Medical insurance has the basic characteristics of social insurance, such as compulsion, mutual assistance and sociality. The medical insurance system is usually legislated and enforced by the state, and a fund system is established. The expenses are paid jointly by the employer and the individual, and the medical insurance premium is paid by the medical insurance institution to solve the medical risks caused by the illness or injury of the employees.
Subsidized medical insurance is medical insurance in which the insurance company pays the insurance premium to the insured by time, day or project according to the subsidy standard stipulated in the contract. Claims have nothing to do with actual medical expenses, and invoices are not needed.
Expense-based medical insurance is to pay insurance money according to the actual medical expenses incurred by customers and the insurance amount agreed in the policy. The purpose is to compensate customers for medical expenses. When making claims, customers need to issue invoices for outpatient or hospitalization, and the scope of claims is basically the same as that of "social security".
Social medical insurance also has strict restrictions. New drugs, imported drugs and expensive drugs are not covered by social medical insurance reimbursement. Medical expenses caused by traffic accidents shall not be reimbursed by social medical insurance. In addition, the expenses that often occur during illness, such as nutrition expenses, nursing expenses, lost time expenses, etc. , not included in the scope of reimbursement.
The insured must go to the designated medical institutions of basic medical insurance to buy medicines, or go to the designated retail pharmacies determined by social insurance institutions with medical prescriptions issued by doctors in designated hospitals.
The medical expenses incurred by the insured in the process of medical treatment must conform to the basic medical insurance drug list, diagnosis and treatment items, the scope of medical service facilities standards and payment standards, and can be paid by the basic medical insurance fund according to regulations.
legal ground
People's Republic of China (PRC) social insurance law
Article 25 The state establishes and improves the basic medical insurance system for urban residents.
The basic medical insurance for urban residents combines individual contributions with government subsidies.
People who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people and minors over 60 years old in low-income families, etc. , subsidized by the government.