Reimbursement scope of serious illness medical insurance

The scope of reimbursement for serious illness medical insurance includes:

1. Malignant tumor treatment: including malignant tumor chemotherapy, including endocrine-specific anti-tumor therapy, malignant tumor radiotherapy, isotope anti-tumor therapy, interventional anti-tumor therapy and traditional Chinese medicine anti-tumor therapy;

2, severe uremia outpatient hemodialysis peritoneal dialysis treatment;

3. Anti-rejection therapy after renal transplantation;

4. Treatment of severe mental illness: schizophrenia, moderate and severe depression, mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis.

The reimbursement process after individuals pay medical insurance is generally as follows:

1. See a doctor: When you see a doctor or buy medicine in a medical institution, you need to show your medical insurance card, ID card and other relevant documents;

2. Preparation of reimbursement materials: after seeing a doctor, you need to go to a medical institution to obtain medical records, doctor's orders, prescriptions, receipts and other related materials, and fill in the relevant reimbursement application form;

3. Submit reimbursement application: submit the prepared reimbursement materials and application forms to the local social security bureau or medical insurance center for reimbursement application. You can also choose to apply for reimbursement online;

4. Review the reimbursement application: the local social security bureau or medical insurance center will review the submitted reimbursement application, and after the approval, the reimbursement will be credited to the personal bank account.

Scope of use of medical insurance card:

1, the insured employees can use the password on the POS card to buy medicines in designated hospitals and pharmacies, but they cannot withdraw cash or transfer money. That is, the scope of use of urban medical insurance cards is also applicable to the scope of use of rural medical insurance cards.

2. Designated pharmacies: Medical insurance consists of two accounts: personal account and overall account. Personal accounts can be used to buy medicines at designated pharmacies, and are mainly responsible for the payment of outpatient expenses and hospitalization expenses paid by individuals. The overall account managed by the medical insurance center pays the expenses incurred by the insured who meet the local medical insurance reimbursement;

3. Designated hospitals: When you go to a designated hospital for medical treatment, you can show your medical insurance card to prove your enrollment and registration. Individuals do not need to pay first and then reimburse, and can directly settle medical insurance reimbursement with the hospital. Only when the account is settled can the self-funded part be paid with the balance of the medical insurance card or cash.

To sum up, in order to avoid problems such as inconvenient settlement of medical expenses and difficult reimbursement, medical insurance cards can usually only be used in the issuing city. For some special circumstances, such as sudden illness, business trip and other situations that require medical treatment in different places, cross-regional settlement and reimbursement can be made through medical insurance networking. This requires going to the local social security bureau for cross-regional medical insurance settlement and filing procedures before seeking medical treatment. The specific operation process needs to be handled according to the regulations of different regions.

Legal basis:

"Detailed Rules for the Implementation of People's Republic of China (PRC) Social Insurance Law" Article 8.

The medical expenses incurred by the insured in the agreed medical institutions that meet the basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards shall be paid from the basic medical insurance fund in accordance with state regulations. If the insured really needs emergency treatment and rescue, he can seek medical treatment in a non-agreement medical institution; The scope of drugs that must be used for rescue can be appropriately relaxed. The specific measures for the administration of emergency and rescue medical services of the insured shall be formulated by the overall planning area according to the local actual situation.