the basic medical insurance of the corresponding level and the third district of Taizhou shall submit two 2-inch color photos with their names and departments written on the back of the photos and a copy of their ID cards to the personnel department of the school, and the personnel department shall handle the insurance formalities in a unified way.

(two) the newly transferred and introduced staff shall be handled according to the following circumstances:

(1) Those who have participated in the basic medical insurance at the same level and in the three districts of Taizhou will hand over their existing medical insurance cards to the school personnel department, which will go through the insurance formalities again.

(2) employees who have participated in the basic medical insurance of non-Taizhou level and three districts in the province need to submit two 2-inch color photos with white background (with names and departments written on the back of the photos) and a copy of their ID cards to the school personnel department for unified insurance procedures. One month after the payment, the personnel department will inform them to issue a cross-regional medical insurance relationship transfer form to Taizhou Social Security Center, and then go to the original medical insurance institution to handle the relationship transfer. The Municipal Medical Insurance Center will press this button. Note: the transfer of relationship should be within 3 months after the interruption of payment, and it will be invalid if it exceeds 3 months, and the transfer outside the province will be invalid.

(3) What about reducing the medical insurance relationship?

① Transfer-out and termination of personnel relationship: The personnel department of the school shall fill in the change and increase form of employees of the transferred insured unit, suspend the corresponding medical insurance benefits from the effective date of business, and handle the corresponding continuation procedures as soon as possible. Those who fail to handle it for more than 2 months will be suspended from participating in the insurance.

② Handling the relationship of medical insurance for retirees: After the unit retirement documents are issued, the personnel department of the school will fill in the employee change and increase form of the insured unit, go through the relevant retirement payment procedures, and ask the retirees to provide their medical insurance cards and certificates.

③ Handling of the medical insurance relationship of the deceased: The personnel department of the school is responsible for filling in the employee change and increase form of the insured unit for cancellation, and will stop enjoying the corresponding medical insurance benefits from the effective date of the business.

④ Time for new employees to enjoy medical insurance benefits: they will enjoy medical insurance benefits from the day after they apply for insurance payment.

Second, the medical insurance personal account

1, transfer

There are three channels to transfer funds from personal accounts: the unit payment of civil servant subsidies, the unit payment of basic medical insurance, and the individual payment of basic medical insurance.

Personal accounts are included in the annual amount of medical insurance settlement of medical insurance IC card in July every year, and the age division is only in July 1 every year. The medical insurance system is actually included on a monthly basis, and the specific inclusion ratio is as follows:

There is a civil servant subsidy for the age group, but there is no civil servant subsidy.

Under 35 years old (1+0.8+2)%

* payment base * 12(0.8+2)%

* payment base * 12

36~45 years old (2+ 1.8+2)%

* payment base * 12( 1.8+2)%

* payment base * 12

46 to retirement age (3+2.8+2)%

* payment base * 12(2.8+2)%

* payment base * 12

retire

Personnel (4+5)%

* payment base * 125%* payment base * 12

Note: In the above table, 1%, 2%, 3% and 4% are included in the civil service subsidy, 0.8%, 1.8%, 2.8% and 5% are included in the basic medical unit payment, and 2% is included in the basic medical individual payment. When handling retirement and adjusting insurance benefits, the corresponding account amount will be adjusted from the month after handling medical insurance procedures.

2. Account usage

Personal accounts are divided into two parts: the current year's quota and the balance over the years, which are referred to as current year's accounts and calendar year's accounts for short. When carrying forward in July every year, all the balances on the card after carrying forward will be converted into historical balances. The amount of the current year is directly used to pay the medical expenses of backward civil servants before outpatient and hospitalization subsidies, and the balance over the years is used to pay the self-sufficient part of personal cash payment, that is, "the balance over the years really belongs to oneself".

3. Account inquiry

At present, the medical insurance transaction in our city is offline, that is, after the medical institution and the insured pay with IC card, the settlement data will be uploaded to the medical insurance institution regularly, and the medical insurance institution can not provide real-time personal account inquiry for the time being. Please check the latest medical insurance settlement bill, which shows the account expenditure and balance.

