The scope of medical insurance reimbursement includes the related medical expenses incurred by the insured in the designated hospitals that meet the three catalogues, which are specifically divided into drug list, diagnosis and treatment project list and medical service facilities standard. Specifically:
1, drug list
Western medicine and Chinese patent medicine in the drug list are divided into "Class A drugs" and "Class B drugs". Class A can enjoy full reimbursement, which is paid by the medical insurance fund in any area, and generally includes drugs that are necessary for clinical treatment, widely used, have good curative effect and have lower prices among similar drugs. However, Class B drugs only enjoy partial payment, and some drugs can be added to Class B drugs. Generally, Class B drugs are available for clinical use with good curative effect, and the prices of similar drugs are higher than those of Class A drugs.
2, diagnosis and treatment project directory
The catalogue of diagnosis and treatment items mainly includes the necessary, safe and effective diagnosis and treatment items, and the charging standard is formulated by the price department. The medical treatment items that cannot be reimbursed include registration fees, medical records, various beauty and bodybuilding items, non-functional cosmetic surgery, orthopedic surgery, etc.
3, medical service facilities directory
The catalogue of medical service facilities mainly includes the service facilities provided by designated medical institutions and necessary in the process of receiving diagnosis, treatment and nursing. If it is the ambulance fee, hospitalization escort fee, washing fee and entertainment fee incurred in the process of medical treatment, it cannot be reimbursed.
In addition to hospitalization, other situations can also be reimbursed, such as special examination, special treatment, outpatient emergency observation and so on.
Extended data
The basic medical insurance does not pay the cost of diagnosis and treatment projects * * * five categories.
The first category is service items: some medical service fees, out-of-hospital consultation fees, medical record production fees, etc. Special medical services such as visiting fees, expedited fees for examination and treatment, additional fees for name-calling surgery, additional fees for name-calling surgery, high-quality and good-price fees, and self-invited special care.
The second category is non-disease treatment items: see the following analysis for details.
The third category is diagnosis and treatment equipment and medical useful materials: inspection and treatment projects carried out by using large-scale medical equipment such as positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic apparatus. Glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation appliances. All kinds of self-use health care, examination and treatment instruments. Disposable medical materials that are not charged separately as stipulated by the provincial price department.
The fourth category is treatment project category: organ source or tissue source of various organ or tissue transplants; Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow; Orthopedic surgery for myopia; Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
The fifth category is other categories: all kinds of scientific research and clinical verification diagnosis and treatment projects.
In addition, the expenses not paid by the basic medical insurance also include: transportation expenses and emergency expenses; Infant incubator fee, food incubator fee, nursing fee, washing fee and outpatient decocting fee; Special living expenses such as meals. Patients should pay for the above items when seeking medical treatment.
Medical insurance reimbursement amount: different regions have different medical insurance reimbursement regulations. When reimbursing, first determine what can be reimbursed. The content that can be reimbursed must reach the deductible line, the part below the deductible line is not reimbursed, and the part above the deductible line can be reimbursed. Under normal circumstances, reimbursement is made according to the expenses of hospitals at all levels. Of course, some areas will be simpler, and reimbursement will only be made according to the level of the hospital. Specifically, if there is a demand for reimbursement in this area, you need to ask the local social security bureau how much you can reimburse. There are more opportunities for medical reimbursement for employees, about 80% can be reimbursed, and there are fewer reimbursement for urban-rural cooperative medical care, about 50-80%.
legal ground
People's Republic of China (PRC) social insurance law
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.
Twenty-eighth 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.