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Reimbursement scope of five insurances and one gold medical insurance
Proportion of medical insurance reimbursement:
1, prerequisite: Qifubiaozhun to the maximum payment limit of the basic medical insurance pooling fund.
2. The proportion of employee contributions is 93% in community hospitals, 88% in first-class hospitals, 86% in second-class hospitals and 84% in third-class hospitals.
3. The contribution rate of retirees is 96.5% in community hospitals, 94% in first-class hospitals, 93% in second-class hospitals and 92% in third-class hospitals.
4. The rest expenses shall be borne by the individual.
Legal basis: People's Republic of China (PRC) Social Insurance Law.
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.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(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.
Thirty-first social insurance agencies may, according to the needs of management services, sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior.
Medical institutions shall provide reasonable and necessary medical services for the insured.
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