In 2025, the outpatient reimbursement policy in Taiyuan, Shanxi has several key highlights. For urban and rural residents' medical insurance, the annual payment limit has been increased to 300 yuan per person, and the single - time limit of 50 yuan has been abolished. The reimbursement ratio for ordinary outpatient services has been raised to 65%, and for hypertension and diabetes patients, it has been increased to 75%. For insured residents who have signed up with family doctors and receive outpatient treatment at primary medical institutions, the payment ratio is further increased by 5% based on the three - level charging standard. There are 46 types of outpatient chronic and special diseases, with no deductible standard, and monthly payment limits are set according to different diseases. Ten types of outpatient chronic and special diseases such as kidney diseases and malignant tumors are included in the "dual - channel" management and implemented according to special policies. For cross - provincial off - site medical treatment, direct settlement covers 10 types of diseases (such as hypertension and diabetes), and for patients who have not completed long - term filing, the reimbursement ratio is reduced by 10 percentage points.
For employee medical insurance, the deductible line is calculated on a per - visit basis, and after the cumulative amount reaches 300 yuan, the deductible standard is waived. The annual cap for on - the - job employees is 2500 yuan, and for retirees, it is 3000 yuan. The reimbursement ratio for retirees is 5% higher than that for on - the - job employees. For Class B drugs, 5% is paid by the individual first, and the remaining part is reimbursed according to the ratio. Outpatient chronic diseases have monthly limits set by disease type, and outpatient special diseases (such as malignant tumors) are managed with reference to inpatient care and have no annual payment limit. Starting from January 1, 2025, paper medical records will be abolished, and face - swiping or activation of the medical insurance electronic voucher can be used for medical treatment.
Here is a more detailed breakdown:
- Urban and rural residents' medical insurance outpatient co - ordination policy
- Payment limit and ratio
- The annual payment limit has been increased to 300 yuan per person, and the single - time limit of 50 yuan has been removed. Now, insured residents can enjoy the treatment in all designated medical institutions in Taiyuan.
- For Class - I (tertiary hospitals) charging medical institutions, the deductible standard is 80 yuan per visit, and the payment ratio is 45%; for Class - II (secondary hospitals), the deductible is 50 yuan per visit, and the ratio is 60%; for Class - III (primary hospitals), there is no deductible, and the ratio is 65%.
- For groups such as the elderly over 70 years old, students, and children, the reimbursement ratio in tertiary hospitals can reach 65% for medical expenses below 100,000 yuan.
- For Class B drugs, 5% is paid by the individual first, and the remaining part is reimbursed according to the ratio.
- Management of special disease types
- There are 46 types of outpatient chronic and special diseases. Among them, 36 fixed - amount disease types are reimbursed at 80% (monthly payment limits are set), and 10 non - fixed - amount disease types are reimbursed at 75%.
- Ten types of outpatient chronic and special diseases including kidney diseases and malignant tumors are included in the "dual - channel" management and are implemented according to special policies.
- Off - site medical treatment settlement
- Cross - provincial off - site medical treatment direct settlement covers 10 types of diseases, including hypertension and diabetes. For patients who have not handled long - term filing, the reimbursement ratio is reduced by 10 percentage points.
- Employee medical insurance outpatient co - ordination policy
- Deductible line and cap
- The deductible line is calculated on a per - visit basis. After the cumulative amount reaches 300 yuan, the deductible standard is waived. The annual cap for on - the - job employees is 2500 yuan, and for retirees, it is 3000 yuan.
- The reimbursement ratio for retirees is 5% higher than that for on - the - job employees. For example, in primary medical institutions, the reimbursement ratio for on - the - job employees is 55%, and for retirees, it is 60%.
- Policy for Class B drugs
- For Class B drugs, 5% is paid by the individual first, and the remaining part is reimbursed according to the ratio.
- Differentiation between outpatient chronic diseases and special diseases
- Outpatient chronic diseases have monthly limits set by disease type. For example, the monthly limit for diabetes is 300 yuan. Outpatient special diseases (such as malignant tumors) are managed with reference to inpatient care and have no annual payment limit.
- Medical insurance electronic voucher
- Starting from January 1, 2025, paper medical records will be abolished, and insured people can use face - swiping or activate the medical insurance electronic voucher for medical treatment.
It should be noted that the above policies are implemented as of January 1, 2025. For the latest and most accurate information, it is recommended to refer to the latest documents of the local medical insurance center.
