新农合知识讲座材料

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1、2012年新农合知识讲座材料1一、在定点医疗机构就医才能享受补助参合农民在本县（市、区）范围内的医疗机构、以及在市级医疗机构所在地的县（区）就医时，必须选择本县定点医疗机构和开展即付即补的市级定点医疗机构就医住院，才能享受合作医疗补助政策。对在本县（市、区）内的非定点医疗机构住院就医的，不予补助。参合农民到本省范围内的其他市（州）、县（市、区）就医住院时，必须选择在省卫生厅或当地确认的新农合省、市、县、乡定点医疗机构就医，住院医疗费用结算后携带相关资料，回县里后，交当地卫生院代为办理报销手续。参合农民在省外医疗机构就医住院时，应选择被当地有关部门认定医疗保障、合作医疗的定点医疗机构就医。其住院

2、医疗费用由病人或家属携带相关资料，回县里后，交当地卫生院代为办理报销手续。参合农民在县外医疗机构就医住院，回县里报销时，需要携带的资料包括：（1）合作医疗证、（2）户口本或身份证、（3）住院费用总清单、（4）疾病诊断证明、（5）出院小结、（6）发票（外省住院限打印发票，手写发票不能作为报销凭据）、（7）外伤病人需要有效的外伤证明、（8）住院分娩病人需要生育证和小孩的出生证等。二、严格票据审核，必须使用就诊票据原件报销规范审核流程，采取网络实时审核与费用清单事后审核双重措施，对病人、病历、处方、收费的真实性、一致性、合理性进行综合审核并定期复核。严格票据审核，必须使用就诊票据原件报销。建立健全稽

3、查制度，通过电话查询、入户回访等方式，对参合患者尤其是异地就医或发生大额医疗费用的参合患者进行跟踪核查。三、2012年新农合住院起付线和封顶线住院起付线：乡、县、市、省级定点医疗机构分别为100元、300元、500元、700元。普通住院封顶线为10万元（即全年累积补偿费用不超过10万元）；意外伤害住院封顶线为2万元。四、2012年新农合报销比例（一）普通住院报销政策：本县乡镇定点医疗机构住院保内费用按100%报销；本县县级定点医疗机构保内费用按85%报销；本市市级定点医疗机构保内费用按70%报销；本省省级定点医疗机构保内费用按65%报销；其他医疗机构住院保内费用按65%报销（该医疗机构必须是当

4、地新农合定点医疗机构，如果当地没有新农合机构则必须是当地医保定点医疗机构）。（二）住院分娩报销政策：参加新农合并符合计划生育规定的住院分娩者，必须严格执行限价标准，乡级医院单胎平产限价600元，双胎增加150元由财政补贴，县级及以上医院单胎平产限价850元，双胎增加150元由财政补贴；乡级医院剖宫产每台限价2000元，县级及以上医院剖宫产限价2500元。乡级医院住院平产单胎导航地图下载由财政补助300元后，剩下部分由新农合进行补助，补助金额在300元以内，县级医院住院单胎平产由财政补助300元后，剩下部分由农合进行补助，补助金额在550元以内；有剖宫产指征到有资质开展剖宫产的定点医疗机构行剖宫

5、产术的由财政补助300元后，剩下部分由农合按按住院报销比例进行补助，出现并发症按住院比例报销（不受限价），但并发症应严格控制10%以内，县外住院分娩参照限价和县外报销比例执行（上级部门政策调整将参照上级部门政策执行）。（三）意外伤害住院报销政策：意外伤害报销比例相应下调20个百分点。（四）统筹普通门诊报销政策：起付线为10元，按40元/人分配，户内可以调剂使用，报销比例为100%。（五）特殊病补助标准A：有下列疾病的参合患者，持二级及以上级别医疗机构疾病诊断证明及相关资料，经县合管办审核批准后，可获得全年2000元的门诊定额补助（不可根治的恶性肿瘤、器官移植抗排斥反应、再生障碍性贫血、地中海贫

