What is the reimbursement scope of medical insurance, and what is the reimbursement scope of medical

Legal analysis: medical insurance reimbursement scope: meet the standards of basic medical insurance drug catalog, diagnosis and treatment items, medical service facilities, and emergency medical expenses.

Reimbursement scope of resident medical insurance: including general outpatient reimbursement, serious illness reimbursement and special outpatient reimbursement; The reimbursement scope of employee medical insurance: it is divided into a co-ordinated account and a personal account, the co-ordinated account can reimburse inpatient medical expenses, special outpatient medical expenses, etc., and the personal account can directly pay for the cost of ordinary outpatient clinics, designated pharmacies, and the personal self-payment part of inpatient medical expenses; Whether it is resident medical insurance or employee medical insurance, when reimbursing related medical expenses, there are usually restrictions on the starting line, reimbursement ratio, and limit.

In addition, although the scope of reimbursement for medical insurance in various places is similar, the regulations on the starting line and reimbursement ratio may be different, so it depends on how the local medical insurance reimbursement policy is stipulated.

Legal basis: Article 23 of the Social Insurance Law of the People's Republic of China Employees shall participate in the basic medical insurance for employees, and the employer and the employee shall jointly pay the basic medical insurance premiums in accordance with the provisions of the state. Individually-owned businesses without employees, part-time employees who have not participated in the basic medical insurance for employees in the employer, and other flexibly employed persons may participate in the basic medical insurance for employees, and the individual shall pay the basic medical insurance premiums in accordance with the provisions of the state.

Medical Insurance Reimbursement Coverage:The types of drugs in China can be mainly divided into class A, class B and class C, and the waist circumference of class A is basically included in the scope of medical insurance **, and reimbursement is given according to certain standards; 80% reimbursement for Class B drugs, and the other 20% are self-paying; Category C drugs are self-financing drugs and will not be reimbursed.

The following drugs are not covered by the basic medical insurance: (1) drugs that mainly play a nutritional tonic role;

2) Some animals and animal organs, dried (water) fruits that can be used for medicine;

3) All kinds of liquor preparations brewed with Chinese herbal medicines and Chinese herbal decoction pieces;

4) Fruit-flavored preparations and oral effervescent agents in various drugs;

5) Blood products and protein products (except for special indications, first aid and rescue);

According to the provisions of the Social Insurance Law, as long as it meets the standards of the basic medical insurance drug list, first aid, rescue medical expenses, diagnosis and treatment items, and medical service facilities, it can be paid from the basic medical insurance ** in accordance with national regulations. Among them, the reimbursement scope of social medical insurance mainly includes the following points:

1. Reimbursement of drugs for basic medical insurance.

Both Class A and Class B drugs that are covered by the basic medical insurance can be reimbursed.

2. Reimbursement of basic medical insurance diagnosis and treatment items.

The scope of diagnosis and treatment items of the basic medical insurance payment project must be determined in accordance with the "Scope of Basic Medical Insurance Diagnosis and Treatment Items" stipulated by the state. If it is in the catalogue of diagnosis and treatment items for part of the basic medical insurance payment, the insured can pay it out of pocket first, and then pay it in accordance with the provisions of the basic medical insurance.

3. Reimbursement for basic medical service facilities.

The reimbursement of the cost of basic medical service facilities covers the necessary living service facilities for the insured person in the process of receiving diagnosis, ** and nursing, including outpatient and emergency observation beds and inpatient beds. For some referral transportation expenses, ambulance fees, baby incubator fees, food incubator fees, nurse fees, and escort fees, basic medical insurance** cannot be reimbursed.

Social Insurance Act

Article 28 In line with the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards and emergency and rescue medical expenses, in accordance with the provisions of the state from the basic medical insurance ** payment.

Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance shall be directly settled by the social insurance agency and the medical institution and the drug business unit. The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits.

