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医保政策问答(二) | 一图读懂医保待遇及报销

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黑马计划weilerangguangdacanbaorengengzhiguan、bianjiedilejieyibaozhengce,guojiayiliaobaozhangjuweituozhongguoyiliaobaoxianzazhishe,genju《yibaozhengcewendashouce》bianxieleyitududongxilie,gong11pian30gedawenti,hangaileshoucedequanbuneirong,bingzuochushidangtuozhanyanshen。huanyingdajiajiehezijideshijiqingkuang,“duihaoruzuo”jiejuezishenzaicanbaohexiangshoudaiyuguochengzhongyudaodenanti。


  医保政策问答(二)


  一 图 读 懂 医 保 待 遇 及 报 销


  1、参加医保后,参保人能够享受怎样的报销待遇?


  da: congquanguozongtiqingkuangkan,zhuyuanbaozhangfangmian,zhigongyibaohejuminyibaozhengcefanweineizhuyuanfeiyongbaoxiaobilifenbiedadao 80% zuoyouhe 70% zuoyou,tongchoujijinnianzuigaozhifuxianefenbiedadaodangdizhigongnianpingjungongzihuojuminnianrenjunkezhipeishourude 6 beizuoyou。menzhenbaozhangfangmian,zhigongyibaohejuminyibaopubiankaizhanlemenzhenmanxingbing(teshujibing)baozhang,juminyibaohaipubiankaizhanlemenzhenfeiyongtongchou。


  2、医保可以报销哪些医疗费用?


  da: yibanqingkuangxia,yibaofeiyongdebaoxiaozunxunzheijitiaoguize,zhiyaozaizheixieguizedefanweineideyiliaofeiyongdoushikeyibaoxiaode:


  zhengchangxiangshoudaiyuqinei(yibaomeiduanjiao);


  zaidingdianyiliaojigoujiuyi;


  fuhe“sangemulu”fanwei;


黑马计划  zaiqifuxianyishanghefengdingxianzhinei;


黑马计划  erxiangduide,zaiguizewaidefeiyongjiubukeyibaoxiao。


  3、什么是医保的“三个目录”?


  da: youyuyibaojijinyouxian,bukenengfugaisuoyoudeyiliaoxuqiu,yinciweibaozhangcanbaorenyuandejibenyiliaoyongyaoxuqiu,helikongzhiyiliaofeiyongzhichu,guifanjibenyiliaobaoxianyongyao、zhenliaodengfangmiandeguanli,baozhengjibenyiliaobaoxianzhidudejiankangyunxing,yiliaobaozhangbumenguidinglejibenyiliaobaoxianduiyaopin、zhenliaoxiangmuheyiliaoheimajihuasheshidebaoxiaofanwei,sucheng“sangemulu”。canbaorenyuanshiyongyaopin、fashengzhenliaoxiangmuhuoshiyongyiliaoheimajihuasheshifashengdefeiyong,ruguoshuyu“sangemulu”neide,keyianguidingjinxingbaoxiao;bushuyu“sangemulu”neide,yibaobuyubaoxiao。zhaodayekaideshiyibaoyaopinbaoxiaomuluwaideyaopin,suoyiwufabaoxiao。muqianchangjianbing、duofabingdezhuyaozhiliaoyongyaodouyinarumulu。


  yibaoyaopinmuluzhongdeyaopinhaifen“jialei”he“yilei”,lianggefenleideyaopinzaijisuanbaoxiaojineshi,narubaoxiaofanweidebiliyebutong


黑马计划  yibaoyaopinmuluneidejialeiyaopinshilinchuangzhiliaobixu、shiyongguangfan、liaoxiaohao,tongleiyaopinzhongjiagedideyaopin。canbaorenshiyongzheileiyaopinshi,keyiquanenarubaoxiaofanwei,anguidingbilibaoxiao。yileiyaopinshikegonglinchuangzhiliaoxuanzeshiyong、liaoxiaohao,tongleiyaopinzhongbijialeiyaopinjiagegaodeyaopin。canbaorenshiyongyileiyaopinshi,yaoxiananbili(gedibutong)kouchuyidingdegerenzifufeiyonghou,jiangyuxiafeiyongzainarubaoxiaofanwei,anguidingbilibaoxiao。


  4、什么是“起付线”和“封顶线”?


