The medical treatment behavior of the insured in other areas of China outside the overall planning area of this Municipality (excluding Hongkong, Macau and Taiwan Province Province, hereinafter referred to as medical treatment in different places) is collectively referred to as medical treatment in different places, including:

(1) Long-term medical treatment in different places: the insured has lived, worked or studied in the same different place in China for more than 6 months, and was treated in the designated medical institution of local medical insurance due to illness (hereinafter referred to as the medical institution in different places).

(2) Emergency treatment in different places: the insured is hospitalized or observed in emergency treatment in medical institutions in different places in China.

(3) Students seek medical treatment in different places: during vacation or illness, students return to their domicile; Or go to a different medical institution for medical treatment during the internship at a different branch school.

(4) Referral from other places: the insured patients in this city are approved to be transferred to other places for treatment.

(five) other medical treatment in different places as stipulated by the policy.

Second, the method of medical treatment in different places

The term "long-term medical treatment in different places" as mentioned in these Measures shall be confirmed by the medical insurance agency of this Municipality in advance. On-the-job insured persons who have worked and studied in different places for a long time shall be uniformly applied by the employer, and other insured persons shall be handled by units or individuals.

Third, you need to prepare materials to apply for medical treatment in different places.

Employers and individuals applying for medical treatment in different places shall provide the following information:

(a) is a long-term residence in different places should provide:

1. If the residence is the domicile, provide a copy of the relevant household registration certificate; If the residence is a non-registered residence, provide the original proof of continuous residence for more than 6 months or a copy of the temporary residence permit issued by the police station, street or neighborhood (village) Committee where the residence belongs;

2. A copy of the applicant's ID card, and a copy of the client's ID card if entrusted by others.

(two) if you work and study in a different place for a long time, you should provide:

A copy of the valid labor contract signed by the insured and the employer, a list of applications for medical treatment in different places by the insured of Guangzhou basic medical insurance or the certificate of studying abroad and related materials issued by the unit (all of which must be stamped with the official seal of the unit).

(3) Relevant certification materials that should be provided as appropriate:

1. If you work in a branch of the employer in different places, you need to provide a copy of the organization code certificate or tax registration certificate of the branch (with the official seal of the employer).

2. If the employer is a non-labor dispatch, but has not set up a branch in a different place, it is required to provide a copy of the employer's project (construction) contract and relevant certificates for purchasing or renting counters or houses (such as rental cabinet agreement, house purchase contract, rental contract, etc.). ) (should be stamped with the official seal of the unit) and other materials, and provide a written explanation.

3. If the employer is a non-labor dispatch, and the working place in different places often changes or there is no fixed working place in different places (such as overseas construction and navigation, etc.). ), a copy of the project (construction) contract, project approval documents, overseas posts and personnel certification materials (with the official seal of the unit) is required.

4. If the employer belongs to the nature of labor dispatch, it is required to provide the employer's business license, qualification certification materials, a copy of the dispatch agreement signed with the employer and the list of dispatched personnel (with the official seal of the employer), a copy of the project contract, the employment agreement issued by the employer and the certification materials for overseas post personnel (with the official seal of the employer).

5. If the human resources service agency handles social security business on behalf of the employer, it shall handle the relevant application in accordance with the above provisions, and shall also provide a copy of the relevant information entrusted by the employer to handle social security business on behalf of the employer.

Fourth, the conditions for stopping the relationship between medical treatment in different places.

In any of the following circumstances, the validity of the confirmation of the insured person's medical treatment in different places shall be terminated accordingly, and the insured person or the employer shall promptly go to the medical insurance agency in this Municipality for cancellation of medical treatment in different places:

(a) the insured person returns to live and work in this city for a long time;

(two) returned to the city after the end of the study;

(3) Changing the insured unit;

(four) due to changes in circumstances, it no longer belongs to the scope of medical treatment in different places stipulated by the social medical insurance of this Municipality.

Verb (abbreviation of verb) is related to the designated hospital for medical treatment in different places.

Long-term medical treatment in different places insured persons must choose designated medical institutions in different places for medical treatment. You can choose 1~3 medical institutions in different places within the jurisdiction of the prefecture-level city where you live as medical institutions for the insured to seek medical treatment in different places.

When the insured chooses medical institutions in different places for medical treatment, they shall go through the confirmation formalities with the medical insurance agencies in this city after being examined and sealed by the selected medical institutions in different places and the local medical insurance agencies. In principle, it will not be replaced within 6 months after selection. Due to the need of illness treatment, relocation of new residence, name or grade change of medical institutions in different places, etc. , should hold the corresponding information to the city's medical insurance agencies to handle the change procedures.

If the insured with strong overseas engineering construction and navigation mobility cannot choose medical institutions in different places, the employer shall issue a certificate and report it to the municipal medical insurance agency for confirmation.

