These eight cases, health insurance can not be reimbursed!

Medicare card in hand, see a doctor to buy medicine without worry. But sometimes settlement reimbursement only to find that there is still a medical insurance can not be reimbursed, this is how it is? Today, I have compiled a list of eight situations in which the health insurance card can not be reimbursed, a careful look before seeing a doctor, settlement reimbursement trouble naturally away from you.

A, Social security card can not be used normally social security payment, payment time is not enough, demagnetization may lead to social security card can not be used normally, medical insurance can not be reimbursed.

Social security payment

When social security payment is cut off, the medical insurance is also cut off, and the medical insurance card naturally can not be reimbursed.

The solution is to pay back your social security. It is important to note that, in general, individuals can not make up for the social security of urban workers, only the unit to pay. The first thing you need to do is to get your hands on a new pair of shoes or boots, and you'll be able to get your hands on a new pair of shoes.

Not enough time to make contributions

Generally speaking, urban workers need to pay for three consecutive months before they can enjoy the health insurance benefits. Urban and rural residents' medical insurance and new rural cooperative medical care can only enjoy the treatment in the year of enrollment. For example, if you enrolled in 2018 but did not enroll in 2019, you can't be reimbursed if you are sick and hospitalized in 2019. Later paid the 2020 health insurance premium, then the participant can only enjoy the health insurance treatment in 2020.

The solution: urban workers continue to pay medical insurance, do not break the payment. The urban and rural residents medical insurance and new rural cooperative each year to the time of payment in time to pay fees.

Social security card demagnetization

Social security card demagnetization is quite common, my own health insurance card has encountered this situation, go to the hospital can not be identified resulting in the reimbursement.

The solution is to get advice from your local social security agency to magnetize or replace your card.

Two,there is a third party responsible there is a third party responsible, should be the third party responsible for the health insurance costs, the health insurance is not reimbursed.

Case

moncler jackets outlet online, on the way home, was knocked down by an electric car that ran a red light, the other side said to take moncler jackets outlet online the medical examination, moncler jackets outlet online said that it is okay to own a health insurance, can be reimbursed, so the other side to hurry to work.

Analysis

This is not the right way to do things. According to the provisions of Article 30 of China's Social Insurance Law, in the case of traffic accidents, fights and assaults where there is a third-party responsible person, the third-party responsible person should bear the cost of medical insurance, and the medical insurance will not be reimbursed.

In addition, if Zhao moncler outlet online himself to the hospital, not to the doctor to explain the real reason for the injury, but let the doctor in accordance with their own accidental fall, etc. to treat themselves and use the health insurance reimbursement, it involves fraud fraudulent insurance, is an illegal act.

Thirdly,It belongs to the scope of payment of the workers' compensation insurance belongs to the scope of payment of the workers' compensation insurance, the medical insurance will not be reimbursed.

Case

Qian aunt in the food company's production workshop work, was instrument stabbed, to the hospital to spend a lot of money, want to take the health insurance card to pay the settlement but was told that the health insurance is not reimbursed.

Four,Preventive Vaccines Preventive Vaccines belong to the public **** health scope, the health insurance is not reimbursed.

Case

Some time ago, the public Mr. Sun held the newborn child to the hospital BCG vaccine and the first shot of hepatitis B vaccine, in the vaccination was told that does not need health insurance reimbursement, because these children's immunization vaccines belong to the public **** health burden within the scope of the health insurance does not need to be reimbursed.

Analysis

Article 30 of the Social Insurance Law clearly stipulates that medical expenses should be borne by the public ****health is not included in the scope of payment of the basic medical insurance fund; 2020 July published the "Interim Measures for the Management of Basic Medical Insurance Drugs," also pointed out that: preventive vaccines are not included in the scope of payment of medical insurance. And belonging to the preventive vaccine rabies vaccine, influenza vaccine, cervical cancer vaccine, pneumonia vaccine, etc., health insurance is not reimbursed.

Fifth, departure for medical treatment abroad Departure for medical treatment abroad, medical treatment abroad, medical insurance is not reimbursed.

