The specific provisions are as follows:

1. For the insured who has paid the basic medical insurance, after the prescribed medical expenses occur, the eligible medical expenses shall be paid by the social medical insurance pooling fund on the premise of meeting the scope of medical insurance reimbursement. For example, the medical expenses incurred by the insured in the hospital are 5000 yuan, of which 4000 yuan belongs to the scope of medical insurance, so this 4000 yuan will be paid by the medical insurance pooling fund, and the remaining 1 000 yuan is the expenses that users need to pay themselves.

2. The medical insurance fund pays not the money deducted from the medical insurance card, but the money deducted from the overall account. The money in the medical insurance card is part of the individual contribution of employee medical insurance. It can usually be used for outpatient clinics and designated pharmacies, as well as expenses that need to be paid by individuals after completing medical insurance reimbursement.

Proportion of national medical insurance reimbursement

The national medical insurance reimbursement ratio is as follows:

1, 88% of the threshold fee is more than 3,000 yuan;

2, 3000-5000 yuan is 90%;

3, 5000- 10000 yuan is 92%;

4. 10000 yuan is 95% of the maximum payment limit.

The process of handling medical reimbursement

1, medical insurance, whether for urban workers or urban residents, must be hospitalized in accordance with the local designated medical institutions approved by the local medical insurance institutions;

2. If you need to go to other medical institutions for treatment, you need to issue a referral certificate to the local community hospital or community health service center or designated medical institutions;

3. If you are hospitalized in a local medical insurance designated medical institution, the hospital will automatically deduct the medical insurance reimbursement when you check out;

4. In the local medical insurance designated places for treatment but not hospitalization, or receiving radiotherapy and chemotherapy treatment, but not reimbursed in the hospital, you can bring the relevant information issued by the hospital to the medical insurance window of the local administrative service center for reimbursement. Details are as follows:

(1) official invoice;

(2) medical diagnosis;

(3) A detailed list of drugs;

(4) Social security card or medical card.

5. If you have been treated in other medical institutions and have a referral certificate, you must reimburse all treatment invoices, hospital diagnosis certificates, hospitalization certificates, ID cards, social security cards, medication lists and medical records before 65438+February 3/0/every year after discharge.

I hope the above content can help you. Please consult a professional lawyer if you have any other questions.

Legal basis: Article 28 of the Social Insurance Law of People's Republic of China (PRC).

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Article 29

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.

The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.