Six, outpatient specific project related matters

If the insured person carries out outpatient specific items (hereinafter referred to as outpatient special treatment) or outpatient designated chronic diseases (hereinafter referred to as outpatient chronic disease treatment) in different medical institutions, he shall seek medical treatment in accordance with the relevant provisions of outpatient special treatment or outpatient chronic disease treatment, and go through the relevant procedures in the following ways:

(1) The insured who has not confirmed the preferential treatment and delayed treatment in the designated medical institutions of the human resources and social security departments of this Municipality shall go through the treatment confirmation procedures in the medical insurance agencies and designated medical institutions of this Municipality with the relevant information such as the disease diagnosis certificate and the application for preferential treatment and delayed treatment of the corresponding medical institutions selected in different places.

(II) The insured who has been confirmed to be treated by the corresponding special medical institution designated by the human resources and social security department of this Municipality shall apply for changing the designated medical institution designated by the special medical institution of this Municipality on the basis of the disease diagnosis certificate of the corresponding medical institution selected in different places and the approved information on medical treatment in different places and special information.

Insured persons who have confirmed the corresponding palliative treatment in the designated medical institutions of medical insurance in this Municipality can directly seek medical treatment in the corresponding medical institutions in different places.

Seven, on the provisions of the local treatment in different places.

Anyone who suffers from diseases that can be treated in this city and the diagnosis and treatment projects that have been carried out cannot be referred to the outside of the city in principle. The designated medical institutions in this Municipality do not have the conditions for diagnosis and treatment of insured patients and need to be transferred to medical institutions outside the city for treatment and hospitalization. After consultation with experts from two tertiary designated medical institutions in this city, the attending doctor of the designated medical institution will fill in the Application Form for Co-ordination of Social Medical Insurance Insured Persons in Guangzhou, which will be signed by the deputy chief physician or the director of the department, and after being audited and sealed by the Medical (Medical Insurance) Management Department, it will be reported to the medical insurance agency in this city for approval and transferred to other places for treatment. The medical expenses incurred in the medical institutions designated by the referral shall be paid according to the regulations. Each referral outside the city is valid for 6 months.

If the insured person needs to be referred again during the treatment outside the city, he shall go through the referral procedures again.

Eight, off-site medical reimbursement regulations

1, the insured person who has been approved for medical treatment in different places meets the prescribed basic medical expenses, and the medical insurance agency in this Municipality will give corresponding treatment according to the relevant standards of basic medical insurance in this Municipality.

Long-term off-site medical personnel general outpatient treatment of the lump sum fee, in accordance with the relevant documents of the city's basic medical insurance.

2. The insured who has gone through the confirmation procedures for medical treatment in different places, and the medical expenses that meet the requirements in the designated (or designated) medical institutions in the overall planning area with the qualification for settlement of medical expenses in different places in this Municipality, shall be accounted for by the designated (or designated) medical institutions according to the relevant provisions. The basic medical insurance drugs, diagnosis and treatment items, medical service facilities directory scope and payment standards shall be implemented in accordance with the relevant provisions of the basic medical insurance in the place of medical treatment, and the treatment standards shall be paid in accordance with the relevant standards of the basic medical insurance in this Municipality.

Nine, it is stipulated that the successful application for medical treatment in different places will be temporarily returned to Guangzhou for medical treatment

The insured person who has gone through the confirmation procedures for medical treatment in different places temporarily returns to the city as a whole for medical treatment, and stays in the designated medical institutions for emergency observation and emergency hospitalization. If the medical expenses meet the requirements, the insured person shall pay the medical expenses first and then apply for sporadic medical expenses reimbursement, and other medical expenses shall not be paid by the medical insurance fund.

If the insured who has gone through the confirmation procedures for medical treatment in different places needs to be hospitalized in non-selected medical institutions in different places due to emergency or rescue, the relevant medical expenses shall be paid in advance by the individual, and after the settlement of medical expenses in accordance with the provisions, they shall be reimbursed for sporadic medical expenses by the municipal medical insurance agency.

The insured person who has been confirmed to be entitled to special care and delayed treatment will temporarily return to the overall city for medical treatment, and the continuous time for reimbursement of sporadic medical expenses will not exceed 6 months.

Medical insurance reimbursement for medical treatment in different places

The first is the conditions for reimbursement of medical insurance in different places.

1. The medical expenses incurred by the insured who have gone through the registration procedures for medical treatment in different places, such as resettlement, visiting relatives, working and studying abroad, are paid in cash at the designated medical institutions of medical insurance in different places.

2, the provincial insured agreed to transfer to Beijing, Shanghai medical insurance designated medical institutions for medical expenses in cash.

