Medical insurance reimbursement process for patients with self-falling and fracture

Legal analysis: reimbursement of medical insurance drugs can be reimbursed not only during hospitalization, but also in social security medical insurance clinics. After discharge, prescribing drugs in the outpatient department of the hospital can also be reimbursed according to regulations. Details are as follows:

1. Outpatient service 1, reimbursement for village clinics and village center clinics 60, prescription drug fee limit for each visit 10 yuan, prescription drug fee limit for temporary rehydration for doctors in health centers 50 yuan;

2. Reimbursement of 40 yuan for medical treatment in the town health center, with the limit of 50 yuan for each medical examination and operation fee and the limit of prescription fee 100 yuan;

3. Reimbursement for medical treatment in secondary hospitals is 30, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan;

4. Reimbursement for medical treatment in tertiary hospitals. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 200 yuan;

5. Chinese medicine invoice with prescription 1 yuan per paste; The annual compensation limit for rural cooperative medical clinics is 5000 yuan.

Second, the scope of hospitalization reimbursement: 1. Drug expenses: auxiliary examination: ECG, X-ray fluoroscopy, photography, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic resonance and other examination expenses 200 yuan; 2. Operation expenses (refer to national standards, those exceeding 1 ,000 yuan will be reimbursed as 1 ,000 yuan). The elderly over 60 years old are hospitalized in health centers, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan. 3. Reimbursement ratio: town health centers reimburse 60; Reimbursement of secondary hospitals 40; Third-level hospital reimbursement 30. Extended data:

Reimbursement ratio: town hospitals reimburse 60; Reimbursement of secondary hospitals 40; Third-level hospital reimbursement 30. In addition to reimbursement for medical insurance hospitalization, after payment of Class B expenses 10, more than 80% of expenses exceeding the deductible line can be "reimbursed" (occupational insurance). You don't have to pay cash in advance, but you will be reimbursed by the bill. Instead, when hospitalized in a designated medical insurance hospital, the medical insurance card will be issued, so that the unified medical insurance settlement system can read the information of the insured person and handle the hospitalization number. At the time of discharge settlement, the medical insurance system will not charge you the "reimbursement" part of the overall payment. Exemption (non-reimbursement): 1, self-seeking medical treatment (no designated hospital or no referral form), self-purchased drugs, drugs that cannot be reimbursed according to the regulations of public medical care, and medical expenses that are not in line with family planning; 2, outpatient treatment fees, visits, hospitalization fees, meals, escort fees, nutrition fees, blood transfusion fees (except for family blood storage, according to the relevant provisions of reimbursement), heating and cooling fees, ambulance fees, allowances and other expenses; 3. Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; 4. Orthopedics, cosmetic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc. ; 5, within the scope of reimbursement, beyond the limit. The difference between medical insurance drugs and non-medical insurance drugs, reimbursement deductible line is also different according to hospital level. Generally, Class A drugs can enjoy full coverage, Class C drugs need to pay all the expenses at their own expense, and Class B drugs are reported as 80, with a ratio of 20.

Legal basis: Article 30 of the Social Insurance Law of People's Republic of China (PRC), the following medical expenses are not included in the payment scope of the basic medical insurance fund:

(a) shall be paid by the industrial injury insurance fund;

(2) It shall be borne by a third party;

(three) shall be borne by public health;

(4) Go abroad for medical treatment.

Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.