黑马计划  da: qifuxianzhideshiyibaojijindeqifubiaozhun,canbaorenyuanzaidingdianyiliaojigoushijifashengde“sangemulu”neideyiliaofeiyong,zijiyaoxianchengdanqifubiaozhunyixiadefeiyong,qifubiaozhunyishangdebufenzaiyouyibaojijinanguiding、anbilibaoxiao。genjudiqu、yiliaojigou、menzhenhuozhuyuandengqingkuangdebutong,qifuxianbiaozhunyegebuxiangtong,congjibaiyuandaoyiqianduoyuanbudeng。


  fengdingxianzhideshiyibaojijindezuigaozhifuxiane,yejiushicanbaorenzaiyigenianduneileijinengcongyibaojijinhuodedezuigaobaoxiaojine。fengdingxianyiwaideyiliaofeiyong,canbaorenkeyitongguocanjiabuchongyiliaobaoxian、shangyeyiliaobaoxiandengbanfajiejue。


  5、如何计算医保报销金额?


  da: canbaorenjiuyihou,fashengleyaopin、zhenliaodengfeiyong,qizhongyaopinyoubaokuojialeiyaopinheyileiyaopin,neimebaoxiaodefangfashi: yileiyaokouchuzifuhoudefeiyong,jiashangjialeiyaoquanbufeiyong,zaijiashangzhenliaodengfeiyongzhongfuheyibaoguidingdefeiyong,keyongyuleijicanbaorendangniandeqifuxian。duiyuchaoguoqifuxian、weidafengdingxiandefeiyong,yijuhuanzhebenrencanbaoleixing、jiuyiyiyuanjibiedenganguidingbilibaoxiao。


  biru——


  jiashechengzhenzhigonglaoguomoucijiuyizhuyuanfashengleyibaomulufanweineidezhenliaodengfeiyong 2000 yuan,jialeiyaopinfeiyong 3000 yuan,yileiyaopinfeiyong 5000 yuan,yileiyaopindezifubilishi 10%,dangdiqifuxianshi 1300 yuan,bencijiuyidefeiyongweichaoguofengdingxian,chengzhenzhigongyibaozaigaijibieyiyuandebaoxiaobiliwei 80%。neimebaoxiaofangfashi:


  jialeiyaoquanbufeiyong 3000 yuan,jiashangjiangyileiyaopinkouchuzifuwaideqiyufeiyong 4500 yuan(yileiyaopinzifubufenwei 5000*10%=500 yuan),zaijiashangfuheyibaoguidingdezhenliaodengfeiyong 2000 yuan,heji 9500 yuan。kouchu 1300 yuandeqifuxian,narubaoxiaofanweidefeiyongshi 8200 yuan。zebencilaoguodeyiliaofeiyong,yibaonenggoubaoxiao 8200*80%=6560 yuan,laoguoxuyaozijichengdan 3440 yuan(qifuxian 1300 yuan + yileiyaozifude 500 yuan + yibaozhengcefanweineianbiliyougerenfudande 1640 yuan)。



  6、超出医保封顶线的费用怎么办?


  da: chaoguojibenyibaofengdingxiandebufen,kegenjushijiyiliaofeiyongfudanqingkuang,naruchengxiangjumindabingbaoxianfanwei。dabingbaoxianshijibenyiliaobaozhangzhidudetuozhanheyanshen,zhuyaoduidabinghuanzhegaoeyiliaofeiyongzaijibenyibaozhifujichushangzaijiyujinyibuzhifu。duicanbaojuminjingjibenyibaozhifuhou,chaochudabingbaoxianqifuxiandefeiyong,anguidingnarudabingbaoxianzhifufanwei。


  muqianlaikan,dabingbaoxianzhengcefanweineifeiyongzhifubilidadao 50% yishang,bingqiebaozhangshuipingzaijinyibutisheng,2019 nian《zhengfugongzuobaogao》mingque“jiangdibingtongyidabingbaoxianqifuxian”“baoxiaobiliyou 50% tigaodao 60%”。2019 nian 4 yueguojiayibaojulianhecaizhengbuyinfa《guanyuzuohao 2019 nianchengxiangjuminjibenyiliaobaozhanggongzuodetongzhi》,yemingqueqifuxianjiangdizhishangyiniandujuminrenjunkezhipeishourude 50%,tongshiyaoqiujinyibujiadaduipinkunrenkoudezhifuqingxielidu,pinkunrenkouqifuxianjiangdi 50%,zhifubilitigao 5gebaifendian,bingquanmianquxiaojiandanglikapinkunrenkoufengdingxian,jinyibujianqingdabinghuanzhe、kunnanqunzhongyiliaofeiyongfudan。


黑马计划  ruguocanbaorenshipinkunrenkouhuodibaoduixiang,haikeyishenqinghuodexiangyingyiliaojiuzhu。



黑马计划1

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