The difference between Beijing social security self-payment and self-payment

Out-of-pocket 1: refers to the amount that individuals should bear in proportion within the scope of medical insurance (for example, the fund should pay 90% for outpatient and retirement supplementary insurance for retirees over 70 years old, and out-of-pocket 1 is 10%).

Out-of-pocket 2: It refers to drugs, examination and treatment, materials and artificial organs that are included in the scope of medical insurance and need to be borne by individuals in advance, but are not covered by medical insurance. Deduct the self-funded part, and the remaining expenses will be reimbursed in proportion.

Scope of medical insurance reimbursement: According to the provisions of the 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.

1, drug reimbursement for basic medical insurance

Drugs included in the basic medical insurance payment scope are divided into Class A and Class B. ..

Class A drugs refer to drugs that are basically unified throughout the country and can ensure the basic needs of clinical treatment. The expenses of such drugs are included in the payment scope of the basic medical insurance fund, and the expenses are paid according to the basic medical insurance payment standard.

The list of Class B drugs shall be adjusted by all provinces, autonomous regions and municipalities directly under the Central Government according to their own conditions. Before such drugs are included in the payment scope of the basic medical insurance fund, the employees shall pay according to a certain proportion and pay according to the basic medical insurance payment standard.

The following drugs do not belong to the basic medical insurance reimbursement scope:

(1) Drugs with nourishing and nourishing effects

(2) Some medicinal animals and animal organs, dried (watered) fruits.

(3) Various wine preparations brewed with Chinese herbal medicines and Chinese herbal pieces.

(4) Fruity preparations and oral effervescent agents in various medicines.

(5) Blood products and protein products (except for special indications and first aid and rescue)

(six) other drugs that are not paid by the basic medical insurance fund as stipulated by the administrative department of social insurance.

2, the basic medical insurance treatment project reimbursement

The basic medical insurance treatment project shall meet the following conditions:

(1) Clinical diagnosis and treatment must be safe and effective, and the cost should be appropriate;

(2) The price department has set the charging standard;

(3) within the scope of designated medical services provided by designated medical institutions for the insured.

The scope of basic medical insurance to pay part of the cost of diagnosis and treatment projects is determined in accordance with the scope of basic medical insurance diagnosis and treatment projects stipulated by the state. Belong to the basic medical insurance payment part of the directory of medical treatment project costs, first by the insured according to the provisions of the proportion of self pay, and then pay according to the provisions of the basic medical insurance. Belonging to the basic medical insurance for employees, belonging to the catalogue of medical treatment projects that are not paid, the basic medical insurance fund for employees will not pay.

3. Reimbursement of basic medical service facilities

The reimbursement scope of medical service facilities in the basic medical insurance includes the living service facilities provided by designated medical institutions and necessary for the insured to receive diagnosis, treatment and nursing, mainly including the hospitalization bed fee or outpatient (emergency) observation bed fee.

The basic medical insurance fund does not pay for living services and service facilities, mainly including:

(1) outpatient and first aid (transfer) transportation expenses;

(2) Air conditioning fee, TV fee, telephone fee, baby incubator fee and food incubator fee;

(3) Escort fee, nursing fee, washing fee and outpatient decocting fee;

(4) meals;

(5) Hospitality and other special life service expenses.

legal ground

People's Republic of China (PRC) social insurance law

Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.

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

Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, 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.