4. Account transfer and withdrawal

When the insured with an account is transferred from other places (it cannot be transferred outside the province, but can only be withdrawn), the balance of personal account can be transferred to the transfer place (the bank, account name and account number of the medical insurance institution in the transfer place need to be provided) or withdrawn (when there is no account in the transfer place); When the account insured terminates the insurance or the insurance benefits are reduced, the account balance can be withdrawn; If an account of the insured dies, the balance of the account can be inherited and withdrawn by family members. When the above-mentioned personnel transfer money, if their accounts are overdrawn (when the IC card is carried forward in July every year, the available amount in the card will be recorded, but the amount will not really arrive in the account until June of the following year), they should pay the overdraft amount in cash before transferring money.

Third, the medical insurance card voucher

1, use, carry forward

Medical insurance medical certificate consists of medical insurance IC card and medical insurance calendar. Insured persons must carry medical insurance cards when they go to designated medical institutions for medical treatment, purchase medicines and go through relevant procedures in medical insurance institutions. The medical insurance card is for personal use only, please keep it properly. Do not bend, twist, scratch, stay away from high voltage, strong electromagnetic field or low temperature and high heat, and avoid contact between the mobile phone and liquid substances.

The medical insurance IC cards of all insured persons should be carried forward at the designated outlets of CCB before use in July each year;

Savings counter of CCB Branch: No.86-2 Gongren Road, Jiaojiang

China Construction Bank Development Zone Savings Office: No.238 Donghuan Avenue

Jiaojiang Chengmentou Savings Office: next door to Jiaojiang Real Estate Trading Center.

Jiaojiang Cuihua Savings Office: No.218, Yu Yan Road.

Jiaojiang Sub-branch Savings Office: No.44 Jiefang North Road

Fu Qian Office of Jiaojiang Zhongshan Sub-branch: No.451Shifu Avenue

Huangyan district Hengjie Road Savings Office: No.220 Hengjie Road, Huangyan.

Huangyan district Tiannan Savings Office: No.460, Hengjie West Road, Huangyan

Counter of huangyan district Construction Bank: No.209 Tianchang North Road, Huangyan.

Luqiao district Zhong Zhen Road Savings Office:No. Ginza Street, Luqiao 1 17.

Luqiao district Chengbei Branch:No. Jinshui Road, Luqiao 108.

Second Savings Office of Linhai Construction Bank: No.65 Chicheng Road, Linhai City

Step 2 receive

The new medical insurance card shall be collected by the medical insurance handling personnel of the unit with my ID card, and the individual insured shall receive it with my ID card. Entrusted, it shall carry the agent's ID card and the principal's ID card. The new IC card has been carried forward and can be used directly during the year.

3. Report the loss and reissue it (Tel: 8556022)

If the medical insurance IC card is lost or damaged, the card replacement business should be handled in time, and the fund loss caused by the failure to report the loss in time shall be borne by the individual. The insured person can report the loss by telephone first (ID number must be checked) to prevent unnecessary losses, and then go to the medical insurance institution for written loss reporting and card replacement business within 3 days (with ID card, you can entrust others to do it for you). The reporting period is 15 days. If it is found within 15 days, you can call the medical insurance center to cancel the loss report in time (the ID number must be checked). After the expiration of the loss reporting period, a new card must be obtained with the loss reporting form accepted and sealed by the medical insurance institution; If you lose your card calendar, you can apply for a new card calendar on the spot with your ID card and original photo.

Replace the calendar with the old calendar, and only one copy can be replaced. The old one will be stamped and invalidated, and it will be returned to me for preservation. IC card replacement charges 20 yuan, and calendar replacement charges 3 yuan.

Four, medical insurance related concepts

Medical expenses not paid by the basic medical insurance.

