The medical insurance adopts the pay-as-you-go system, and there are effective time rules for the first enrollment and the second enrollment after the payment deadline. Medical insurance can only be reimbursed when it takes effect, and how long will it take to be reimbursed for the first time? Under normal circumstances, employees who are insured by the unit can enjoy medical insurance benefits from the month after the employer pays the medical insurance premium and after the Social Security Bureau inquires about the payment records.
However, only the expenses incurred in hospitalization belong to the basic medical insurance drug list, diagnosis and treatment items and so on. Can they be reimbursed? If it is not within the above range, it can only be borne by the insured.
The medical insurance reimbursement process is as follows:
1, medical insurance is divided into two accounts, and the money reflected in the personal account in the medical insurance card can be used to buy medicines at designated pharmacies, pay outpatient expenses and pay the out-of-pocket part of hospitalization expenses;
2. When seeking medical treatment, show the medical insurance card to the designated hospital to prove the identity of the insured. At the time of checkout, the part paid by the individual shall be paid by the individual with medical insurance card or cash.
Hospitalization expenses reimbursed by medical insurance
According to national regulations, the hospitalization expenses that can be reimbursed by medical insurance include: bed fee, medical treatment fee, operation fee, examination fee, laboratory test fee, radiation fee, blood transfusion fee and nursing fee. But there are also some restrictions, such as high-end drugs, imported drugs, cosmetic surgery and high-end medical devices. No reimbursement.
According to the basic requirements of the payment of basic medical insurance benefits in China, the insured person who goes to the medical insurance institution to reimburse the medical expenses incurred by himself for medical treatment generally meets the following conditions:
1, the insured person must go to the designated medical institution of basic medical insurance or the designated retail pharmacy determined by the social insurance institution with the medical prescription issued by the doctor in the designated hospital.
2. The medical expenses incurred by the insured in the process of medical treatment must conform to the scope and payment standards of the basic medical insurance drug list, medical treatment items and medical service facilities standards, and can be paid by the basic medical insurance fund according to regulations.
3. The medical expenses incurred by the insured that meet the payment scope of basic medical insurance shall be paid by the social medical pooling fund in a unified proportion, with the expenses above the Qifubiaozhun and below the maximum payment limit.
To sum up, the hospitalization statement and related materials should be reported to the medical insurance agency, which will be used as the basis for monthly pre-allocation and year-end final accounts after audit.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 26
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Article 28
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.