legal subjectivity:
The following are the specific contents of the reimbursement scope of social security medical insurance.
1. Drug reimbursement of basic medical insurance
The types of drugs in China can be mainly divided into Class A, Class B and Class C. The waist circumference of Class A is basically included in the scope of medical insurance fund and reimbursed according to certain standards; 8% of Class B drugs are reimbursed, and the other 2% are at their own expense; Class C drugs are self-sufficient drugs and will not be reimbursed.
The following drugs are not covered by the basic medical insurance reimbursement: (1) drugs that mainly play a nourishing role; (2) Some animals and animal organs that can be used as medicine, dried (watered) fruits; (3) Various wine preparations brewed with Chinese herbal medicines and Chinese herbal pieces; (4) Fruity preparations and oral effervescent agents in various medicines; (5) Blood products and protein products (except for special indications and first aid and rescue); (6) Other drugs that are not paid by the basic medical insurance fund as stipulated by the administrative department of social insurance.
2. Reimbursement of basic medical insurance diagnosis and treatment items
Basic medical insurance diagnosis and treatment items should meet the following conditions: (1) Clinical diagnosis and treatment must be safe, effective and appropriate; (2) The price department has set the charging standard; (3) within the scope of designated medical services provided by designated medical institutions for the insured.
3. Reimbursement of basic medical service facilities
Reimbursement of medical service facilities of basic medical insurance covers the living service facilities provided by designated medical institutions and necessary for the insured in the process of receiving diagnosis, treatment and nursing, mainly including hospital bed fee or bed fee for outpatient (emergency) observation.
Second, what does the second reimbursement of medical reimbursement mean?
The second reimbursement of medical insurance is the reimbursement of supplementary medical insurance. The supplementary medical insurance in the six insurances is different from the general medical insurance, because medical insurance is the insurance content in social security, and it is also a national welfare policy, and it is also compulsory for employees of public institutions. However, supplementary medical insurance is not mandatory, and if social security cannot be reimbursed, it can be reimbursed.
First of all, we should understand that supplementary medical insurance is different from general medical insurance. There is no card for supplementary medical insurance, and it cannot be reimbursed directly with a card. Second, the second reimbursement of supplementary medical insurance requires a manual declaration procedure. This shows that if you want to use the second reimbursement, you should keep all the payment documents when you are in hospital. These are the vouchers for the second reimbursement.
The original intention of supplementary medical insurance is not to let the masses reimburse as much as possible, but in special circumstances, the family's financial ability is limited and the problem cannot be solved through medical insurance, so the second reimbursement can play a role. Therefore, it does not mean that supplementary medical insurance is used for secondary reimbursement if medical insurance cannot be reimbursed.
III. What is the proportion standard for the second reimbursement of medical insurance
According to the regulations, when the basic medical insurance is used to pay the hospitalization expenses for the first time in a year, the deductible amount of both working and retired people is 1,3 yuan.
The threshold for medical expenses for the second and subsequent hospitalization is determined as 5%, which is 65 yuan. The maximum payment of the basic medical insurance pooling fund (hospitalization expenses) in a year is currently 7, yuan.
the personal payment ratio of retirees is 6% of the personal payment ratio of employees, but the part below the minimum threshold is the same, all of which are paid by individuals. The standard of hospitalization reimbursement is related to the level of the medical institution where the insured person lives. Note: outpatient service and hospitalization are two deductible lines.
medical insurance refers to social medical insurance. Social medical insurance is a social insurance system established by the state and society to provide basic medical needs protection for workers within the scope of protection. The basic medical insurance fund consists of overall funds and individual accounts. The basic medical insurance premiums paid by individual employees are all included in individual accounts; The basic medical insurance premium paid by the employer is divided into two parts, one part is included in the personal account and the other part is used to establish the overall fund.
the specific secondary reimbursement standard for medical insurance is based on the actual reimbursement amount in your area.
