How to reimburse employees' social security medical expenses

The hospitalization reimbursement standard is related to the hospital level where the insured lives:

1. If you live in a tertiary hospital, the employee pays 15%, that is, 85% is reimbursed, and the minimum threshold is 30,000 yuan.

Expenses ranging from 23,000 yuan to 40,000 yuan are paid by employees themselves 10% and reimbursed by 90%.

3, more than 40000 yuan to the maximum payment limit, 95% can be reimbursed, employees only need to pay 5%.

4, and the individual contribution ratio of retirees is 60% of the on-the-job (that is, the above-mentioned) employees, but below the minimum threshold, they are all paid by individuals.

There are three main situations for employee medical insurance reimbursement:

1, outpatient expenses reimbursement

If the employee's medical insurance insured person does not carry the medical insurance card after seeing a doctor in a designated medical institution, he/she must pay the relevant expenses first, and then bring the materials to the medical insurance center to reimburse the outpatient expenses. This part of the reimbursement expenses is also deducted from the funds of the employee's personal medical insurance account. First, the medical insurance expenses paid this year are deducted, and then the reimbursement expenses are distributed to the insured's personal medical insurance account.

However, with the promotion and implementation of the outpatient economic system, employees' social security insured persons can also use the overall fund for reimbursement according to a certain proportion when they are undergoing outpatient treatment. The individual medical insurance account of employees' medical insurance insured persons can be used together with their spouses, elders and children, and the funds in the individual account can be used together when registering and ensuring that their family members also pay basic medical insurance normally.

2, pharmacies to buy drugs

When purchasing medicines in chain retail pharmacies with medical insurance network, employees' medical insurance participants need to issue their own medical insurance cards, then tell the pharmacy staff their own diagnosis and treatment categories and the medicines they need, and pay by credit card according to the corresponding use process. If you buy medicine for others because of special circumstances, you need to show your identity certificate for the pharmacy staff to file.

It should be noted that only drugs that meet the medical insurance reimbursement catalogue can be paid by medical insurance card, and health care and beauty drugs cannot be paid by medical insurance card.

3, hospitalization reimbursement

When an employee's medical insurance insured person is hospitalized in a designated medical institution, he needs to pay a part of the deposit first, and the medical insurance card will be directly used for medical insurance reimbursement at the time of discharge settlement, and the deposit will be refunded. If you are hospitalized in a different place, you need to make a good record of medical insurance in different places or refer it to the hospital for record, so that you can use the medical insurance card for settlement and reimbursement in different places normally.

1. What materials are needed for reimbursement of hospitalization expenses?

1, the original and photocopy of the insured's ID card (if entrusted by others, the original and photocopy of the client's ID card shall also be provided);

2. The original and photocopy of the insured's medical insurance card. If there is no medical insurance card, the insured shall provide the original and photocopy of his bank passbook (card);

3. The original and photocopy of the charge receipt;

4. Detailed list of hospitalization expenses (note: it is not a list of daily expenses);

5. Discharge summary or discharge record. If the discharge summary is handwritten on the medical record, copy the discharge summary and the cover of the medical record;

6, disease diagnosis certificate (death, death certificate must be provided);

7. Minors should provide household registration book (copy) and guardian ID card at the same time. In case of birth or termination of pregnancy, relevant certificates from the family planning department (marriage certificate, original and photocopy of birth permit) should also be provided, rural five-guarantee households should provide valid certificates issued by the civil affairs department, drivers' licenses and original and photocopy of driving licenses should be provided in case of traffic accidents, accident confirmation from the Public Security Traffic Management Bureau and mediation from traffic accident compensation, and the injury process should be increased in case of fracture;

8. Those who have been filed for medical treatment outside the city need to bring the application form for transfer (diagnosis) or the application form for medical insurance non-designated medical institutions. If you live in other places for a long time, you must provide proof of residence issued by the neighborhood Committee or village Committee.

Second, what are the conditions for medical insurance reimbursement?

1, normal insurance payment (indicating the insurance payment status at the time of hospitalization) and the treatment review expires (unit insurance payment is 30 days, and individual insurance payment is 6 months).

2, the disease conforms to the "basic medical insurance inpatient disease directory"

3. The information is complete.

I hope the above content can help you. If in doubt, please consult a professional lawyer.

Legal basis:

Article 26 of People's Republic of China (PRC) Social Insurance Law

The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Article 28 of People's Republic of China (PRC) Social Insurance Law

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Article 29 of People's Republic of China (PRC) Social Insurance Law

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.