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Measures for reimbursement of new rural cooperative medical care in Jiyang County

Article 1 In order to ensure that rural residents who participate in the new rural cooperative medical system (hereinafter referred to as "participating farmers") can reimburse medical expenses in time, these measures are formulated according to the implementation plan and financing level of the new rural cooperative medical system in Jiyang County.

Article 2 Medical expenses are divided into outpatient expenses, chronic disease expenses and hospitalization expenses.

Article 3 The outpatient expenses incurred by participating farmers in designated medical institutions in counties and villages shall be compensated according to the proportion of 40%, and the prescription value shall not exceed 30 yuan, and the maximum compensation amount per person per year shall be 60 yuan; Outpatient medical expenses incurred in designated medical institutions at the town level in the county shall be reimbursed at a rate of 50%, and the prescription value shall not exceed that of 70 yuan. In the village-level designated medical institutions, the total amount of outpatient services is prepaid. Outpatient expenses incurred in medical institutions at or above the county level (including the county level) shall not be reimbursed.

Fourth chronic diseases are diagnosed by designated medical institutions above the town, and diagnosed according to the diagnostic criteria of chronic diseases in our county. Mainly refers to the following fifteen chronic diseases:

1, malignant tumor; 2. Chronic renal insufficiency (decompensated period)

3. Allogeneic organ transplantation; 4. Sequela of acute cerebrovascular disease

5. Diabetes with serious complications; 6. Liver cirrhosis (decompensated stage of liver cirrhosis)

7. Myocardial infarction; Coronary heart disease; 8. Hypertension (with complications)

9, chronic bronchitis emphysema; 10, rheumatoid arthritis

1 1, tuberculosis; 12, schizophrenia;

13, aplastic anemia; 14, systemic lupus erythematosus;

15, chronic cardiac insufficiency (cardiac function Ⅲ).

Article 5 When participating farmers suffer from chronic diseases, they can go to the outpatient clinic to see a doctor and get medicine with the chronic disease certificate, special prescription for outpatient chronic diseases and medical records jointly issued by county farmers.

Sixth outpatients with chronic diseases should go to the designated medical institutions in counties and townships of their choice for medical treatment. Patients with special chronic diseases can go to the designated medical institutions designated by the county agricultural cooperative.

Seventh chronic medical expenses of patients with chronic diseases, according to the proportion of inpatient medical institutions to calculate the amount of compensation. Maximum annual reimbursement for individual outpatient service 1500 yuan.

Article 8 The reimbursement ratio and calculation method of hospitalization medical expenses for participating farmers:

(a) participating farmers in the town-level designated medical institutions hospitalization medical expenses in accordance with the standards of 200 yuan set deductible, policy within the scope of medical expenses deductible part according to the proportion of 85% reimbursement (including basic drugs), rural low-income households, the disabled according to the proportion of 90% reimbursement.

(II) For participating farmers hospitalized in designated medical institutions at the county level, the hospitalization medical expenses shall be reimbursed according to the standard deductible line of 500 yuan, 65% for medical expenses within the policy range of 500 yuan-20,000 yuan, and 70% for rural low-income households and disabled people; 75% of medical expenses within the policy range of 20000-30000 yuan, and 80% of rural low-income households and disabled people; Within the scope of the policy, the medical expenses of more than 30,000 yuan will be reimbursed by 80%, and the rural low-income households and the disabled will be reimbursed by 85%.

(3) For farmers hospitalized in municipal hospitals, the deductible line is set according to the standard of 1 10,000 yuan, and the medical expenses within the policy range of1-30,000 yuan are reimbursed by 45%, and the rural low-income households and the disabled are reimbursed by 50%; Within the scope of the policy of 30,000-50,000 yuan, medical expenses will be reimbursed by 50%, and rural low-income households and disabled people will be reimbursed by 55%; Within the scope of the policy, the medical expenses of more than 50,000 yuan will be reimbursed at the rate of 55%, and the rural low-income households and the disabled will be reimbursed at the rate of 60%.

(4) If the participating farmers are hospitalized in designated hospitals at the provincial level, the deductible line is set according to the standard of 1.200 yuan, and the medical expenses within the policy of 1.200 yuan-40,000 yuan are reimbursed by 40%, and the rural low-income households and the disabled are reimbursed by 45%; Within the policy range of 40,000-60,000 yuan, medical expenses will be reimbursed at the rate of 45%, and rural low-income households and disabled people will be reimbursed at the rate of 50%; Within the scope of the policy, the medical expenses of more than 60,000 yuan will be reimbursed at the rate of 50%, and the rural low-income households and the disabled will be reimbursed at the rate of 55%.

(five) in a participating year, the participating farmers are hospitalized in the same hospital, and only one deductible is deducted.

Article 9 Participating farmers shall provide the following documents and materials for reimbursement of hospitalization medical expenses.

(1) physical examination certificate (card); (2) household registration book; (3) receipt of medical expenses; (4) A list of expenses; (5) the first page of medical records; (6) discharge records.

In case of hospitalization due to accidental injury, a copy of hospitalization medical records (including admission records) shall be issued when handling reimbursement procedures.

If you really can't get the compensation from the third responsible person due to unilateral traffic accidents, hit-and-run and other reasons. Relevant certificates issued by the traffic police or other relevant departments shall be provided when handling the reimbursement procedures.

If you are hospitalized for family planning, you should first apply for hospitalization subsidy for rural pregnant women, and then apply for hospitalization compensation procedures for the new rural cooperative medical system, and you must provide a birth certificate issued by the family planning department.

