The scope of medical insurance reimbursement in social security

The coverage of medical insurance in social security includes: outpatient, emergency medical expenses and hospitalization medical expenses in designated hospitals that meet the qifubiaozhun of the basic medical insurance pooling fund, covering emergency rescue observation and hospitalization medical expenses, and the observation medical expenses before hospitalization shall not exceed 7 days; Dialysis, radiotherapy, chemotherapy, anti-rejection drugs and other medical expenses, such as outpatient medical expenses, examination fees, surgery fees, bed fees, nursing fees, medicine fees, etc., can be reimbursed through medical insurance in social security.

Third, how is the medical insurance in social security reimbursed?

In social security, there is a top line for reimbursement of outpatient and emergency medical expenses, and a deductible line for reimbursement of hospitalization medical expenses. The provisions of the maximum amount vary from place to place. Only the part that exceeds the deductible line can be reported for reimbursement of hospitalization medical expenses. As long as the medical expenses within the scope of medical insurance are met, they can be reimbursed according to a certain proportion, and the higher the hospital level, the lower the reimbursement ratio.

Take Zhengzhou as an example: the deductible line of outpatient medical expenses for on-the-job employees is 2000 yuan, and the maximum limit is 20 thousand yuan, which can be reimbursed by 50%;

The deductible line for retired workers' outpatient service is 1.300 yuan, and the maximum amount is 20,000 yuan. 70% can be reimbursed under 70 years old, and 80% can be reimbursed over 70 years old.

If the insured is hospitalized in a designated hospital, the deductible line for the first hospitalization is 1.800 yuan, and the maximum amount is 250,000 yuan, accounting for about 95% of the reimbursement rate in a first-class hospital, 85% in a second-class hospital and 80% in a third-class hospital. From the deductible to the expense of 30,000 yuan, the reimbursement ratio increased by 3 percentage points to 30,000 yuan.

If it is a retired employee, the reimbursement ratio will be higher than that of an on-the-job employee, generally 2-3 percentage points.

Legal basis: Article 28 of the full text of People's Republic of China (PRC) Social Insurance Law conforms to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue medical expenses, and shall be paid by the basic medical insurance fund in accordance with state regulations.