Medical insurance refers to social medical insurance. 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. The basic medical insurance fund consists of a pooled fund and individual accounts.
All basic medical insurance premiums paid by individual employees are included in their personal accounts. Basic medical insurance premiums paid by employers are divided into two parts, one part is transferred to the personal account, and the other part is used to establish a pooling fund.
There are two reimbursement processes for medical insurance reimbursement:
One is that the insured person brings the medical insurance card with him when he is hospitalized. In this case, he can directly show it when making settlement. The medical insurance card is paid at the hospital's medical insurance settlement window. The system will automatically identify which items belong to the medical insurance catalog and complete the settlement directly.
The other is if you forget to bring your medical insurance card for medical treatment (emergency or off-site). When you are discharged from the hospital, you need to prepare a list of medical expenses, original invoices, discharge certificates, and hospital diagnosis certificates, and go to the hospital after sorting out the information. Relevant local medical insurance agencies apply for reimbursement, and after approval, the reimbursement funds will be transferred to personal accounts.
Legal basis:
"Social Insurance Law of the People's Republic of China"
Article 2 The state establishes basic pension insurance, basic medical insurance, and work-related injury insurance , unemployment insurance, maternity insurance and other social insurance systems to protect citizens’ rights to obtain material assistance from the state and society in accordance with the law in the event of old age, illness, work injury, unemployment, childbirth, etc.
Article 26: The treatment standards of basic medical insurance for employees, new rural cooperative medical insurance and basic medical insurance for urban residents shall be implemented in accordance with national regulations.
Article 28: Medical expenses that comply with the basic medical insurance drug catalog, diagnosis and treatment items, medical service facility standards, and emergency and rescue expenses shall be paid from the basic medical insurance fund in accordance with national regulations.
Article 29: The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit.
The social insurance administrative department and the health administrative department should establish a medical expense settlement system for medical treatment in other places to facilitate insured persons to enjoy basic medical insurance benefits.
Article 30 The following medical expenses are not included in the payment scope of the basic medical insurance fund:
(1) Should be paid from the work-related injury insurance fund;
( 2) Should be borne by a third party;
(3) Should be borne by the public health department;
(4) Seek medical treatment abroad.
Medical expenses should be borne by a third party in accordance with the law. If the third party fails to pay or the third party cannot be identified, the basic medical insurance fund shall pay first. After the basic medical insurance fund has paid in advance, it has the right to recover compensation from the third party.