What medical expenses can social security reimburse?

First, the definition of social insurance

Social insurance (1) (referred to as social security for short) is a social and economic system that provides income or compensation for people who are unable to work, temporarily unemployed or suffer losses due to health reasons. The main items of social insurance include old-age insurance, medical insurance, unemployment insurance, industrial injury insurance and maternity insurance, which guarantees citizens' right to get material help from the state and society in case of old age, illness, industrial injury, unemployment and maternity.

Among them, social security can reimburse basic medical expenses, work-related injury medical expenses and maternity medical expenses.

II. Medical expenses that can be reimbursed by social security (1) Basic medical expenses

Taking Zhuji City (II) in Zhejiang Province as an example, employees can reimburse outpatient and inpatient medical expenses through the basic medical insurance in social security.

1. outpatient co-ordination fund reimbursement?

In a medical insurance year, the expenses incurred by the insured in the general outpatient service of the second-level medical insurance unit within the scope of the policy, from the Qifubiaozhun to the maximum payment limit, will be reimbursed by the overall fund according to the following proportions: for those who seek medical treatment in primary medical and health institutions, 75% will be reimbursed by on-the-job employees and 80% will be reimbursed by retirees; In other designated medical institutions or retail pharmacies in the city, 65% of employees are reimbursed and 70% of retirees are reimbursed. The qifubiaozhun for general outpatient service is 400 yuan, and the maximum payment limit is 5,000 yuan;

2. Hospitalization and special outpatient services

Medical expenses within the scope of hospitalization and outpatient policies for special diseases shall be reimbursed by the overall fund according to the following proportions: 85% of employees and 90% of retirees will be reimbursed in primary medical and health institutions if the minimum deductible is more than 50,000 yuan; In other medical institutions, employees are reimbursed 80% and retirees 85%. The part of more than 50,000 yuan to 654.38+10,000 yuan is treated in primary medical and health institutions, and 90% of the employees are reimbursed and 95% of the retirees are reimbursed; In other medical institutions, employees are reimbursed 85% and retirees are reimbursed 90%. For the part exceeding 654.38+10,000 yuan to 250,000 yuan, 90% of the employees are reimbursed and 95% of the retirees are reimbursed. For the part exceeding 250,000 yuan, 90% will be reimbursed, and there is no upper limit.

In addition, social security can also go to local designated pharmacies and health centers to buy medicines for reimbursement. ?

(2) Maternity medical expenses

Taking Foshan City as an example, according to the provisions of the Notice on Printing and Distributing the Implementation Measures of Maternity Insurance for Employees in Foshan City (III), employees can reimburse maternity medical expenses (including maternity medical expenses, family planning medical expenses and other project expenses stipulated by laws and regulations) through social security cards;

1. Maternity medical expenses

Maternity medical expenses mainly refer to the medical expenses incurred by female workers during pregnancy and childbirth, including the expenses of prenatal examination and termination of pregnancy, and the medical expenses during childbirth and hospitalization.

① Prenatal check-up expenses

The project scope of prenatal examination includes:

Routine items: prenatal examination, blood routine, blood type, blood sugar, urine routine, liver function, renal function, hepatitis B surface antigen, syphilis serological detection, HIV screening, electrocardiogram, fetal heart monitoring, B-ultrasound;

Items for future reference: maternal aneuploidy serological screening, hepatitis C antibody determination, hemoglobin electrophoresis test, anti-D titer screening (Rh negative), thyroid function screening, vaginal discharge examination, cervical exfoliative cytology examination, cervical secretion Neisseria gonorrhoeae detection and cervical secretion Chlamydia trachomatis detection.

(2) the cost of terminating pregnancy.

Medical expenses that meet the prescribed scope when terminating pregnancy;

③ Medical expenses of delivery hospitalization.

Expenses for delivery, operation, hospitalization, medicine, diagnosis and treatment of pregnancy complications, complications and other medical expenses within the prescribed scope.

2. Family planning medical expenses

The medical expenses of family planning include the medical expenses incurred by workers in placing or taking out intrauterine devices, tubal ligation and recanalization, induced abortion and induction of labour.

3. Other project expenses stipulated by laws, regulations and rules.

Maternity medical expenses enjoyed by unemployed spouses of employees shall be implemented according to the subsidy standard of maternity medical expenses of local residents' basic medical insurance.

(3) Medical expenses for work-related injuries

According to Article 30 of the Regulations on Work-related Injury Insurance (IV), employees who suffer from accidents or occupational diseases due to work shall enjoy medical treatment for work-related injuries.

Workers can reimburse medical expenses for accidental injuries and occupational diseases through industrial injury insurance. The premise of reimbursement is that accidents or occupational diseases suffered by employees should be recognized as work-related injuries.

3. Warm reminder, social insurance guarantees citizens' right to get material help from the state and society in case of old age, illness, work injury, unemployment and maternity. You can pay attention to the latest local policy documents and safeguard your rights and interests.

Reference data

Social insurance. Baidu baike

In 20 17, the proportion of reimbursement for employee medical insurance policy adjustment was greatly improved. zhejiangnews

On the issuance of the "Foshan city maternity insurance implementation measures" notice (Fofuban [2065438+05] No.50), the third chapter of the article 12, Foshan Chancheng District Social Insurance Fund Management Bureau

Article 30 of Chapter 5 of the Regulations on Work-related Injury Insurance stipulates that China People's Congress Network