The outpatient (emergency) medical expenses incurred in a treatment year shall be paid 50% in the community medical institution fund and 30% in the non-community medical institution, and the annual fund payment limit shall be 300 yuan; After enjoying the overall treatment of outpatient service, the individual pays more than 2000 yuan for the outpatient medical expenses that continue to occur. In community medical institutions, the fund pays 50%, in non-community medical institutions, the fund pays 30%, and the annual fund payment limit is 2600 yuan.

Serious illness clinic, the elderly residents and other residents fund to pay 80%, students, children and college students fund to pay 85%.

2, Nanjing medical insurance reimbursement rate of chronic diseases:

For the insured who are undergoing dialysis treatment (including hemodialysis and peritoneal dialysis) in the outpatient department of chronic renal failure, the limit of dialysis medical expenses incurred in designated medical institutions is 63,000 yuan/year, and the limit of supplementary examination drug medical expenses fund payment is 8,000 yuan/year.

3, Nanjing medical insurance hospitalization reimbursement ratio:

The proportion of fund payment for elderly residents and other residents is: 65% for tertiary medical institutions, 85% for secondary medical institutions, 90% for first-class and below medical institutions, and the proportion of fund payment for elderly people over 80 years old at all levels is increased by 5 percentage points on the above basis; Medical institutions at all levels pay 80%, 90% and 95% for students, children and college students respectively.

With reference to Article 16 of the Detailed Rules for the Implementation of the Measures for the Basic Medical Insurance for Urban and Rural Residents in Nanjing, the medical expenses that meet the payment scope of medical insurance for urban and rural residents within one treatment year shall be paid by the fund, and the part above the Qifubiaozhun shall be paid according to the regulations, as follows:

(1) Holistic outpatient treatment. Qifubiaozhun 200 yuan, 50% of outpatient (emergency) medical expenses in a treatment year are paid by the fund in community medical institutions, 30% in non-community medical institutions, and the annual fund payment limit is 300 yuan. The proportion of fund payment for elderly residents over 80 years old will be increased by 5 percentage points on the basis of the above payment ratio, and the annual fund payment limit will be increased by 10%.

(two) outpatient high cost compensation. In a treatment year, after enjoying the overall treatment of outpatient service, the individual pays more than 2,000 yuan for outpatient medical expenses, 50% for treatment in community medical institutions, 30% for treatment in non-community medical institutions, and the annual fund payment limit is 2,600 yuan.

(3) outpatient treatment of serious illness. Outpatient serious diseases include malignant tumor, hemodialysis (including peritoneal dialysis) treatment of severe uremia, anti-rejection treatment after organ transplantation, hemophilia, aplastic anemia and systemic lupus erythematosus. In a treatment year, the proportion of medical expenses in special outpatient clinics of designated medical institutions is 80% for elderly residents and other residents, and 85% for students, children and college students. The fund payment regulations and payment limits are as follows:

1, outpatient treatment of malignant tumor. The insured person with malignant tumor will receive radiotherapy and chemotherapy (intravenous or interventional chemotherapy) in the outpatient department of designated medical institutions, and the fund payment limit is 1.2 million yuan/year;

The fund will pay 80,000 yuan/year for targeted drug treatment expenses such as endocrine therapy for breast cancer and prostate cancer, immunotherapy for renal cancer and melanoma, oral chemotherapy for malignant tumor (including molecular targeted drugs), bladder perfusion, anti-bone metastasis or late analgesic treatment within five years from the date of diagnosis. If treatment is still needed after five years, the treatment period may be extended after evaluation by designated medical institutions;

The expenses of adjuvant therapy other than radiotherapy and chemotherapy and targeted drug therapy are: 654.38 million yuan/year in the first three years, 5,000 yuan/year in the fourth five years, and 2,000 yuan/year in the sixth year and beyond.

2, chronic renal failure outpatient dialysis treatment. For the insured who are undergoing dialysis treatment (including hemodialysis and peritoneal dialysis) in the outpatient department of chronic renal failure, the limit of dialysis medical expenses incurred in designated medical institutions is 63,000 yuan/year, and the limit of supplementary examination drug medical expenses fund payment is 8,000 yuan/year.

3. Outpatient anti-rejection therapy after organ transplantation. The fund payment limit of anti-rejection drug treatment expenses in designated medical institutions is: 80,000 yuan in the first year, 75,000 yuan in the second year, 70,000 yuan in the third year, and 65,000 yuan/year in the fourth year and beyond. The cost of adjuvant therapy is paid by the fund:

8,000 yuan in the first year; 6000 yuan in the second year; 4,000 yuan in the third year; 2000 yuan for the fourth year and beyond. The treatment period of outpatient anti-rejection treatment after hematopoietic stem cell (allogeneic) transplantation is the year of operation and the first year after operation, and the treatment standard is implemented according to the corresponding years of outpatient anti-rejection treatment after transplantation.

The insured person suffers from the above-mentioned outpatient serious illness, and the outpatient serious illness medical expenses that occurred in the current year after diagnosis or operation shall be paid by the fund according to the first-year treatment standard.