Case

Ms. Li's son went abroad to study, and during the study period, he had a serious illness and spent tens of thousands of dollars. I heard that you can settle the reimbursement, Ms. Lee will take her son's medical settlement materials to the local social security center, the results of the staff said that the overseas medical treatment can not be reimbursed, and the different medical treatment, but Ms. Lee did not listen to the explanation, but also made a fuss. In desperation, the local health insurance center chose to call the police ......

Analysis

In this case, although Ms. Li's son participated in the basic medical insurance, according to the regulations, the medical insurance fund will not pay for medical expenses incurred in overseas medical treatment.

Sixth, Non-designated Medical InstitutionsThere is no reimbursement for medical expenses incurred in non-designated medical institutions, unless it is an emergency.

Case

Xiao Zhou and Wu traveled to Beijing on a temporary business trip, and did not apply for the record of foreign medical treatment in Beijing. In the course of the business trip, Xiaozhou sudden acute gastroenteritis, near a designated hospital emergency medical treatment, the doctor told Xiaozhou can take the emergency materials and other medical expenses related bills will be health insurance manual reimbursement. The old Wu due to rheumatoid arthritis attack to the same hospital, the hospital does not give reimbursement. The old Wu is very puzzled: "Why Zhou can be reimbursed for medical treatment, I can not?"

Analysis

The medical insurance designated hospital is the social security department announced the jurisdiction of the region with the social security medical qualification list of hospitals, according to the published list, selected their own medical hospital.

Participants with medical insurance vouchers to the designated medical institutions, can be reimbursed in accordance with the relevant provisions of the medical expenses. The medical expenses can not be reimbursed unless they are incurred in an emergency, as they are required to apply for a medical record in advance.

Seven, outside the scope of medical expenses medical insurance directory need to pay for the part of the medical insurance directory and medical insurance directory outside of the full out-of-pocket part, need to bear the individual, the medical insurance can not be reimbursed.

What medical expenses are covered by the health insurance depends mainly on the health insurance catalog.

The "three catalogs" of the health insurance: the catalog of medicines, the catalog of diagnostic and therapeutic items, and the catalog of medical service facilities.

Taking the drug catalog as an example:

Class A drugs: 100% reimbursement;

Class B drugs: 70%-80% reimbursement, and the rest out-of-pocket;

Class C drugs: no reimbursement, 100% out-of-pocket!

So what is the percentage of Class A, Class B, and Class C?

The total number of drugs approved for sale in China is currently around 200,000, and the new 2020 version of the medical insurance catalog*** includes 2709 drugs (Class A and Class B), accounting for only 1.3% of the total number of drugs.

A lot of good drugs, special drugs, targeted drugs are out of the catalog, the health insurance is not reimbursed. And the more serious the disease, the more drugs used outside the scope of medical insurance, all out-of-pocket expenses!

Eight, Below the starting line, above the ceiling line Below the starting line, above the ceiling line need to be self-paying, the medical insurance can not be reimbursed.

According to the health insurance catalog, medical expenses that are covered by health insurance are not 100% reimbursed.

Currently, there is a starting line and a ceiling line for both outpatient and inpatient care. The first line is below the ceiling and the second line is above the ceiling, which is not reimbursable and needs to be borne by you.

In Nanjing, for example, the starting line for outpatient care for working employees is 1,200 yuan, and the cap line is 2,000 yuan. For hospitalization in a tertiary hospital, the starting line is 1,000 RMB and the cap line is 180,000 RMB.

This is why in the era of universal health care, there are still so many easy fundraisers and water drop fundraisers.

Warm tips

Tips on what to do before you see a doctor(1) Familiarize yourself with the eight situations in which health insurance is not reimbursable;

(2) If you're not sure if your health insurance card can be used normally or if your social security changes due to a job change, etc., you can call your local health insurance bureau before you go to the doctor.

(3) go to the health insurance designated medical institutions, if you are not sure, you can call the local health insurance bureau phone or medical institutions phone in advance of the inquiry;

(4) buy a commercial medical insurance, to make up for the lack of reimbursement of health insurance.