(1) medical expenses beyond the drug list specified by the provincial labor and social security department and the medical treatment items, medical service facilities and payment standards specified by the provincial and municipal labor and social security departments;

(2) Going to a non-designated medical institution or a non-designated retail pharmacy for medical treatment or medicine purchase without the approval of the social security institution;

(three) transferred to other places for medical treatment without approval;

(four) to carry out special inspection and treatment without approval;

(5) Medical expenses incurred due to violation of law, crime, suicide, self-mutilation, fighting, drug abuse and alcoholism;

(6) Medical expenses incurred during going abroad or leaving the country;

(7) the medical expenses that should be paid for the liability for compensation such as traffic accidents, medical accidents and large-scale food poisoning.

Designated medical institutions and retail pharmacies

Designated medical institutions in the city: Taizhou Hospital, Taizhou Central Hospital, Taizhou Hospital, Taizhou Hospital of Traditional Chinese Medicine, Taizhou First People's Hospital, huangyan district Hospital of Traditional Chinese Medicine, Luqiao Hospital of Taizhou Hospital, Luqiao Hospital of Traditional Chinese Medicine, various maternity and child care hospitals and township hospitals.

Provincial designated medical institutions: First Affiliated Hospital of Zhejiang University Medical College, Second Affiliated Hospital of Zhejiang University Medical College, Obstetrics and Gynecology Hospital of Zhejiang University Medical College, Run Run Shaw Hospital of Zhejiang University Medical College, Zhejiang Cancer Hospital, Zhejiang Provincial People's Hospital, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Zhejiang Hospital, Hangzhou Third People's Hospital and Zhejiang Tongde Hospital.

Designated retail pharmacies: Longxiang Pharmacy, Jiaojiang Dafu Pharmacy, Jianchuntang Pharmacy, Huangyan Wuzhou Pharmacy, Tongrentang Pharmacy, Renji Pharmacy, Luqiao Jianmin Pharmacy, Baohetang Pharmacy, Linhai Fangyiren Pharmacy, etc.

Catalogue of medical insurance drugs and medical insurance services

The scope of payment of medical insurance fund in our city shall uniformly implement the catalogue of basic medical insurance drugs and medical services in Zhejiang Province. Both catalogues are subject to access management, and medicines, medical services and medical materials outside the two catalogues are used. The medical insurance fund will not pay, and all of them belong to individuals at their own expense. The drugs, medical services and medical materials in the two catalogues of medical insurance are divided into "Class A" and "Class B": the expenses incurred in the "Class A" project are paid according to the relevant provisions of medical insurance; The expenses incurred by the "Class B" project shall be paid by the insured according to the relevant provisions of medical insurance after taking care of themselves in a certain proportion. That is, all the medical expenses of the insured except the self-paid part and the self-paid part are the settlement expenses for entering the medical insurance fund, which is called the prescribed medical expenses.

V. Medical treatment and expense settlement of medical insurance

Outpatient account and civil servant subsidy payment

The basic medical outpatient service of enterprises shall be undertaken by enterprises or individuals;

An account insured person directly carries the medical insurance card voucher to the designated medical institution outpatient service, and after settlement with the medical insurance IC card, the individual only needs to pay the "cash payment" amount on the settlement invoice.

The specific settlement method is as follows:

The prescribed medical expenses incurred by the basic medical outpatient service can be paid by the personal account of the current year, and after the account is used up, it will be paid by the personal cash (if there is a calendar year account, it will be paid by the calendar year account first);

The prescribed medical expenses incurred in the outpatient service of civil servants' Medicaid treatment can be paid by the personal account of that year. When the accounts are used up in the current year, the subsidy fund for civil servants will be distributed according to the age proportion (75% under 45, 85% under 46 and 90% for retirees), and the rest will be paid by individuals in cash (if there are calendar year accounts, they will be paid by calendar year accounts first);

Drugstore purchase medicine

It is basically the same as the outpatient service, and the over-the-counter drugs prescribed by the state can be purchased by the insured at designated retail pharmacies. Prescription drugs must be issued by doctors in designated medical institutions, signed by doctors and stamped with the special seal for external prescriptions of designated medical institutions before they can be purchased in designated retail pharmacies.

Local hospitalization co-ordination, personal account, civil service subsidy payment

If the insured person needs to be hospitalized due to illness, he shall go through the hospitalization formalities at the designated medical institution with the medical insurance card and his ID card. After leaving the hospital, individuals only need to pay the "cash payment" amount on the settlement invoice.