Second, the reimbursement rate of medical insurance in different places (up to 90%)

1, outpatient reimbursement ratio

There is no deductible line for general outpatient service, and all insured residents enjoy the treatment of general outpatient service. Within a medical insurance year, there is no deductible line for general outpatient service, and the medical expenses within the scope of outpatient co-ordination fund payment are reimbursed according to the proportion of 60%, and the annual maximum personal payment limit of co-ordination fund is 400 yuan.

2. Proportion of hospitalization reimbursement

The longer the continuous insurance period, the greater the reimbursement ratio. The proportion of hospitalization reimbursement of medical insurance fund will be increased by 5 percentage points every 5 years after the insured residents pay continuously, and the cumulative reimbursement ratio will not exceed 10 percentage point. If you continue to participate in insurance 10 years from 2007, the reimbursement rates of hospitalization in tertiary, secondary and primary hospitals will reach 70%, 80% and 90% respectively.

3. Secondary reimbursement ratio

After the "second reimbursement", the medical expenses incurred by the insured residents in a single hospitalization are part of the payment scope of the urban residents' basic medical insurance pooling fund, and there may be "second reimbursement". After the basic medical insurance fund is paid in proportion, if the personal burden exceeds 8,000 yuan, the serious illness insurance fund will give "second reimbursement" to the excess part according to the proportion of 55%.

After the basic medical insurance payment and "second reimbursement", the annual accumulated hospitalization medical expenses of the insured residents (including the compliant and reasonable self-funded part) exceed 25,000 yuan, and the excess part is "reimbursed" again by the serious illness insurance fund according to the proportion of 55%, and the annual maximum payment limit of the serious illness insurance fund is 250,000 yuan.

4. Reimbursement amount

The maximum annual reimbursement is 370,000 yuan for residents who participate in medical insurance for urban residents in our city. The annual payment limit for basic medical insurance is 6,543,800 yuan+0.2 million yuan, and the annual payment limit for serious illness insurance is 250,000 yuan. Therefore, Enoch Finance found that the insured can be reimbursed up to 370,000 yuan per year.

Third, the process of medical insurance reimbursement in different places.

1, to receive or download the Application Form for Working and Living in Different Places of the Municipal Basic Medical Insurance (hereinafter referred to as the Application Form) on the social security website;

2, according to the provisions of the fill in, and by the foreign social insurance (medical insurance) agencies stamped "declaration form";

3 will fill out the "declaration form" back to the social insurance agency responsible for the division of labor for review and confirmation. Need to apply for a medical card in different places in the province, with the "declaration form" after examination and confirmation to the municipal social security center audit department for registration, and then to the social security card management department for the card making procedures in different places in the province;

4. The insured person's personal social security card cannot be used after filing; If the insured person returns for medical treatment, he should go to the municipal social security agency for cancellation of medical registration, and his personal social security card can be used in designated medical institutions from the next day;

5. Implement the principle of reporting changes but not reporting.

Fourth, the materials needed for medical insurance reimbursement in different places.

1, copy of application form for medical treatment in different places

2. The formal invoice of pharmacy (supervised by State Taxation Administration of The People's Republic of China Finance Department, with the details of purchased drugs listed on the invoice) or the outpatient receipt of designated hospital.

3. Patient ID card and agent ID card

4. My passbook bank card account number (except for rural credit cooperatives) (bank name is required in external account)

Development direction of medical insurance reimbursement in different places

Yin Weimin, Minister of Ministry of Human Resources and Social Security, said that the problem of direct settlement of medical treatment in different places will be solved in three steps.

The first step: realize the direct settlement of medical treatment in different places in the province. Statistics show that the proportion of medical treatment in different places in the province is the largest. By the end of 20 16, 30 provinces in China had achieved card settlement for medical treatment in different places within the province. The second step: in the first half of this year, the hospitalization expenses of retired and resettled people across provinces will be directly settled. Yin Weimin said: "When retired parents are taken to the place where their children work, they can directly see a doctor and settle accounts in different places."

The third step: before the end of this year, realize the direct settlement of hospitalization expenses for all eligible persons.

According to the report of Ministry of Human Resources and Social Security, the national remote medical treatment settlement system 20 16 was put into trial operation at the end of 2006. During the trial operation, 15 provinces have connected to the system and started the pilot project.

Medical treatment in different places is mainly aimed at four groups of people, namely:

1 Resettlement of retirees in different places, that is, people who have settled in different places after retirement and moved to their places of residence;

2. Long-term residents in different places refer to those who live in different places and meet the conditions of the insured place;

3. The resident in different places refers to the personnel who are stationed in different places by the employer and meet the conditions of the insured place;

4. Referrals from different places refer to those who meet the referral conditions of the insured place.

Previously, the medical expenses for medical treatment in different places were paid in advance by individuals, and after the treatment, I or my agent took the bill to the medical insurance center for reimbursement.