4, hemophilia treatment. The corresponding medical expenses of patients with hemophilia (hereditary coagulation factor ⅷ and ⅸ defects) for examination and replacement treatment in designated medical institutions are 6,543,800 yuan, 50,000 yuan and 6,543,800 yuan respectively according to the light, medium and heavy hemophilia.

5. Treatment of aplastic anemia and systemic lupus erythematosus. The minimum threshold for medical expenses incurred in designated medical institutions is 1 ,000 yuan, and the annual fund payment limit is 1 ,000 yuan.

(4) outpatient psychiatric treatment. Suffering from schizophrenia, schizophrenic affective disorder, paranoid psychosis, bipolar disorder, epileptic psychosis, mental retardation with psychosis, depressive episode (moderate or severe), obsessive-compulsive disorder and other mental diseases, the proportion of medical expenses incurred in outpatient service is 80% for elderly residents and other residents, and 85% for students, children and college students.

(5) Outpatient AIDS treatment. HIV-infected people and AIDS patients enjoy free outpatient anti-HIV and opportunistic infections treatment and related examinations, which are used by designated medical institutions according to the quota standard of 1 000 yuan per person per quarter.

(6) hospitalization. Medical expenses incurred in hospitalization in designated medical institutions, Qifubiaozhun for tertiary medical institutions 1000 yuan, secondary medical institutions in 500 yuan, and primary and below medical institutions in 300 yuan. For the above part of Qifubiaozhun, the proportion of fund payment for elderly residents and other residents is: 65% for tertiary medical institutions, 85% for secondary medical institutions, 90% for first-class and below medical institutions, and the proportion of fund payment for elderly people over 80 years old at all levels is increased by 5 percentage points on the above basis; Medical institutions at all levels pay 80%, 90% and 95% for students, children and college students respectively.

If the patient is hospitalized for the second time or more within a treatment year, the hospitalization Qifubiaozhun shall be calculated according to 50% of the prescribed hospitalization Qifubiaozhun. There is no hospitalization Qifubiaozhun for patients hospitalized due to serious diseases, mental illness and AIDS. The insured is referred to the next designated medical institution for hospitalization by the first-level designated medical institution, and the Qifubiaozhun for hospitalization in the next designated medical institution is cancelled; Cumulative calculation of Qifubiaozhun at transfer.

(7) Reproductive medicine. The medical expenses for prenatal examination and delivery in line with the national family planning policy will be included in the payment scope of the medical insurance fund for urban and rural residents. The fund will pay 40% of the expenses for prenatal examination within one treatment year, and the limit of the fund payment is 300 yuan; The hospital delivery expenses shall be implemented according to the hospitalization payment policy, and 75% of the medical expenses of tertiary medical institutions shall be paid by the fund.

Extended data

With reference to Article 2 of the Detailed Rules for the Implementation of the Measures for the Basic Medical Insurance for Urban and Rural Residents in Nanjing, urban and rural residents who meet the insurance conditions in this Municipality can bring their household registration books, identity cards and other related materials to the relevant agencies (hereinafter referred to as "grass-roots agencies") responsible for social insurance handling in the streets (towns) and communities (villages) where their household registration is located. The following personnel also need to provide relevant materials:

1, 18 years old and above who are insured as students or children need to provide the school registration certificate issued by the education department or school in the high school stage of our city (including high school equivalent);

2. According to the residence permit insurance regulations of this Municipality, a residence permit within the validity period is required;

3. If the newborn is insured (/kloc-born within 0/2 months), it is necessary to provide birth medical certificate and parents' ID card;

4. If the prospective newborn is insured, it is necessary to provide the parents' household registration book and ID card;

5. During the year, retired soldiers, employees whose medical insurance was interrupted and released from prison should provide relevant materials such as retired employees, employees whose medical insurance was interrupted and released from prison.

With reference to Article 3 of the Detailed Rules for the Implementation of the Measures for Urban and Rural Residents' Basic Medical Insurance in Nanjing, the age of each insured person shall be determined based on his/her ID card, and the determination time shall be as of June 5438+February 3 1 of the year of enrollment registration, and the determination time of the insured person in the middle of the year shall be as of June 65438+February 3 1 of the previous year.

According to Article 4 of the Detailed Rules for the Implementation of the Measures for the Basic Medical Insurance for Urban and Rural Residents in Nanjing, the medical insurance for urban and rural residents shall be paid annually, with the payment period of 1 to1on February 25, 2008. If the insurance formalities are completed and the full payment is made within the specified payment period, the service life will be 1 in the following year.

In principle, college students pay according to the academic system, and pay medical insurance premiums in one lump sum according to the annual payment standard. The payment period is from September 1 day to 1 October 25th, and the treatment period is from September1day of the school year to August 3 1 day of the following year. Colleges and universities should organize the registration and payment of college students during the payment period. The above-mentioned treatment enjoyment period is collectively referred to as "a treatment year".

= Nanjing Human Resources and Social Security Bureau-Detailed Rules for the Implementation of Measures for Basic Medical Insurance for Urban and Rural Residents