In a medical insurance year, the deductible standard and the maximum payment limit are set and announced at the end of June each year: the deductible standard is about 10% of the average salary of employees in the whole province in the previous year, and the deductible standard for the second hospitalization is reduced by 50%, and the deductible expenses are borne by individuals; The maximum payment limit is about 4 times of the average salary of employees in the province last year. (The annual minimum payment standard for medical insurance in 2006 is tentatively set at 1.200 yuan, and the maximum payment limit is tentatively set at 8 1.000 yuan).

The specific settlement method is as follows (calculation by sections, cumulative payment):

It is stipulated that the medical expenses should be above Qifubiaozhun and below 2 times of the average salary of employees in the previous year (the medical insurance year in 2006 is tentatively set at 40,500 yuan), with employees bearing 20% and retirees bearing15%; In the last year, if the average wage of employees in the province reached more than 2 times the maximum payment limit, the incumbent was responsible for 15% and the retiree was responsible for10%; (The tertiary and secondary hospitals in the city are all implemented according to the above standards, and the Qifubiaozhun and individual conceit ratio of tertiary hospitals outside the city are all up by 20%)

If the insured has an account and the amount of the current year is not used up, the above self-sufficient amount can be paid with the account of the previous year;

If the insured still enjoys the Medicaid treatment for civil servants, the above-mentioned conceited part (which may include the conceited part of individuals suffering from major diseases) will be subsidized by the civil servant subsidy fund according to the age proportion after being paid by the account of the current year; (50% under 45, 60% between 46 and retirement, 70% for retirees)

Finally, if the insured has a surplus in each account over the years, the self-sufficient part that should be paid in personal cash in the end can be paid in each account over the years first;

After the above payment (including major illness payment) is completed, the remaining amount will be paid by personal cash.

Overall payment for outpatient special diseases

Workers suffering from diseases within the scope of special diseases (including various malignant tumor radiotherapy and chemotherapy, systemic lupus erythematosus, hemophilia, aplastic anemia, dialysis treatment of chronic renal failure, anti-rejection treatment after tissue or organ transplantation, decompensated cirrhosis and psychosis) will be hospitalized in 1 designated medical institutions for one time with medical insurance ic card after going through the examination and approval procedures for special diseases. The specific settlement method is the same as local hospitalization. This treatment is for all insured persons, and must provide materials such as "Taizhou City Urban Basic Medical Insurance Special Disease Diagnosis Certificate and Outpatient Treatment Approval Form", diagnosis certificate, medical record, relevant examination, laboratory test sheet, pathological section report and so on issued by designated secondary and above medical institutions;

Critical illness insurance payment.

Hospitalization medical expenses (including special disease outpatient service) shall be paid by serious illness insurance in proportion to the part above the maximum payment limit. Critical illness insurance is borne by commercial insurance companies, but it is uniformly collected by medical insurance institutions and bundled with basic medical insurance.

The specific settlement method is as follows:

It is stipulated that 90% of medical expenses with a maximum payment limit of 6,543,800 yuan or more shall be paid by critical illness insurance, and 654.38+ 00% shall be borne by individuals; The above part stipulates that for every increase of 6.5438+0 million yuan in medical expenses, the proportion of individual conceit will increase by 654.38+0%; Within a medical insurance year, the accumulated payment for critical illness insurance shall not exceed 200,000 yuan.

Go abroad for medical treatment

If it is really necessary to transfer to other hospitals or other places due to illness (in principle, only to designated medical institutions in the province, and only to public tertiary hospitals in Shanghai under special circumstances), the designated medical institutions shall fill out the Taizhou Urban Basic Medical Insurance Referral Approval Form, and the hospital and the unit shall affix their seals to handle the transfer examination and approval procedures. (to be filled in by tertiary medical institutions designated in different places)

