Scope of diseases reimbursed by medical insurance

Medical insurance is mainly to compensate medical expenses caused by diseases, and not all medical expenses can be reimbursed.

1. What are the scope of medical insurance reimbursement?

1. Medical treatment at one's own expense (no designated hospital or referral form), drugs purchased at one's own expense, drugs that cannot be reimbursed according to the regulations of public medical care and medical expenses that do not meet the requirements of 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.

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Second, what is the medical insurance reimbursement process?

Bring all the information to the relevant departments of the local social security center. Upon examination, if the information is complete and meets the requirements, it can be handled immediately.

When applying for reimbursement of outpatient medical expenses, the applicant should first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.

Three, medical insurance reimbursement matters needing attention

1. When the insured is admitted to or discharged from the hospital, they must go through the registration formalities at the medical insurance management window of the designated medical institution with the medical insurance card. If you need to be hospitalized, you need to pay a medical deposit first, and pay more and less after discharge.

2. If the insured person needs to be referred or transferred due to illness, he shall submit the referral opinions agreed by the attending physician of the hospital, and the unit where he works shall fill in the application form, report to the municipal (district) social security agency for approval and go through the referral (hospital) procedures. Among them, the referral is limited to provincial specialized hospitals, and the expenses need to be paid in advance. The reimbursement standard should be 10% first, and then the reimbursable amount should be calculated according to local regulations.

3. After discharge, the hospital will calculate the amount of medical insurance reimbursement and personal payment according to relevant policies. The amount of medical insurance reimbursement can be directly reimbursed at the hospital medical insurance settlement office, and the part paid by individuals needs to be settled by the insured.

4. The standard part of the deductible line for pooling funds after hospitalization will be different according to different local policies. Under normal circumstances, based on 10% of the average annual salary of employees in this city last year, the medical expenses for multiple hospitalizations are accumulated in a basic medical insurance settlement year. I hope the above contents are helpful.

Legal objectivity:

Article 23 of the Social Insurance Law of People's Republic of China (PRC), employees shall participate in the basic medical insurance for employees, and the employer and employees shall jointly pay the basic medical insurance premium according to the provisions of the state. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.