The items not paid by the medical insurance pooling fund mainly include self-funded items, non-statutory items, high-end drugs and non-statutory medical institutions. The specific non-payment items may vary from region to region, so it is recommended to consult the local medical insurance department or professional lawyer for accurate information.
the medical insurance pooling fund is a system that provides medical security for the broad masses of the people, but it does not cover all medical expenses. According to the relevant laws, regulations and policies, the items that are not paid by the medical insurance pooling fund mainly include the following aspects:
1. Self-funded items: The medical insurance pooling fund only pays the medical expenses that meet the requirements, while some unnecessary self-funded items, such as cosmetic surgery and Chinese herbal medicine expenses that are not needed for medical purposes, are not covered by medical insurance.
2. Non-statutory items: The medical insurance pooling fund only pays medical expenses that meet the scope of statutory items, such as some high-end medical devices and special treatment methods. If they are not within the scope of statutory items, they will not be paid by medical insurance.
3. High-end drugs: Some expensive drugs such as specific drugs, imported drugs and innovative drugs may not be paid by the medical insurance pooling fund if they are not in the medical insurance catalogue.
4. Non-statutory medical institutions: Medical insurance only pays for legal medical services in medical institutions recognized by the state. If the medical institutions seeking medical treatment have not obtained corresponding qualifications or signed medical service agreements, medical expenses will not be paid by medical insurance.
The refusal decision of medical insurance pooling fund is usually based on medical necessity, cost-effectiveness and policy provisions. When enjoying medical services, it is recommended to know the medical insurance policy in advance and fully communicate with doctors to avoid the economic burden caused by the refusal of fees.
to sum up, the expenses refused by the medical insurance pooling fund usually include some specific medical services or drugs, which do not meet the payment conditions stipulated in the medical insurance policy.
Legal basis:
Article 3 of the Social Insurance Law of the People's Republic of China
The following medical expenses are not included in the payment scope of the basic medical insurance fund:
(1) Those that 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 basic medical insurance fund shall pay in advance. After the basic medical insurance fund has paid in advance, it has the right to recover from the third party.