Can private hospitals be reimbursed?

Private hospitals need to be designated medical insurance hospitals in order to be reimbursed, otherwise not.

According to the Social Insurance Law, as long as the private hospital belongs to the legal medical institutions recognized by the Department of Health, and at the same time belongs to the scope of payment of the insurance fund, excluded from the Workers' Compensation Insurance Fund, the third person, the public **** health, as well as private hospitals outside of the country to pay for the private hospital, if you meet the above conditions, then the private hospital medical expenses can be reimbursed. In addition, if the private hospital is a medical institution designated by the NIC, it can also be reimbursed according to the local agreement. It is also important to note that the private hospital where the reimbursement is made needs to be a specific medical institution, otherwise it cannot be reimbursed.

The specific standards for reimbursement of residents' medical insurance are as follows:

1, the reimbursement rate for residents: 60% for town health centers; 40% for secondary hospitals; 30% for tertiary hospitals;

2, for urban residents, in a settlement year, the medical expenses below 100,000 yuan which are eligible for reimbursement, the starting standard for tertiary hospitals is 659 yuan, the reimbursement rate is 50% ceiling is 2,000 yuan; the starting standard for hospitalization in second-level hospitals is 300 yuan, and the reimbursement rate is 55%; first-level hospitals do not have a starting standard, and the reimbursement rate is 60%;

3. If the reimbursement is made in a different place, the reimbursement needs to go back to the old place where the insured person is enrolled and the reimbursement rate is between 35-65%, and the rate varies according to the level of the hospitals.

Medicare reimbursement rates are based on local policies and regulations, and may vary from region to region. Generally speaking, the reimbursement ratio of medical insurance includes two aspects:

1. Basic medical insurance payment ratio: the basic medical insurance payment ratio refers to the proportion of the medical insurance fund, generally ranging from 70% to 80%;

2. Individual out-of-pocket expenses: the individual out-of-pocket expenses ratio refers to the proportion of medical expenses that the individual needs to bear, generally ranging from 20% to 30%.

Medical insurance reimbursement process:

1, confirm the scope of reimbursement: in the process of treatment, you need to confirm that their own treatment items belong to the scope of reimbursement of medical insurance;

2, collection of reimbursement materials: collection of the relevant records of treatment, drug receipts, medical cost lists and other related materials;

3, the social security department to handle the reimbursement: submit the relevant materials to the local social security department to handle the reimbursement.

4. Waiting for the audit: the social security department will carry out relevant audits and comparisons to confirm the reimbursement rate and reimbursement amount; receiving the reimbursement payment: after the audit is approved, you can receive the reimbursement payment of the medical insurance at the designated bank.

In summary, private hospitals need to be designated medical insurance hospitals in order to be reimbursed, otherwise not. Participants must go to a designated medical institution for basic medical insurance to purchase medicines, or go to a designated retail pharmacy determined by the social insurance organization to purchase medicines out of the hospital with a medical prescription issued by a doctor at the designated hospital.

Legal basis:

Article 28 of the Social Insurance Law of the People's Republic of China

Medical expenses that are in line with the basic medical insurance drug list, diagnostic and therapeutic items, and medical service facility standards, as well as those for emergencies and resuscitations, shall be paid out of the basic medical insurance fund in accordance with state regulations.

Article 29

The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.

The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.