After the direct settlement of medical insurance across provinces and different places is realized, the insured citizens do not need to advance medical expenses (except at their own expense), and they do not need to take invoices for reimbursement. They only need to hold social security cards to seek medical treatment in designated hospitals. When seeing a doctor, the reimbursement ratio is directly settled on the card, and individuals only need to deposit their own funds directly on the card.

Can rural medical insurance be reimbursed in different places?

Answer: Yes, the new rural cooperative medical system can be reimbursed within 10 working days after discharge. Reimbursement should bring ID card, diagnosis certificate, household registration book, registration form, payment details stamped by the hospital, hospitalization documents, copies of cases and so on. However, the reimbursement rate is much lower than that of local medical treatment.

It should be clear how to handle the five steps of medical insurance in different places

Non-reimbursement scope of medical insurance

1. See a doctor at one's own expense (there is no designated hospital or referral form), buy medicines at one's own expense, medicines 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 fee, visiting fee, hospitalization fee, food fee, escort fee, nutrition fee, blood transfusion fee (except for family blood donors, reimbursed according to relevant regulations), cooling and heating fee, ambulance fee, special nursing fee, etc.

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.

Note: None of the above are within the scope of rural medical insurance reimbursement.

Scope of reimbursement for medical insurance drugs

Drugs included in the basic medical insurance payment range are divided into Class A and Class B ... Class A drugs refer to drugs that are basically unified throughout the country and can ensure the basic needs of clinical treatment. The expenses of such drugs are included in the payment scope of the basic medical insurance fund, and the expenses are paid according to the basic medical insurance payment standard.

Reimbursement of basic medical insurance diagnosis and treatment items

The basic medical insurance treatment project shall meet the following conditions:

(1) Clinical diagnosis and treatment must be safe and effective, and the cost should be appropriate;

(2) The price department has set the charging standard;

(3) within the scope of designated medical services provided by designated medical institutions for the insured.

Reimbursement of basic medical service facilities

The reimbursement scope of medical service facilities in the basic medical insurance includes the living service facilities provided by designated medical institutions and necessary for the insured to receive diagnosis, treatment and nursing, mainly including the hospitalization bed fee or outpatient (emergency) observation bed fee.

What diseases can urban medical insurance reimburse?

Sexual tumor, leukemia, uremia, liver organ transplantation, kidney organ transplantation, aplastic anemia, pulmonary heart disease complicated with chronic heart failure, diabetic complications, rheumatoid arthritis, autoimmune diseases, hepatitis, cirrhosis, old myocardial infarction, chronic glomerulonephritis, cerebral thrombosis, cerebral hemorrhage, hypertensive heart disease, femoral head necrosis, malignant tumor, nephrotic syndrome, cardiovascular stent, cerebrovascular stent and vascular stent. Schizophrenia, Parkinson's disease, myelodysplastic syndrome, polycythemia vera, primary thrombocytosis, primary myelofibrosis, rheumatic valvular heart disease, myasthenia gravis, hemophilia and pituitary adenoma.

Diseases reimbursed by urban and rural medical insurance

Diseases are divided into four categories: malignant tumor, uremia, organ or tissue transplantation and hemophilia.

There are 8 kinds of second-class diseases, including leukemia, aplastic anemia, old myocardial infarction, myelodysplastic syndrome, active hepatitis, stent implantation, nephrotic syndrome and autoimmune diseases.

Systemic lupus erythematosus, hypertension, diabetes, rheumatoid arthritis, femoral head necrosis, severe psychosis, congenital adrenal hyperplasia, congenital hypothyroidism, liver cirrhosis, cerebral thrombosis and sequelae of cerebral hemorrhage, myasthenia gravis, cor pulmonale, phenylketonuria and cerebral palsy in children 14.

Off-site reimbursement process:

1. Bring the patient ID card, two one-inch color photos and the new rural cooperative medical certificate to the county joint management office for referral and filing procedures.

2. Bring the patient ID card, the certificate of the new rural cooperative medical system and the referral filing procedures to the referral hospital for medical treatment, and go through the hospitalization procedures of the new rural cooperative medical system.

3, after discharge, with the patient's ID card (or household registration book), the new rural cooperative medical certificate, a copy of medical records, hospitalization statements (some in the form of invoices), hospitalization expenses list, referral filing procedures to the joint management office for reimbursement.

Remarks:

1. Migrant workers who seek medical treatment at their workplaces can seek medical treatment first, and go through the referral filing procedures at the county joint management office during hospitalization or after discharge.

2. The medical unit must be a local designated medical institution of the new rural cooperative medical system, otherwise it will not be reimbursed.

The list of Class B drugs shall be adjusted by all provinces, autonomous regions and municipalities directly under the Central Government according to their own conditions, among which