First, according to the basic requirements for the payment of basic medical insurance benefits in China, the insured person reimburses the medical expenses incurred by his medical treatment to the medical insurance institution, which generally meets the following conditions:
(1) The insured must go to the designated medical institution of basic medical insurance or to 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 basic medical insurance drug list, diagnosis and treatment items, the standard scope of medical service facilities and payment standards, and be paid by the basic medical insurance fund according to regulations.
(III) Among the medical expenses that the insured meets the scope of payment of basic medical insurance, the part that is higher than the Qifubiaozhun of the social medical co-ordination fund and lower than the maximum payment limit shall be paid by the social medical co-ordination fund in a unified proportion.
Second, the reimbursement ratio.
1, outpatient and emergency medical expenses: the medical expenses that met the requirements of the basic medical insurance in that year (1 10/February/31February) exceeded 2,000 yuan.
2. Settlement ratio: 50% of the part of the dispatched personnel above 2,000 yuan will be reimbursed during the contract period, and 50% will be paid by the individual; Within one year, the maximum amount of accumulated reimbursement for outpatient and emergency services of dispatched personnel is 20,000 yuan.
3. The insured shall properly keep the medical documents (including receipts and prescriptions for large amounts) in the outpatient department of the designated hospital. ), as a medical expense reimbursement certificate.
Three, 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.
Legal basis:
Criminal law of the people's Republic of China
Article 198 Whoever commits insurance fraud under any of the following circumstances, if the amount is relatively large, shall be sentenced to fixed-term imprisonment of not more than five years or criminal detention, and shall also be fined not less than 10,000 yuan but not more than 100,000 yuan, or if there are other serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than five years but not more than 10 years, and shall also be fined not less than 20,000 yuan but not more than 200,000 yuan, or if there are other particularly serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than 10 years and fined not less than 200,0
(1) The applicant intentionally fabricates the subject matter of insurance to defraud the insurance money;
(2) The applicant, the insured or the beneficiary fabricates false reasons or exaggerates the loss of the insured accident to defraud the insurance money. (3) The applicant, the insured or the beneficiary fabricates an insurance accident that has never happened to defraud the insurance money;
(4) The applicant or the insured intentionally causes an insurance accident that causes property losses and defrauds the insurance money;
(5) The applicant or beneficiary intentionally causes the death, disability or illness of the insured to defraud the insurance money. Whoever commits the acts listed in Items 4 and 5 of the preceding paragraph, which constitutes other crimes, shall be punished in accordance with the provisions of combined punishment for several crimes. Where a unit commits the crime mentioned in the first paragraph, it shall be fined, and the persons who are directly in charge and other persons who are directly responsible for it shall be sentenced to fixed-term imprisonment of not more than five years, or the amount of criminal detention is huge or there are other serious circumstances, and the amount of fixed-term imprisonment of not less than five years but not more than 10 years is especially huge or there are other particularly serious circumstances, and it shall be sentenced to fixed-term imprisonment of not less than 10 years.