If you come from the countryside.
First, if it is an outpatient service, the reimbursement rate for outpatient service is as follows:
Outpatient reimbursement ratio
(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.
Grade III and Grade A belong to Article 4, with 20% reimbursement.
Second, hospitalization reimbursement:
(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 health centers, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan.
(2) Reimbursement ratio:
60% reimbursement for town hospitals; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.
Third-class A reimbursement 30%
Third, the proportion of reimbursement for serious illness.
All inpatients who participate in cooperative medical care, whose medical expenses exceed 5,000 yuan at one time or cumulatively throughout the year, should be compensated by stages, that is, 500 1- 10000 yuan is 65%, and1-18000 yuan is 70%. 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.
Fourth, it is not within the scope of 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.
If you are a city resident.
Qifubiaozhun and reimbursement ratio of basic medical insurance for urban residents are determined according to the categories of insured persons.
First, students and children. In a settlement year, medical expenses below RMB 6,543,800+0,800 yuan that meet the scope of reimbursement occurred. The threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 55%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
The second is the elderly over 70 years old. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold of tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
Third, other urban residents. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold of tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%.
Urban residents hospitalized for more than two times in a settlement year, starting from the second hospitalization, no longer charge Qifubiaozhun fees. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.
If you are a city worker.
Generally speaking, the economic development in different regions is different, so the reimbursement ratio is different. The following is an explanation of the proportion of employees' medical insurance in Beijing.
After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed.
No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 500 yuan can reimburse 50%, that is, 250 yuan.
If it is hospitalization expenses, the minimum payment for employees and retirees is 1300 yuan when the basic medical insurance is used for the first time within one year in 2009. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. The maximum annual payment limit (hospitalization expenses) of the basic medical insurance pooling fund is currently 70,000 yuan.
The reimbursement standard for hospitalization is related to the level of the hospital where the insured person is located. For example, in a tertiary hospital, employees have to pay 15%, that is, 85%, from the threshold to 30,000 yuan. The expenses of 30,000-40,000 yuan shall be paid by employees themselves 10%, and 90% shall be reimbursed; If the expenses exceed 40,000 yuan to the maximum payment limit, 95% can be reimbursed, and employees only need to pay 5%. Retirees pay 60% of the on-the-job employees, but all below the minimum threshold are paid by individuals.
The medical treatment items that employees' basic medical insurance does not pay are mainly those that are clinically unnecessary and have uncertain curative effects, and those that need special medical services, including services such as registration fees, non-disease treatment items such as beauty, therapeutic equipment and medical materials hearing AIDS, magnetic therapy and other types of infertility treatment. According to the scope of the national basic medical insurance treatment project, the details are as follows:
(1) service items. (1) Registration fee, out-of-hospital consultation fee, medical record fee, etc. (2) Special medical services, such as visiting fees, expedited fees for examination and treatment, additional fees for roll-call surgery, high-quality and low-price fees, and self-invited intensive care.
(2) Non-disease treatment projects. (1) all kinds of beauty and bodybuilding, as well as non-functional plastic surgery and orthopedic surgery; (2) all kinds of weight loss, weight gain and height increase projects. (3) various health checks; (4) all kinds of preventive health care and diagnosis projects; (5) all kinds of medical consultation and medical appraisal.
(3) Diagnostic equipment and medical materials. (1) Examination and treatment items of large medical equipment such as positron emission tomography (PET), electron beam cT and ophthalmic excimer laser therapeutic instrument; (2) glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation devices; (3) all kinds of self-use health care, massage, examination and treatment equipment; (4) The provincial price department stipulates that one-time medical treatment cannot be charged separately.
(4) Treatment items. (1) The organ source or tissue source of various organ or tissue transplants; (2) Transplantation of organs or tissues other than kidneys, heart valves, corneal skin, blood vessels, bones and bone marrow; (3) Orthopedic surgery for myopia; (4) Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
(5) others. (1) various infertility (pregnancy) and sexual dysfunction diagnosis and treatment projects; (2) all kinds of scientific research and clinical verification of diagnosis and treatment projects.
Reimbursement of this piece is very troublesome, and it should be decided according to your medication situation. Please refer to it in detail by yourself, or go to the special reimbursement window of the hospital to ask, and they will have detailed answers, hoping to help you.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.