Shanghai medical insurance outpatient reimbursement rules

Shanghai medical insurance outpatient reimbursement rules are as follows:

1. Reimbursement scope: The reimbursement scope of Shanghai medical insurance outpatient service includes medical expenses such as drugs, medical services, diagnosis and treatment equipment, but excludes self-funded drugs and high-end medical services;

2. Reimbursement ratio: the reimbursement ratio of Shanghai medical insurance clinic is 60%, that is, 60% of medical expenses can be reimbursed, and the remaining 40% needs to be paid by individuals;

3. Reimbursement capping line: Shanghai medical insurance outpatient reimbursement has a reimbursement capping line, that is, after the outpatient reimbursement amount reaches a certain amount every year, the excess part will not be reimbursed. Specific capping line standards can be consulted in local medical insurance institutions;

4. Reimbursement restrictions: There are some reimbursement restrictions for outpatient reimbursement of Shanghai medical insurance. For example, certain drugs or medical services must meet certain conditions before they can enjoy reimbursement. Specific restrictions can be consulted in local medical insurance institutions;

5. Reimbursement process: The reimbursement process of Shanghai medical insurance clinic generally includes three steps: seeing a doctor, settlement and reimbursement. The specific process can be consulted at the local medical insurance institution.

Attention should be paid to reimbursement of outpatient medical insurance in Shanghai:

1. Patients must prepare the resident medical insurance card, otherwise they cannot apply for reimbursement;

2. The toll collector can adjust the reimbursement standard according to the patient's condition, and the patient should carefully check the bill to avoid additional expenses;

3. When taking medicine, patients need to check the validity period and manufacturer of the medicine;

4. According to the regulations, each resident can be reimbursed for more than15,000 yuan per year, and the excess can apply for full reimbursement;

5. The reimbursement period is one year, and patients should be careful not to exceed the time limit before applying for reimbursement.

Shanghai medical insurance outpatient reimbursement conditions include:

1, normal insurance payment, overdue treatment review (unit insurance for 30 days, individual insurance for 6 months);

2, the disease in accordance with the "basic medical insurance inpatient disease directory";

3. The reimbursement materials are well prepared. Including my ID card, social security card or medical insurance card, special receipt for outpatient medical expenses, special receipt for emergency medical expenses, relevant medical history materials and copies, medical records of outpatient and emergency departments or settlement list of hospitalization medical expenses;

4. If it is an emergency patient, it is necessary to provide emergency medical records, emergency diagnosis certificates, outpatient medical records, inspection reports and other materials.

To sum up, different types of medical insurance may be different in different cities. Please consult the local social security department or relevant institutions for specific reimbursement conditions and procedures.

Legal basis:

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 30

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;

(3) 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.