For diseases within the medical insurance scope transferred to designated medical institutions in the province or public tertiary hospitals in Shanghai, the medical expenses shall be paid by myself, and the part paid by individuals exceeding RMB 654.38+10,000 yuan shall be paid by the school (654.38+10,000 yuan medical expenses payment documents and renewal notice, the medical expenses paid by the school shall be remitted to the hospital account by the financial department, and the unused medical expenses after discharge shall be remitted to the school account by the hospital, and the medical expenses paid by the school shall be returned, and the rest shall be settled by me in the medical insurance institution. )。 Then go to the medical insurance institution to settle the reimbursement. When they settle accounts, the minimum payment standard and the proportion of individual self-sufficiency will be increased by 20%. Those who transfer to Shanghai must first stipulate the total amount of self-funded medical expenses of10, and the rest will be settled with local hospitalization.

relocate

Retirees are resettled in different places, and on-the-job personnel go abroad to work and study (for more than 3 months). They can enjoy the medical treatment of resettlement in different places with the application form of Taizhou urban basic medical insurance resettlement (stationed) approved by the unit seal, the grade certificate of local designated medical institutions (two designated medical institutions can be selected in the same overall planning area), and the medical guarantee calendar. Medical expenses are paid in advance by myself, and then settled and reimbursed by medical insurance institutions. The specific settlement method is the same as the local hospitalization (outpatient).

8. Go out for first aid

When going out on business or on vacation, if you are hospitalized in the field due to emergency, you need to report to your unit within 5 working days, and your unit will go through the registration formalities at the center with a notice of hospitalization or a copy. Medical expenses are paid in advance by myself, and then settled and reimbursed by medical insurance institutions. The specific settlement method is the same as the local hospitalization (outpatient).

9, window settlement reimbursement

Window settlement reimbursement is only for cash reimbursement of medical expenses incurred during the period of approved medical treatment, relocation, emergency treatment, computer failure of designated medical institutions or loss reporting of medical insurance IC cards (which needs to be proved by the medical insurance office of designated medical institutions or medical insurance agencies on the corresponding bills), and the rest will not be reimbursed, and the expenses will be borne by the unit or individual.

The insured person needs to bring medical insurance calendar, medical insurance IC card, medical expense list, medical expense receipt, medical institution grade certificate and medical record, inpatient discharge summary, copy of doctor's advice and other related materials for reimbursement.

Reimbursement time: 5- 15 days per month, and those who go out for emergency treatment should be reimbursed within 30 days from the date of discharge (outpatient service).

10, medical insurance settlement invoice description

Holding a medical insurance IC card, there are medical insurance settlement items on the invoices after settlement in designated medical institutions and retail pharmacies:

"Cash compensation" refers to the amount of cash that the insured should pay;

"Card payment amount" refers to the amount payable in the personal account of the insured person, including the total payment in the current year and previous years, which is deducted by the medical institution on the IC card;

"Civil servant subsidy" refers to the amount paid by the civil servant subsidy fund, which is paid in advance by the medical institution;

"Overall payment" refers to the part of the hospitalization expenses paid by the overall fund, which is paid in advance by the medical institution;

"Serious illness relief" refers to the amount paid by the serious illness insurance fund after the annual hospitalization expenses exceed the maximum amount of overall payment, which is paid in advance by medical institutions;

"Self-paid amount" refers to the accumulated self-paid amount of the hospitalized individual, and the amount is equal to the "cash payment" amount-self-paid amount+account payment amount over the years (the account balance over the years belongs to me). After the individual's accumulated "self-funded amount" exceeds a certain limit in a medical insurance year, the qualified units should be reimbursed. (In a medical insurance year of our school, the individual snail rice "at his own expense" outpatient service 1.500 yuan or above, the school will give subsidies to those who retire 1.200 yuan or above. The standard is 90% on the job and 95% retired; If the hospitalization exceeds 1.500 yuan and the retirement exceeds 1.200 yuan, the school will give subsidies. Please keep the annual invoice as the subsidy certificate. )

"Card balance" refers to the remaining available amount in the medical insurance IC card, which is the sum of the account amount of the current year and the account balance over the years. At present, the medical insurance system in our city adopts offline transaction mode, and the available amount of IC card is prepaid for one year when it is carried forward every year. Therefore, due to settlement data, abnormal payment and other factors, the balance on the IC card may not match the real book balance in the medical insurance system. When the IC card is carried forward every year, the balance in the card will be automatically checked and adjusted, that is, the real balance of the account will be calculated based on the book balance of the medical insurance system (the balance on the invoice of the first transaction in the medical insurance year).

