1. What is the scope of medical insurance reimbursement?
According to the regulations, the basic medical insurance for five types of diagnosis and treatment projects will not be paid.
The first category is service items: some medical service fees, out-of-hospital consultation fees, medical record production fees, etc. Special medical services such as visiting fees, expedited fees for examination and treatment, additional fees for name-calling surgery, additional fees for name-calling surgery, high-quality and good-price fees, and self-invited special care.
The second category is non-disease treatment items: see the following analysis for details.
The third category is diagnosis and treatment equipment and medical useful materials: inspection and treatment projects carried out by using large-scale medical equipment such as positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic apparatus. Glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation appliances. All kinds of self-use health care, massage, examination and treatment equipment. Disposable medical materials that are not charged separately as stipulated by the provincial price department.
The fourth category is treatment project category: organ source or tissue source of various organ or tissue transplants; Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow; Orthopedic surgery for myopia; Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
The fifth category is other categories: all kinds of scientific research and clinical verification diagnosis and treatment projects.
In addition, the expenses not paid by the basic medical insurance also include: transportation expenses and emergency expenses; Infant incubator fee, food incubator fee, nursing fee, washing fee and outpatient decocting fee; Special living expenses such as meals. Patients should pay for the above items when seeking medical treatment.
Among them, non-disease treatment projects include these:
1, various cosmetic plastic surgery projects: such as acne, scar cosmetic, laser cosmetic, cosmetic tooth washing, hair transplant, etc.
2. Orthopedic treatment items: stuttering, dentition disorder, denture restoration (including post crown, crown fitting, denture installation), dental implantation, nasal snoring surgery (except respiratory distress), flat feet and other items (except congenital torticollis, cleft lip and palate, sequelae of polio).
3. Various bodybuilding treatment items: such as losing weight, gaining weight and increasing height.
4. Various physical examination items: such as employee physical examination and disease investigation.
5. Various preventive health care and diagnosis projects: such as various vaccines, fitness massage, etc.
6. Various medical consultation and health prediction diagnosis and treatment items: such as various disease consultation fees (except psychological consultation conducted by secondary and tertiary mental health prevention and control institutions), including pulse meter, microcirculation tester, meridian diagnostic instrument (including computer diagnostic instrument of traditional Chinese medicine) and vital information diagnostic instrument.
7. Various medical appraisal items: such as labor ability appraisal (diagnosis and appraisal of workers' labor, work-related injuries and occupational diseases), judicial appraisal of mental patients, medical accident appraisal, and various inspection expenses.
Second, is there a time limit for medical reimbursement?
There is no time limit for medical reimbursement.
(1) Settlement procedures for inpatient and outpatient treatment of special diseases
Designated medical institutions shall submit the expense list, hospitalization list and related materials of patients discharged from hospital last month to the medical insurance agency before 10 every month, which will be used as the basis for monthly pre-allocation and year-end final accounts after examination. The medical insurance agency pre-allocated the hospitalization and outpatient expenses for special diseases last month.
Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately.
(2) Emergency settlement procedures
The medical expenses incurred by the insured due to emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall handle the reimbursement procedures according to the provisions with the emergency hospitalization medical records, inspection, laboratory test sheets, invoices and detailed list of medical expenses.
(three) resettlement procedures for resettlement personnel in different places
1. The designated medical institution designated as 1-2 by the unit where employees are resettled in different places shall be reported to the medical insurance agency for the record.
2. The medical expenses incurred by the off-site staff in the outpatient department of the designated medical institution in their place of residence shall be paid in advance by themselves or their units. After the treatment, the unit should hold the diagnosis, medical records and effective expenses of the insured.
Use bills, compound prescriptions, hospitalization expenses list, etc. Settle with the social medical insurance agency on the specified date.
(4) Referral and settlement.
1. If the insured person is transferred to other medical institutions for diagnosis and treatment due to the conditions of designated medical institutions or specialized diseases, the approval form for referral and transfer shall be filled in. The reason for referral and transfer is put forward by the attending physician, the director of the department puts forward the opinion of referral and transfer, the medical institution medical insurance office reviews it, the dean in charge signs it, and it can be transferred only after being reported to the municipal medical insurance center for examination and approval.
2. In principle, referrals should be made outside the city, inside the province and outside the province. The city's referral regulations are carried out between designated medical institutions. The referral outside the city is proposed by the designated medical institutions above Grade III in this Municipality.
3. The medical expenses incurred after the insured person is referred to another hospital shall be paid by the individual or unit in cash. After the medical treatment, the insured person or his agent will submit the referral approval form, medical record certificate, prescription and valid documents to the medical insurance agency for reimbursement of hospitalization expenses that fall within the scope of the overall fund payment.
3. Is there an upper limit for medical insurance reimbursement?
Medical reimbursement is limited. No matter what kind of people, the maximum payment for outpatient and emergency medical expenses is 20 thousand yuan per year. However, different groups of people have different reimbursement rates. The maximum payment limit of the basic medical insurance pooling fund for hospitalization 1 year is 70,000 yuan.
Generally speaking, the economic development in different regions is different, so the reimbursement ratio is different. The following is an explanation of the proportion of employees' medical insurance in Beijing.
After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 700 yuan can reimburse 50%, that is, 350 yuan.
If it is hospitalization expenses, the minimum payment for employees and retirees is 1300 yuan when the basic medical insurance is used for the first time within one year in 2009. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan.
The reimbursement standard for hospitalization is related to the level of the hospital where the insured person is located. For example, in a tertiary hospital, employees have to pay 15%, that is, 85%, from the threshold to 30,000 yuan. The expenses of 30,000-40,000 yuan shall be paid by employees themselves 10%, and 90% shall be reimbursed; If the expenses exceed 40,000 yuan to the maximum payment limit, 95% can be reimbursed, and employees only need to pay 5%. Retirees pay 60% of the on-the-job employees, but all below the minimum threshold are paid by individuals.
There is an upper limit on the amount of medical insurance reimbursement, with a maximum of 20,000 yuan per year for outpatient service and 70,000 yuan for hospitalization.
The above is the relevant content covered by the scope of medical insurance reimbursement. To sum up, the above contents are not reimbursed by medical insurance, such as various cosmetic, plastic and orthopedic treatment projects.