With the reform of the medical insurance system, on the basis of employee medical insurance inpatient insurance and outpatient chronic disease protection, the new establishment of employee medical insurance general outpatient insurance system, minor illnesses rely on general outpatient reimbursement, chronic diseases have outpatient chronic disease protection, hospitalization has inpatient reimbursement, serious diseases have serious illness reimbursement protection, but insured employees rarely know the specific reimbursement standards, Heilongjiang Province general outpatient reimbursement has been talked about before, today we will learn about Heilongjiang Province inpatient reimbursement standards!
1. Scope of medical insurance reimbursement
Not all medical expenses incurred by employee insured personnel can be included in the scope of reimbursement, but can be reimbursed within the scope of the policy, and the expenses in the three directories of drug list, diagnosis and treatment item catalogue and medical service facility scope can participate in reimbursement.
The drugs and projects listed in these three lists are also divided into two categories, Class A drugs and projects are directly reimbursed by medical insurance, Class B drugs and projects need to pay a certain proportion of their own and then carry out medical insurance overall reimbursement, and Class A and B standards are uniformly formulated by the state.
2. Heilong Province medical insurance hospitalization
At the end of 2022, the number of people participating in basic medical insurance in Heilongjiang Province was 27.678 million, down by 1.9%, of which 8.902 million participated in basic medical insurance for urban employees and 18.775 million participated in basic medical insurance for urban and rural residents.
The hospitalization treatment of medical insurance for insured persons in Heilongjiang Province is slightly different from one municipality under its jurisdiction, and the specific inpatient treatment of the latest medical insurance in each city shall prevail. Here we take Harbin City as an example for specific analysis, for reference only.
Harbin employee hospitalization reimbursement treatment:
Harbin scientifically sets the minimum payment standard, reimbursement ratio and ceiling line for hospitalization according to the local economic situation and the affordability of the medical insurance fund. The minimum payment standard and reimbursement ratio are set according to the hospital level.
Payment ratio: 90% for active staff pooled fund and 93% for retirees.
Minimum payment standard:
Tertiary medical institutions: 720 yuan for the first time, 612 yuan for the second time and above;
Secondary medical institutions: 480 yuan for the first time, 408 yuan for the second time and above;
First-level medical institutions: 240 yuan for the first time, 204 yuan for the second time and above;
Community and other primary medical institutions: 200 yuan for the first time, 170 yuan for the second time and above.
The maximum annual payment limit is 100,000 yuan, and the excess amount to 250,000 yuan will be paid by the serious illness fund.
3. Case study
Retired Uncle Zhang of Harbin City, for the first time this year, in a tertiary medical institution, the hospitalization cost is 10,000 yuan, of which the personal out-of-pocket part of the detailed list of hospitalization expenses is 1,000 yuan (refers to the proportional part of Class B drugs, diagnosis and treatment items, service facilities and expenses outside the scope of basic medical insurance).
1. The personal payment of 1,000 yuan in the list shall be borne by the individual
2. The minimum payment standard of 720 yuan for hospitalization in tertiary medical institutions shall be borne by the individual
3. Deduct 1 and 2 parts, and reimburse according to the proportion (10000-1000-720) * 93% = 7700.4 yuan
This time, Uncle Zhang was reimbursed a total of 7700.4 yuan for hospitalization, and 2299.6 yuan was paid by individuals, with an actual reimbursement rate of 77%.
4. Heilongjiang Province's off-site reimbursement policy
The inpatient, general outpatient and outpatient chronic disease medical expenses that are directly settled for medical treatment across provinces are generally implemented in the directory of medical treatment places and the policies of the place of insurance. Before inter-provincial medical treatment, the filing procedures for medical treatment in different places can be carried out offline in the National Mini Program for Filing Medical Treatment in Different Places, the Mini Program of the State Council, or the handling institution of the participating place. After filing, direct settlement can be made at all inter-provincial networked designated medical institutions.
According to its own economic level and the affordability of the medical insurance fund, Heilongjiang Province scientifically formulates the minimum payment standard, reimbursement ratio and ceiling line for outpatient reimbursement. The reimbursement ratio of medical insurance hospitalization reimbursement is different for different levels of medical institutions, and Harbin City has reduced the minimum payment standard for two or more hospitalizations in a natural year. At the same time, cross-province medical treatment can be directly settled after filing, and the directory of medical treatment and the policy of the place of insurance can be implemented. #秋日生活打卡季#