Conditions of use of medical insurance

Health has always been an important thing we rent. Many people worry that they will have no money to treat serious illness, so they will buy medical insurance, but many people don't know the conditions for the use of medical insurance. Here, I have compiled the legal knowledge about the conditions of medical insurance for you, hoping to help you.

First, the conditions for the use of medical insurance

1, outpatient fee

(1) Reimbursement scope: general outpatient and emergency expenses incurred by the insured in designated medical insurance hospitals or specialized hospitals, traditional Chinese medicine hospitals and 3A hospitals (Friendship, Xuanwu, Guang 'anmen Traditional Chinese Medicine, Tongren, Sheikh, Third Hospital of Beijing Medical University, Peking University People, Peking University One, Jishuitan, Chaoyang, Gong Jian and Liangxiang).

(2) Reimbursement ratio: the total emergency expenses of general outpatient clinics in a natural year exceed 2,000 yuan, 50% of which are paid by some large medical mutual funds with a price of more than 2,000 yuan, and 50% are paid by individuals themselves. The retirees have accumulated more than 1.300 yuan, and the part that exceeds 1.300 yuan is covered by the large medical mutual aid fund over 70 years old, with 70% paid by individuals, 30% paid by individuals, 80% paid by the large medical mutual aid fund over 70 years old and 20% paid by individuals. The maximum payment limit in a natural year is 20000 yuan.

(3) Medical management: individual cash payment for general outpatient and emergency expenses, and the medical expenses incurred shall conform to the scope of the three major medical insurance catalogues. When purchasing drugs, special prescriptions should be issued in designated hospitals and stamped with the special seal for medical insurance outsourcing, and then drugs should be purchased in designated pharmacies.

(4) Reimbursement process: If the cumulative Qifubiaozhun exceeds the minimum Qifubiaozhun in a natural year, the insured shall submit the documents to the unit or social security office, which will enter the documents into the enterprise version and declare the electronic information and documents to the medical insurance center. The medical insurance center will complete the examination, settlement and payment within 15 working days.

(5) Application materials: general outpatient and emergency receipts, medical insurance prescriptions (dual-price prescriptions), and details of examination and treatment expenses.

(VI) Date of declaration: every month1-20th, the expenses of the current month will be declared next month, and the expenses of the current year will be declared again before1October 20th, 65438+.

2. Hospitalization expenses

(1) Reimbursement scope: hospitalization expenses incurred by the insured in designated hospitals or specialized hospitals, Chinese medicine hospitals and 3A hospitals selected by the individual.

(2) Reimbursement ratio: The minimum threshold for the first hospitalization in a natural year is 1.300 yuan, and 650 yuan every time thereafter. The payment ratio is divided into three grades. Take a tertiary hospital as an example. The floating standards are: 30,000 yuan, 85% on the job, 9 1% for retirement, 90% for 30,000-40,000, 94% for retirement, more than 40,000, 95% for employment and 97% for retirement. 90 days of general hospitalization is a settlement cycle. Psychiatric hospitalization for 360 days is a settlement cycle, and the floating standard is halved. In a natural year, the overall fund pays a maximum of 70,000 yuan. The maximum hospitalization amount is 654.38+10,000 yuan, and the hospitalization ratio is 70%.

(3) Medical management: Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays in full, the individual only needs to pay part of the hospitalization prepayment to go through the hospitalization procedures. The medical expenses incurred should conform to the scope of the three major catalogues of medical insurance.

(IV) Reimbursement process: When leaving the hospital, the hospital and the individual will settle the self-funded and self-funded amount, and the reimbursement amount of the overall fund will be settled by the hospital and the district medical insurance center.

3, outpatient special diseases

(1) Reimbursement scope: outpatient medical expenses incurred by the insured after going through the examination and approval procedures for special diseases due to radiotherapy and chemotherapy for malignant tumors, renal dialysis and taking anti-rejection drugs after renal transplantation.

(2) Reimbursement ratio: Reimbursement ratio is the same as hospitalization. The settlement period of outpatient special diseases is 360 days.

(3) Medical management: the insured can only choose one hospital as the designated hospital for special diseases. Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays the full amount, the individual only needs to pay the personal out-of-pocket expenses and the self-funded part, and the reimbursement amount of the overall fund is settled by the hospital and the district medical insurance center.

(4) Reimbursement process: the insured submits the documents to the unit or social security office, and the unit declares the documents to the medical insurance center. The medical insurance center completed the audit, settlement and payment on the same day.

Second, the legal basis

The goal of China's medical insurance system reform is to realize a multi-level medical insurance system. Therefore, the state encourages enterprises to establish a supplementary medical insurance system to ensure that the level of medical insurance benefits for employees of enterprises will not decrease. The specific provisions are: enterprises that participate in various social insurances according to regulations and pay social insurance premiums in full and on time can decide whether to establish supplementary medical insurance.

The supplementary medical insurance fund is used for enterprises to participate in local basic medical insurance according to regulations, and in addition to the treatment paid by the basic medical insurance system for urban employees, appropriate subsidies are given to the medical expenses paid by individual employees to reduce the burden of medical expenses for insured employees. The part of enterprise supplementary medical insurance premiums within 5% of the total wages can be directly charged from the cost, and is no longer approved by the financial department at the same level. The supplementary medical insurance measures for enterprises should be linked with the local basic medical insurance system. The supplementary medical insurance fund for enterprises is used and managed by enterprises or industries in a centralized way, and is managed by separate accounts. Medical expenses subsidies for employees and retirees with heavy personal burdens in enterprises shall not be included in the personal accounts of basic medical insurance, nor shall they be set up separately or used for other expenses of employees in disguise. The financial department and the labor and social security department should strengthen the supervision and financial supervision over the management of supplementary medical insurance funds of enterprises, and prevent illegal acts such as misappropriation of funds.

Among them, everyone needs to pay attention to: besides exercise, you need good sleep and rest to stay healthy. A good sleep can make you relax and feel healthier.