Generally speaking, medical reimbursement is the reimbursement of drugs and hospitalization, and the categories of reimbursement are very detailed. When reimbursing many drugs, it is necessary to check what diseases the patients have, that is, they are not within the scope of indications. Not all hospitalizations can be directly reimbursed, but there are conditions and restrictions. Legal objectivity:
Medical insurance is an insurance to compensate the medical expenses caused by diseases. Social insurance in which employees are provided with necessary medical services or material assistance by society or enterprises due to illness, injury or childbirth. Such as free medical care and labor insurance medical care in China. The medical expenses of employees in China are shared by the state, units and individuals, so as to reduce the burden on enterprises and avoid waste. The scope of medical insurance is very wide, and medical expenses are generally distinguished according to the characteristics of medical services, mainly including doctors' outpatient expenses, medicine expenses, hospitalization expenses, nursing expenses, hospital miscellaneous expenses, operation expenses, and various inspection expenses. Medical expenses are all kinds of expenses incurred by patients for treating diseases, which include not only doctors' medical expenses and operation expenses, but also hospitalization, nursing and hospital equipment. Proportion and scope of reimbursement of medical insurance: 1. Outpatient and emergency medical expenses: the medical expenses of employees who meet the scope of basic medical insurance during the year (January 1 ~ December 31) have accumulated more than 2, yuan. 2. Settlement ratio: 5% of the part of the dispatched personnel over 2, yuan will be reimbursed during the contract period, and 5% will be paid by the individual; In a year, the maximum amount of accumulated reimbursement for dispatched personnel for outpatient and emergency services is 2, yuan. 3, the insured should be properly kept in the designated hospital outpatient medical documents (including large part of the receipt, prescription, etc.), as a medical expense reimbursement certificate. 4. Outpatient treatment for three kinds of special diseases: When the insured person needs to take anti-rejection drugs after radiotherapy and chemotherapy for malignant tumor, renal dialysis and kidney transplantation, the second-and third-level designated hospitals where the insured person goes to see a doctor will issue a "disease diagnosis certificate", fill in the "Declaration and Approval Form for Special Diseases of Medical Insurance" and report it to the district medical insurance center for approval and filing. Outpatient treatment and drug collection for these three special diseases are limited to designated hospitals approved for treatment, and cannot be purchased at designated retail pharmacies. If the medical expenses incurred meet the prescribed scope of outpatient special diseases, they shall be settled with reference to hospitalization. 5, hospitalization, medical insurance paid enough for 2 years, can enjoy the medical insurance reimbursement after retirement. Proportion and scope of reimbursement for rural cooperative medical insurance: 1. Outpatient compensation: (1) 6% reimbursement for visits to village clinics and village center clinics, with prescription drug fee limit of 1 yuan for each visit, and 5 yuan for temporary rehydration prescription drug fee limit for doctors in health centers. (2) 4% reimbursement for medical treatment in town health centers, with the examination fee and operation fee limit of 5 yuan and prescription drug fee limit of 1 yuan. (3) 3% reimbursement for medical treatment in secondary hospitals, with the limit of each examination fee and operation fee in 5 yuan and the limit of prescription drug fee in 2 yuan. (4) 2% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 5 yuan and the limit of prescription drug fee in 2 yuan. (5) The invoice of traditional Chinese medicine is attached with a prescription with a limit of 1 yuan per paste. (6) The annual compensation limit for township-level cooperative medical clinics is 5, yuan. 2. Hospitalization compensation (1) Reimbursement scope: A. Drug expenses: auxiliary examination: 2 yuan for examination expenses such as ECG, X-ray fluoroscopy, radiography, laboratory test, physiotherapy, acupuncture, CT and nuclear magnetic resonance; Operation expenses (refer to national standards, and those exceeding 1 yuan will be reimbursed by 1 yuan). B, the elderly over 6 years old are hospitalized in Xingta Town Health Center, and the treatment and nursing expenses are compensated to 1 yuan every day, with a limit of 2 yuan. (2) Reimbursement ratio: town hospitals reimburse 6%; 4% reimbursement for secondary hospitals. 3. Compensation of Town Risk Fund for Serious Illness Compensation: All inpatients who participate in cooperative medical care should report medical expenses of more than 5, yuan at one time or for the whole year, that is, 65% for 5,1-1, yuan and 7% for 1,1-18, yuan.