How much medical expenses can Shanghai Social Security reimburse?

Guidelines for Shanghai Medical Insurance

Reimbursement ratio

Outpatient emergency of insured persons

The medical expenses incurred by outpatient emergency of insured persons (including family beds) are set with a minimum threshold. The part of medical expenses that exceeds the minimum threshold in one year shall be paid by the urban and rural residents' medical insurance fund according to a certain proportion, and the rest shall be borne by individuals.

The minimum payment standard is:

People aged p>6 and above, severely disabled people, primary and secondary school students and infants are from 3 yuan;

People over 18 years old and under 6 years old are 5 yuan.

The proportion of urban and rural residents' medical insurance fund payment is:

7% for outpatient emergency treatment in community health service centers (or first-class medical institutions); 6% in the outpatient emergency of secondary medical institutions; In the third-level medical institutions outpatient emergency, pay 5%.

the medical expenses incurred by the insured in the clinic of the village clinic are not included in the Qifubiaozhun, and 8% are paid by the urban and rural residents' medical insurance fund.

hospitalization of the insured

The minimum payment standard is set for the medical expenses incurred by the insured in each hospitalization (including the observation in the emergency observation room). The part exceeding Qifubiaozhun shall be paid by the urban and rural residents' medical insurance fund according to a certain proportion, and the rest shall be borne by the individual.

qifubiaozhun is:

first-level medical institution 5 yuan, second-level medical institution 1 yuan and third-level medical institution 3 yuan.

The proportion of urban and rural residents' medical insurance fund payment is:

9% for people aged p>6 and above and severely disabled people who are hospitalized in community health service centers (or first-class medical institutions), 8% for those hospitalized in second-class medical institutions and 7% for those hospitalized in third-class medical institutions;

for people under 6 years old, 8% will be paid for hospitalization in community health service centers (or first-class medical institutions), 75% will be paid for hospitalization in second-class medical institutions and 6% will be paid for hospitalization in third-class medical institutions.

reimbursement scope

1 On-the-job employees

On-the-job employees pay medical insurance at 2% of their monthly salary (unit 11%). When guarding the emergency room, you need to use up the amount included in the medical insurance in that year first, and then enter the self-sufficiency section, with the self-sufficiency amount of 15 yuan.

On-the-job employees are hospitalized

If hospitalization is needed, as long as medical insurance is paid, most medical expenses can be borne by medical insurance.

First, pay the deductible expenses of 1,5 yuan, and the expenses exceeding the deductible can be reimbursed by medical insurance in proportion. If it exceeds the maximum payment limit, it can also be paid by the additional fund in proportion.

2 retirees

3 non-working retirees

4 college students

More detailed information: 216 Shanghai's latest medical insurance policy, Shanghai Medical Insurance Reimbursement Standards and Scope

Non-reimbursement:

According to the provisions of the Social Insurance Law, the following medical expenses are not included in the payment scope of the medical insurance fund for urban and rural residents:

(1) They should be paid from the industrial injury insurance fund.

(2) It shall be borne by a third party;

(3) It shall be borne by public health;

(4) seeking medical treatment abroad.

the medical expenses shall be borne by the third party according to law. if the third party fails to pay or cannot determine the third party, the medical insurance fund for urban and rural residents shall pay in advance. Urban and rural residents' medical insurance fund has the right to recover from the third party after paying in advance.

reimbursement conditions

1. Being insured and paying fees normally (referring to being still insured and paying fees when leaving the hospital) and the expiration of treatment review (being insured for 3 days as a unit and being insured for 6 months as an individual)

2. The diseases conform to the Catalogue of Hospitalized Diseases of Basic Medical Insurance

3. The materials are complete

The reimbursement materials

The outpatient and emergency medical expenses are reimbursed. Insured persons should carry valid certificates (ID card, household register, etc.), social security card or medical insurance card, special receipts for outpatient medical expenses, special receipts for emergency medical expenses, relevant medical history data and copies, emergency supplementary pages and copies of the Record Book of Outpatient and Emergency Medical Treatment (the medical treatment relationship is the medical expenses incurred by the personnel of this Municipality in the designated medical institutions of this Municipality). If the Medical Insurance Card is reported to be damaged, a Notice of Damage to the Medical Insurance Card is also required.

reimbursement of observation expenses in hospital

To apply for reimbursement of observation expenses in hospital and emergency observation room, the insured should provide special receipt for medical expenses, list of medical expenses during hospitalization (list of medical expenses in emergency observation room) and its copy, discharge summary and copy.

sporadic reimbursement of outpatient medical expenses for serious illness

To apply for sporadic reimbursement of outpatient medical expenses for serious illness, the insured shall provide special receipts for outpatient medical expenses, disease diagnosis certificates and photocopies, and relevant inspection reports and photocopies.

entrust others to reimburse

the insured person may entrust others to handle it on his behalf. The client needs to bring the valid certificates (ID card, household registration book, etc.) of himself and the insured at the time of handling.

reimbursement location

Pudong New Area Medical Insurance Affairs Center

Address: No.359, Zhangyang Road, Pudong New Area

Tel: (21)5353961

Minhang District Medical Insurance Affairs Center

Address: No.53-546, Shuiqing Road, Minhang District (reported recently ..

Tel: 5413563

Changning Medical Insurance Center

Address: No.72 Wuyi Road, Changning District

Tel: 21-52654

Xuhui Medical Insurance Affairs Center

Address: No.999 Nanning Road