Reiterate several concepts:

Out-of-pocket expenses refer to 65,438+00% of the expenses incurred by using drugs or services outside the medical insurance catalogue and the prepaid expenses for going abroad for medical treatment, and cannot enter the prescribed medical expenses paid by medical insurance, nor can they enter the self-funded amount reimbursed by refundable units; Self-care refers to the use of drugs or services in the medical insurance catalogue, but individuals must first bear part of the expenses incurred, and cannot enter the prescribed medical expenses paid by medical insurance, but they can enter the self-funded part of the unit reimbursement; Conceit refers to the part of the medical expenses that individuals bear in proportion and the amount of conceit that can be reimbursed back to the unit among the prescribed medical expenses that enter the scope of medical insurance payment; Cash payment includes all out-of-pocket payment, all or part out-of-pocket payment (when there is an account in the past years) and all or part out-of-pocket payment (when there is an account in the current year and there is a civil servant subsidy).

Six, personal health insurance inspection supervision and punishment

Monthly cumulative outpatient visits are greater than15; For three consecutive months, the number of outpatient visits has accumulated more than 30 times; Monthly outpatient medical expenses accumulated more than 3000 yuan; The accumulated outpatient expenses in a medical insurance year are more than 8,000 yuan for employees and 1 10,000 yuan for retirees; In the designated retail pharmacies, the cost of single dispensing and drug purchase is above 200 yuan; The accumulated hospitalization medical expenses reached 50,000 yuan in a medical insurance year; The insured outpatient, drug purchase and hospitalization in one of the above circumstances, included in the key audit management object.

Incorporate into the key audit management object, change the original accounting settlement method based on medical insurance IC card to direct cash settlement, and bring relevant information to the medical insurance institution for registration, explain the situation and cooperate with the audit.

The insured person provides his medical insurance card to others or uses another person's medical insurance card to seek medical treatment and purchase medicines; Repeated and excessive dispensing in violation of regulations; Those who meet the discharge conditions and are unwilling to leave the hospital; Resort to deceit caused the loss of medical insurance fund; The loss of the medical insurance card is not reported in time, resulting in the loss of the medical insurance fund; For the insured who has the above-mentioned and other acts in violation of the provisions of medical insurance, the medical insurance institution shall suspend its medical insurance benefits, notify the employer and recover the losses, and the administrative department of labor and social security shall impose a fine according to the circumstances, and if the case constitutes a crime, it shall be transferred to the judicial organs for handling.

Seven, maternity insurance:

Our school participated in the maternity insurance for urban workers in Taizhou. Relevant policy issues are as follows:

(1) Q: What is maternity insurance?

A: Maternity insurance is a social system that provides timely living security and material assistance to working women when they temporarily stop working due to maternity through national legislation. Its purpose is to maintain, restore and improve the health of pregnant women by providing maternity allowance, medical services and maternity leave, and to enable babies to be carefully cared for and nurtured.

(2) Q: What are the conditions for enjoying maternity insurance benefits?

Answer: 1. Employers must participate in maternity insurance according to regulations and fulfill their payment obligations.

2. Workers who give birth or perform family planning operations must meet the conditions stipulated in the Population and Family Planning Law of the People's Republic of China, that is, those who give birth to their first child in line with the national family planning policy, or those who meet the conditions for giving birth to another child and are approved by the family planning department, or those who meet the above fertility conditions but have an abortion (induced labor) after pregnancy.

(3) Q: How is the maternity allowance calculated?

A: Maternity allowance = payment base ×600%× number of maternity leave months is compensated to the employer. During the maternity leave of female employees, the employer shall pay maternity leave wages according to regulations. If the maternity leave salary is lower than the maternity allowance, it shall be paid according to the maternity allowance; If it is higher than the maternity allowance, it will be paid according to the actual calculation, and the difference will be borne by the employer.

