Such as outpatient, inpatient, obstetrics, outpatient and emergency chronic diseases. When employees enjoy medical insurance benefits, the medical insurance department will make settlement according to the balance in the overall account. If the account balance is insufficient, the medical insurance department will allocate it from the medical insurance fund.
The funds in the overall medical insurance account can be used under the following circumstances:
1. Hospitalization reimbursement: When an employee is hospitalized due to illness or accident, the money in the medical insurance pooling account is used to pay the portion of hospitalization expenses that can be reimbursed according to regulations.
2. Outpatient reimbursement: When an employee visits an outpatient clinic due to illness or accident, the money in the medical insurance co-ordination account is used to pay the outpatient expenses that can be reimbursed according to regulations.
3. Outpatient and emergency chronic disease reimbursement: When an employee suffers from a prescribed chronic disease in an outpatient or emergency department, the money in the medical insurance pooling account will be used to pay the part of the expenses related to chronic diseases that can be reimbursed according to regulations.
4. Maternity reimbursement: When employees need hospitalization or outpatient treatment due to childbirth, the money in the medical insurance co-ordination account will be used to pay the part of maternity expenses that can be reimbursed according to regulations.
It should be noted that the money in the medical insurance pooling account is not unlimited, and there is generally a certain reimbursement limit. At the same time, there are certain restrictions on the reimbursement of medical insurance pooling accounts, such as the scope, proportion and limit of reimbursement. When the insured uses the funds in the medical insurance pooling account, they need to abide by the relevant provisions of the medical insurance policy to ensure the rational use of funds.
To sum up, the money in the overall medical insurance account is used to pay the medical expenses incurred by the insured in the designated hospitals or pharmacies of medical insurance, as well as other medical expenses within the scope of medical insurance reimbursement. When the insured uses the funds in the medical insurance pooling account, they need to abide by the relevant provisions of the medical insurance policy to ensure the rational use of funds.
Legal basis:
People's Republic of China (PRC) social insurance law
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.