The scope of reimbursement of medical insurance is

The following is the specific content of the scope of social security medical insurance reimbursement.

1, drug reimbursement for basic medical insurance

The types of drugs in China can be mainly divided into Class A, Class B and Class C. The waist circumference of Class A is basically included in the scope of medical insurance funds and reimbursed according to certain standards. 80% of Class B drugs are reimbursed, and the other 20% are paid at their own expense; Class C drugs are self-sufficient drugs and will not be reimbursed.

The following drugs are not covered by the basic medical insurance reimbursement: (1) drugs that mainly play a nourishing role; (2) Some animals and animal organs and dried fruits that can be used as medicine; (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 diagnosis and treatment project should meet the following conditions: (1) Clinical diagnosis and treatment must be safe and effective, and the cost is 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.

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.

Second, what does the second reimbursement of medical expenses mean?

The second reimbursement of medical insurance is the reimbursement of supplementary medical insurance. Supplementary medical insurance among the six major insurances is different from general medical insurance, because medical insurance is an insurance content in social security, a national welfare policy and a compulsory payment for employees of public institutions. However, supplementary medical insurance is not compulsory, social security cannot be reimbursed, and supplementary medical insurance can be reimbursed.

First of all, we should understand that supplementary medical insurance is different from general medical insurance. Supplementary medical insurance has no card, so it cannot be reimbursed directly by card. Second, the second reimbursement of supplementary medical insurance requires manual declaration procedures. This shows that if you want to use the second reimbursement, you should keep all the payment documents when you are in hospital. These are the vouchers for the second reimbursement.

The original intention of supplementary medical insurance is not to let the people reimburse as much as possible, but under special circumstances, the family's financial ability is limited and it is impossible to solve the problem through medical insurance, so the second reimbursement can play a role. Therefore, it does not mean that supplementary medical insurance is used for secondary reimbursement if medical insurance cannot be reimbursed.

3. What is the standard for the second reimbursement of medical insurance?

According to the regulations, when the current basic medical insurance is used to pay the hospitalization expenses for the first time in a year, the deductible amount of both working and retired people is 1300 yuan.

The medical expenses for the second and subsequent hospitalization are determined according to the deductible line of 50%, which is 650 yuan. The maximum annual payment limit (hospitalization expenses) of the basic medical insurance pooling fund is currently 70,000 yuan.

The individual contribution ratio of retirees is 60% of the individual contribution ratio of employees, but the part below the minimum deductible is the same, and all of them are paid by individuals. The standard of hospitalization reimbursement is related to the level of the medical institution where the insured person is located. Note: Outpatient service and hospitalization are two deductible lines.

Medical insurance refers to social medical insurance. Social medical insurance is a social insurance system established by the state and society to provide basic medical needs for workers within the scope of protection. The basic medical insurance fund consists of overall funds and individual accounts. The basic medical insurance premiums paid by individual employees are all included in individual accounts; The basic medical insurance premium paid by the employer is divided into two parts, one part is included in the personal account, and the other part is used to establish the overall fund.

The specific secondary reimbursement standard for medical insurance is based on the actual reimbursement amount in your area.

Generally speaking, medical reimbursement is the reimbursement of medical expenses and hospitalization expenses, and the categories of reimbursement are very detailed. When reimbursing many drugs, it is necessary to check what disease the patient has, that is, it is not within the scope of indications. Not all hospitalizations can be reimbursed directly, but there are conditions and restrictions.

Legal objectivity:

Medical insurance is insurance to compensate medical expenses caused by diseases. Social insurance in which employees are provided with necessary medical services or material assistance by society or enterprises due to illness, injury or childbirth. For example, free medical care and labor insurance medical care in China. The medical expenses of employees in China are shared by the state, units and individuals to reduce the burden on enterprises and avoid waste. The scope of medical insurance is very wide. Generally, medical expenses are distinguished according to the characteristics of medical services, including doctor's outpatient expenses, medicine expenses, hospitalization expenses, nursing expenses, hospitalization miscellaneous expenses, operation expenses, and various inspection expenses. Medical expenses are all kinds of expenses incurred by patients to treat diseases, including not only doctors' medical expenses and operation expenses, but also hospitalization expenses, nursing expenses and hospital equipment expenses. Proportion and scope of medical insurance reimbursement: 1, outpatient and emergency medical expenses: medical expenses within the accumulative scope of employees' basic medical insurance year (11February1February 3 1) exceed 2,000 yuan. 2. Settlement ratio: 50% of the part of the dispatched personnel above 2,000 yuan will be reimbursed during the contract period, and 50% will be paid by the individual; Within one year, the maximum amount of accumulated reimbursement for outpatient and emergency services of dispatched personnel is 20,000 yuan. 3. The insured shall properly keep the medical documents (including receipts and prescriptions for large amounts) in the outpatient department of the designated hospital. ), as a medical expense reimbursement certificate. 4. Outpatient treatment of three kinds of special diseases: when the insured person needs to take anti-rejection drugs after radiotherapy and chemotherapy for malignant tumor, renal dialysis and renal transplantation, the second-and third-level designated hospitals where the insured person is treated will issue the Certificate of Disease Diagnosis, fill in the Application and Approval Form for Special Diseases of Medical Insurance, and report it to the district medical insurance center for approval and filing. Outpatient treatment and drug collection for these three special diseases are limited to designated hospitals that have approved treatment, and cannot be purchased in designated retail pharmacies. The medical expenses incurred meet the prescribed scope of outpatient special diseases, with reference to hospitalization settlement. 5, hospitalization, medical insurance paid for 20 years, can enjoy medical insurance reimbursement after retirement. The reimbursement ratio and scope of rural cooperative medical insurance: 1, outpatient reimbursement: (1) 60% for village clinics and village center clinics, and the limit of prescription drug cost per visit is 10 yuan, and the limit of prescription drug cost for temporary rehydration of doctors in health centers is 50 yuan. (2) Reimbursement for medical treatment in town health centers is 40%. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 100 yuan. (3) The reimbursement for medical treatment in secondary hospitals is 30%, and the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 200 yuan. (4) 20% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan. (5) The prescription attached to the invoice of traditional Chinese medicine is limited to 1 yuan. (6) The annual compensation limit for rural cooperative medical clinics is 5,000 yuan. 2. Reimbursement scope of hospitalization compensation (1): a. Drug expenses: auxiliary examination: examination expenses such as electrocardiogram, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic resonance, etc. 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan). B, the elderly over 60 years old are hospitalized in Xingta Town Health Center, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan. (2) Reimbursement ratio: town hospitals reimburse 60%; 40% reimbursement for secondary hospitals. 3. Serious illness compensation town risk fund compensation: All inpatients who participate in cooperative medical care whose medical expenses exceed 5,000 yuan at one time or for the whole year shall be compensated by stages, that is, 500 1- 10000 yuan is 65%,1001-.