Article 30 The following medical expenses are not included in the scope of payment of basic medical insurance**: (A) shall be paid from work-related injury insurance**; (2) It shall be borne by a third party; (3) It shall be borne by public health; (4) Seeking medical treatment outside the country. Medical expenses shall be borne by the third party in accordance with the law, and if the third party does not pay or the third party cannot be determined, the basic medical insurance shall pay in advance.

After the basic medical insurance** is paid in advance, it has the right to recover from a third party.

If you still have questions about this issue, it is recommended that you organize the relevant information and communicate with a professional in detail.

Medical Insurance Reimbursement Coverage:The types of drugs in China can be mainly divided into class A, class B and class C, and the waist circumference of class A is basically included in the scope of payment of the insurance for medical care and treatment, and reimbursement is given according to certain standards; Class B drugs reimburse 80% of the old lead, and the other 20% is self-paying; Category C drugs are self-financing drugs and will not be reimbursed.

The following drugs are not covered by the basic medical insurance: (1) drugs that mainly play a nutritional tonic role;

2) Some animals and animal organs, dried (water) fruits that can be used for medicine;

3) All kinds of liquor preparations brewed with Chinese herbal medicines and Chinese herbal decoction pieces;

4) Fruit-flavored preparations and oral effervescent agents in various drugs;

5) Blood products and protein products (except for special indications, first aid and rescue);

According to the regulations on basic medical insurance for urban workers in China and the provisions of relevant laws and regulations, the reimbursement scope of medical insurance is as follows: 1. Drugs that are allowed to be reimbursed within the reimbursement scope of basic medical insurance; 2. Diagnosis and treatment items that are allowed to be reimbursed within the scope of basic medical insurance reimbursement; 3. The expenses incurred by the medical service facilities that are allowed to be reimbursed within the scope of basic medical insurance reimbursement. The reimbursement expenses are mainly paid by the co-ordination**, and the individual also has to pay the corresponding part.

1. General medical insurance. It mainly includes outpatient expenses, medical expenses, examination fees, etc.

2. Hospitalization insurance. The main expenses are daily hospitalization, use of hospital equipment, surgery, medical expenses, etc.

3. Surgical insurance. Cover all costs incurred as a result of the necessary surgeries performed by the patient.

4. Comprehensive medical insurance. The cost range includes everything from medical treatment to hospitalization and surgery.

5. Special disease insurance. Certain special diseases often bring catastrophic costs to patients, which are difficult for ordinary families to bear. For example, cancer and heart disease, etc.

The critical illness that provides protection to the policyholder can be a single item, such as a malignant tumor, or even a certain type of cancer in the malignant tumor.

How is medical insurance reimbursed? How to save money by reimbursement? 》

The reimbursement scope of medical insurance can be divided into three major catalogs, the details are as follows:

It can be seen that the three major catalogs of medical insurance are the drug catalog, the diagnosis and treatment project catalog and the medical service facility catalog. Daddy will then analyze the three major catalogs of medical insurance in detail.

1.Catalogue of diagnosis and treatment items

The list of diagnosis and treatment items mainly contains some items that are necessary and have a definite effect but are expensive, such as hemodialysis, bone marrow transplantation, etc.

It must be noted that non-essential, uncertain or special medical items such as cosmetology and cosmetic surgery are not covered by the reimbursement.

2.List of medicines

The drugs we prescribe in the hospital must be specified in the medical insurance catalogue in order to be reimbursed.

The drugs that can be reimbursed by medical insurance can be divided into the following two categories:

1) Class A drugs: Drugs that are necessary for clinical use and are cheap and easy to use, and the state has unified regulations and can be reimbursed according to the proportion of 100%.

2) Class B drugs: drugs that can be used and are easy to use but slightly more expensive, generally reimbursed at a rate of 70%-80%.

However, it should be noted that nourishing health care drugs such as ** medicines, hangover drugs, and some special drugs and imported drugs are not included in the drug list and cannot be reimbursed.

3.Directory of medical service facilities

The list of medical facilities refers to the cost of services that must be paid in the process, such as bed fees. However, non-essential services such as hospitalization fees, caregiver fees, and recreational activities are not reimbursable.