(4) Q: What are the reproductive medical expenses?

A: Maternity medical expenses refer to medical expenses such as prenatal examination fees, delivery fees, bed fees, treatment fees, medicine fees and postpartum visit fees. , in line with the requirements of female workers due to childbirth.

(5) Q: How to set the standard of maternity medical expenses?

A: Maternity medical expenses are compensated in a fixed amount. Full payment within the amount of compensation, beyond the amount of compensation standards shall be borne by the employees themselves.

1, early pregnancy outpatient abortion (including drug abortion) 150 yuan.

2, early pregnancy hospital abortion 900 yuan.

3. Induced labor in the second trimester 1200 yuan.

4. Normal vaginal delivery 1500 yuan

5, vaginal surgery midwifery (instrument midwifery, lateral incision midwifery) 2000 yuan.

6, cesarean section (including analgesic pump) 3500 yuan.

(6) Q: How to reimburse the medical expenses of birth complications?

A: After the medical expenses of the following complications during childbirth are borne by the employees themselves, they will be paid by the maternity insurance fund: 1, ectopic pregnancy; 2. Pregnancy induced hypertension syndrome; 3. Placenta previa; 4. Early placental abruption; 5. stillbirth (stillbirth); 6, maternal and infant blood type incompatibility; 7. Cholestasis of pregnancy; 8. Uterine rupture; 9, postpartum hemorrhage; 10, amniotic fluid embolism; 1 1, Sheehan syndrome; 12, eclampsia; 13 puerperal infection.

(7) Q: How to reimburse the medical expenses of family planning operation?

Answer: Family planning operation includes: 1, placing intrauterine contraceptive ring (ordinary contraceptive ring only); 2. Take out the intrauterine contraceptive ring; 3. Take the residual ring and the embedded ring; 4. subcutaneous implantation; 5. Take out the subcutaneous implant; 6. Tubal ligation; 7. vasectomy; 8. Tubal anastomosis; 9, vasectomy. The medical expenses incurred by the employees in carrying out the above-mentioned family planning operations that meet the requirements shall be paid in full by the maternity insurance fund.

Q: What are the regulations on the scope of drug use, diagnosis and treatment items and service facilities standards?

A: The scope of medication (except obstetric therapeutic medication), diagnosis and treatment items and service facilities standards for workers giving birth or carrying out family planning operations refer to the relevant provisions of Taizhou's basic medical insurance for urban workers.

Q: What are the benefits for male workers?

A: Male employees who have participated in maternity insurance, whose spouses are unemployed or unemployed in rural areas or towns, can be reimbursed for 50% of maternity medical expenses if they meet the requirements stipulated in the Population and Family Planning Law of the People's Republic of China.

Q: What are the designated medical institutions for maternity insurance?

A: The designated hospitals for regional medical insurance and the family planning technical service institutions at or above the county level are designated medical institutions for maternity insurance.

Q: What are the procedures for maternity insurance?

Answer: 1. After pregnancy or before the implementation of family planning, the employer or employee shall apply to the Municipal Medical Insurance Center for the "Reproductive Medicine Certificate" or "Family Planning Surgery Medical Certificate" and voluntarily determine a designated hospital.

2, the worker with "diagnosis" or "family planning operation diagnosis" to the designated hospital delivery or surgery.

3, the employer within 30 days after the expiration of maternity leave, family planning operation to the city medical insurance center to apply for maternity insurance benefits.

(12) q: what information should I provide to apply for the medical certificate of fertility or the medical certificate of family planning operation?

Answer: The original and photocopy of employee ID card and reproductive health service certificate.

Q: What information should I provide to apply for maternity insurance benefits?

Answer: The original and photocopy of my ID card; Birth medical certificate or birth certificate; Original medical records; Invoice and list of hospitalization medical expenses; "Reproductive Medical Certificate" or "Medical Certificate of Family Planning Operation".

Q: What should I do if I want to give birth or have a family planning operation in a medical institution outside the overall planning area?

A: The employee himself submits a written application report and reports it to the municipal medical insurance center for approval.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.