6、血、系统性红斑狼疮第二年办理特殊病门诊时可拿原疾病诊断证明书但要附村委会证明，证明患者尚存且需要用药）：（1）、恶性肿瘤（二级肿瘤专科医院和三级医院疾病诊断证明）（2）、器官移植抗排斥用药的（三级医院疾病诊断证明）（3）、再生障碍性贫血（要求附检验报告单）（4）、地中海贫血（要求附检验报告单）（5）、系统性红斑狼疮（附检验报告单）B：有下列疾病的参合患者，持县级（二级）及以上医院疾病诊断证明及相关资料，经县合管办审核批准后，可获得全年1000元的定额门诊补助：（1）、肝硬化晚期（2）、甲亢（附检验报告单）（3）、糖尿病（有并发症的并附检验报告单）（4）、器质性病变类心脏病（有心功能三级以上）（

7、5）、精神病（专业机构诊断证明）（6）、脑血管意外卧床治疗（7）、癫痫C :肺结核病辅助治疗可享受200元/人/年。D: 动物咬伤接种狂犬疫苗的按100元/人/年。E: 肾病需血透患者到本县中医院、人民医院进行血透按住院比例进行报销，启付线300元（每季计一次）。县外血透的按县外住院方式报销，全年封顶5000元/人。享受县外血透特殊病补助后本年内不再享受县内特殊病血透待遇，两者不能重复享受。F:肾病需腹膜透析并开展腹膜透析的患者全年可享受4000元补助。以上特殊病患者只能享受一种特殊病补助，特殊病患者如果有两种及以上特殊病的在办理特殊病门诊时可自由选择其中一种。五、加强转诊管理严厉禁止用不规范

8、的转诊方式引导参合农民在县级或县级以上医疗机构就医。严厉禁止各级医疗机构对下级医疗机构（或个人）导航地图下载转诊或介绍病人给予回扣的行为，对基层医疗机构（或个人）在转诊病人收受回扣的行为进行严肃查处；禁止以免费健康检查为名，在乡村组织参合农民进行体检，小病大治地批量收治参合农民住院治疗。参合农民到县外住院不转诊或不电话告知的，补偿时报销比例下调2%。六、新生儿随母参合政策（一）新生儿随母享受新农合住院补偿政策，必须符合以下条件：1、新生儿母亲全家必须参合。注释：农合参合要求以户为单位进行；母亲是外县并在外县参合的，则在外县报销；新生儿母亲是外县的或属非农业户口，但是已经在男方参合的，需提供身份

9、证明。2、新生儿父亲全家必须参合。注释：新生儿父亲是外县的，或者属非农业户口的，需提供身份证明。3、新生儿必须是计划生育政策内出生的。（二）新生儿随母享受新农合住院补偿政策，必须提供以下证明：1、 新生儿父母双方的户口本（外县的提供身份证也可）；2、 新生儿父母双方的农合本（外县或城镇居民户口的除外）；3、 医院出具的新生儿出生医学证明；4、 计生部门出具的准生证（即生育证）。七、严格控制住院率、住院时间和住院次均费用和出院标准2012年全县住院率严格控制在11%以内，住院率超标的按怀化市卫生局住院率控制方案执行。为了防止出现过度治疗的现象，本县乡镇定点医疗机构实行保内费用100%报销后，要严

10、格控制住院时间，患者在乡镇定点医疗机构连续住院时间超过12天，从第13天起每5天内加收一次起付线。参合农民因疾病需要住院治疗的，必须先交费，出院时再由定点医疗机构按照规定予以补偿。乡镇定点医疗机构实行保内费用100%报销后要严格控制次均住院费用上涨，不严格控制超过者将按次均住院费用标准扣减报销费用。患者达到出院标准的医院要及时通知，及时办理出院手续。八、坚持基本药物和新农合目录内用药严格坚持基本药物和新农合目录内用药，严格坚持自费药品比例和可报销比例。QcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTW

11、N60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3P tGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgK tGZ7R4I30kA1DkaGhn3X

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14、aGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI

15、92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2 tGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I

16、30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHY

17、i2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2tG

18、Z7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGeR4I30kA1DkaGhn3XtKknBYCUDxq

19、A7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7X

20、Av2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGh

21、n3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92t

22、gKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1Dk

23、aGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI9

24、2tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv HhI92tgKQ

25、cWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYD

26、IAWGeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tg

27、KQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGGeaUw

28、YDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI9

29、2tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30