Medical insurance refers to individuals using various insurance tools to build their own medical security system. Personal medical insurance includes social medical insurance and commercial medical insurance.
So how to use medical insurance and under what circumstances can it be reimbursed? Now, the answer will only be from social medical insurance.
1. According to the "Notice on Issuing the Interim Measures for the Management of Designated Medical Institutions for Basic Medical Insurance for Urban Employees" (Labor and Social Affairs Bureau [1999] No. 14) issued by the Ministry of Labor and Social Security and other departments, insured persons should seek medical treatment at selected designated medical institutions.
, and can decide independently to purchase medicines at designated medical institutions or to purchase medicines at designated retail pharmacies with prescriptions.
Except for emergencies and emergencies, the medical expenses incurred by insured persons at non-selected designated medical institutions shall not be paid by the basic medical insurance fund.
Therefore, if an employee is seriously ill and cannot go to the selected hospital for treatment, he or she must go to a nearby hospital for treatment and hold a hospital emergency certificate. The medical expenses can be paid by the basic medical insurance fund in accordance with regulations.
Moreover, it needs special explanation here that for emergency and first-aid medical treatment involving accidental injuries, even if the treatment is at a designated medical institution, the medical insurance card is not allowed to be paid directly. The purpose is to avoid traffic accidents and work-related injury insurance, because
, these two types of medical expense reimbursement are conducted through separate channels.
2. Social medical insurance is a social insurance system established by the state and society in accordance with certain laws and regulations to provide workers within the coverage with basic medical needs when they fall ill.
Employers and individuals pay insurance premiums in a certain proportion to establish a social medical insurance fund to pay employees' medical expenses.
Individuals only need to pay the money to the relevant departments of their units or enterprises every month, or they can pay to the local social security bureau.
3. Personal medical insurance is a supplement to social insurance. Since social insurance has a minimum payment limit, does not reimburse out-of-pocket expenses, and has exclusions, it is very necessary to purchase personal medical insurance, which can provide sufficient and comprehensive protection.
4. The advantage of social medical insurance is that people enjoy benefits according to unified standards.
The same access conditions, the same charging standards, and the same benefits, there is no difference between high and low.
Employees' outpatient expenses can be deducted from their personal accounts, and after the deduction is completed, the employees will pay by themselves.
Employee hospitalization expenses are reimbursed on a pro-rata basis: 86% of expenses of 10,000 yuan are reimbursed by tertiary hospitals; 88% of expenses of 10,000 to 20,000 yuan are reimbursed by tertiary hospitals; and 92% of expenses of 20,000 to 40,000 yuan are reimbursed by tertiary hospitals.
If the employee does not fall ill for several consecutive years, the personal account funds can be accumulated and rolled over.
In social medical insurance, there is a basic deductible for each hospitalization, which is: 500 yuan for first-level hospitals, 750 yuan for second-level hospitals, and 1,000 yuan for third-level hospitals. These expenses need to be borne by the employees themselves.
Category A drugs and Category B drugs are reimbursed on a proportional basis. Imported drugs are not reimbursed. If you exceed the coverage limit of 40,000 yuan, you have to pay for it yourself.