Tenth participating farmers in the medical institutions to carry out immediate declaration of hospitalization, discharge directly for reimbursement procedures; After being discharged from the designated hospital of Xinnonghe, they went to the county and farmers for reimbursement with relevant materials and certificates before reporting immediately.

Eleventh migrant workers and temporary migrant workers who are hospitalized due to illness must be hospitalized in designated medical institutions at or above the county level in their workplace or destination. After discharge, the reimbursement procedures shall be handled with the employer's certificate or a copy of the temporary residence permit, a copy of the medical record and the relevant materials specified in Article 9 of these Measures.

Twelfth newborn medical expenses incurred in the insured year, the mother can enjoy the new rural cooperative medical compensation policy in the name of the mother.

Thirteenth patients to participate in commercial insurance, reimbursement must provide a copy of the patient's insurance contract, payment vouchers and the relevant information or copies stipulated in Article 9. A copy of the receipt for medical expenses must indicate that "this piece is consistent with the original, and the original has been retained. Handler ⅹⅹⅹⅹ ",and affix the seal of the insurance department.

When the participating farmers go through the compensation procedures for the new rural cooperative medical system for the first time, each new rural cooperative medical system agency shall provide a copy of the receipt of medical expenses, indicating that "this piece is consistent with the original, and the original has been retained. Handling procedure X ",and affix the official seal of this institution.

Fourteenth Chinese herbal pieces, Chinese herbal preparations, Chinese medicine appropriate technology (refers to Chinese massage, acupuncture, massage, excluding deep acupoint hyperthermia, electrotherapy, voice therapy, etc.). The hospitalization expenses will be increased by 65,438+00% on the basis of Article 8.

Article 15 The annual maximum reimbursement limit for single hospitalization medical expenses is150,000 yuan.

Article 16 The new rural cooperative medical system implements single-disease quota compensation for common inpatient diseases that are subject to single-disease price limit in people's hospitals below the county level and county traditional Chinese medicine hospitals, and also applies to hospitals above the county level outside the county. Township hospitals calculate compensation in accordance with the provisions of the first paragraph of Article 8.

1, hernia surgery compensation 1700 yuan (extra cost for using the patch);

2. Surgical compensation for simple appendicitis 1700 yuan;

3, complex (suppuration, perforation, poor resistance, etc. ) Appendicitis surgery compensation 2500 yuan;

4. Compensation for flat delivery in 300 yuan (plus rural women's hospital delivery subsidy in 500 yuan);

5, maternal horizontal compensation in 600 yuan (plus rural women in hospital delivery subsidies in 500 yuan).

6, cesarean section compensation of 2000 yuan (plus rural women's hospital delivery subsidies in 500 yuan);

7. Compensation for external hemorrhoids 1500 yuan; 8. Compensation for mixed hemorrhoids 1700 yuan;

9. Cataract compensation 1000 yuan (lens only, excluding phacoemulsification);

10, the compensation for hysteromyoma is 3200 yuan.

Seventeenth increase the reimbursement rate of the following hospitalization diseases:

1. The reimbursement rate of hospitalization expenses for rural children within the limits of major diseases in the following designated places has increased to 70%: (1) childhood leukemia (2) congenital heart disease in children (3) simple cleft lip in children.

2. Incorporate severe mental illness, breast cancer, cervical cancer, leukemia, end-stage renal disease and hemophilia into serious illness planning, and the reimbursement rate of hospitalization expenses within the policy scope is 70%.

3. Children with major diseases who seek medical treatment in designated hospitals at the county level and patients with critical illness who are hospitalized in designated medical institutions at the county level, in line with the principle of high, their hospitalization expenses can be compensated according to the proportion of hospitalization reimbursement for other diseases.

Eighteenth national basic medical insurance nine medical rehabilitation projects are all included in the new rural cooperative medical insurance coverage.

Article 19 When a farmer receives compensation, the patient himself or his immediate family members must carry the ID cards of the patient and his agent to collect it.

Article 20 Whoever forges or alters the tickets related to the new rural cooperative medical system, or lends the new rural cooperative medical system card to others to defraud the new rural cooperative medical system fund, shall recover the reimbursement, cancel the eligibility of participating farmers for reimbursement in the current year, and hand it over to the relevant departments for investigation of the discipline and legal responsibility of the parties, depending on the circumstances and the amount of reimbursement.

Article 21. For patients who have suffered accidental injuries such as falls, sprains, wounds, burns, scalds and poisoning (excluding crimes, fights, alcoholism, drug abuse, suicide, self-mutilation, intentional violation of regulations, traffic accidents, etc.). ), the individual pays 30% of the hospitalization expenses first, and the rest of the medical expenses within the policy scope are compensated according to normal diseases.

Twenty-second the following circumstances shall not be compensated:

1, medical expenses incurred by farmers who did not participate in the new rural cooperative medical system due to illness;

2. Medical expenses incurred in non-designated medical institutions due to illness;

3. The information of the participating patients is obviously wrong;

4, family members did not all participate in the new rural cooperative medical system, the medical expenses of all family members;

5. Participate in medical expenses that have not occurred within the annual period;

6, Shandong Province, the new rural cooperative medical care essential drugs directory and diagnosis and treatment directory provisions will not be reimbursed for drug costs and diagnosis and treatment project costs;

Twenty-third in case of major adjustment of national policies, these measures should be revised accordingly.

Twenty-fourth approach by the county health bureau is responsible for the interpretation of.

Article 25 These Measures shall be implemented as of 20 12/month 1 day, and the original reimbursement method (Jiyang He Nong [20 11]1) shall be abolished at the same time.