Medicare reimbursement includes medical expenses incurred by insured persons in designated hospitals in accordance with the three major catalogs, which are specifically divided into drug catalogs, diagnostic and therapeutic item catalogs, and medical service facility standards, specifically:
1, drug catalogs
Western medicines and proprietary Chinese medicines in the Drug Catalog are classified as "Class A drugs" and "Class B drugs. Category A drugs are eligible for full reimbursement and are uniformly paid for by the medical insurance fund regardless of the region, and generally include drugs that are necessary for clinical treatment, widely used, have good efficacy, and are low-priced among similar drugs. However, Class B only enjoys partial reimbursement, Class B list of drugs, localities can add some drugs into it, generally Class B drugs for clinical treatment options, efficacy, similar drugs than Class A drugs in the price of drugs.
2. Diagnostic and treatment item catalog
The diagnostic and treatment item catalog mainly includes diagnostic and treatment items that are necessary for clinical treatment, safe and effective, with appropriate costs and fees set by the price department, and the diagnostic and treatment items that are not eligible for reimbursement include the registration fee, the cost of medical records, as well as a variety of cosmetic and beauty items, non-functional cosmetic surgery and orthopedic surgeries.
3, medical services and facilities catalog
Medical services and facilities catalog mainly includes services and facilities provided by designated medical institutions, which are necessary in the process of diagnosis, treatment and care. The cost of emergency ambulance, hospitalization escort, laundry and recreational activities incurred during the consultation period cannot be reimbursed.
Besides hospitalization, there are other conditions that can be reimbursed, such as special outpatient examinations, special treatments, emergency room stays, and so on.
Expanded information
There are five categories of treatment items that are not covered by basic medical insurance***.
The first category is the class of services: part of the medical service fee, out-of-hospital consultation fee, medical records cost; visit fee, examination and treatment of expedited fee, naming surgery surcharge, naming surgery surcharge, high quality and premium fee, self-requested special nurses and other special medical services.
The second category is the category of non-disease treatment programs: see the following analysis.
The third category is the category of diagnostic and therapeutic equipment and medically useful materials: the application of positron emission tomography device (PET), electron beam CT, ophthalmic excimer laser treatment instrument and other large-scale medical equipment for examination and treatment programs. Eyeglasses, denture, eye prosthesis, prosthetic limbs, hearing aids and other rehabilitative devices. All kinds of health care, examination and treatment equipment for personal use. Provincial price departments do not charge a separate disposable medical materials.
The fourth category is the category of therapeutic projects: all types of organ or tissue transplantation of organ or tissue source; in addition to kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation; myopic orthopedics; qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other complementary therapeutic projects.
The fifth category is other categories: various scientific research, clinical verification of the diagnosis and treatment program.
In addition, the basic medical insurance does not pay the cost of transportation, emergency vehicle fees; baby warming box fee, food warming box fee, nursing fee, cleaning fee, outpatient decoction fee; meal costs and other special needs living services. The patient will have to pay for all the above items.
Medicare can reimburse the amount: the reimbursement of medicare is different in each region. In the case of reimbursement, the first thing to do is to determine what can be reimbursed. The first thing that you need to do is to get to the top of the list, and then you can get to the bottom of the list, and then you can get to the top of the list, and then you can get to the top of the list, and then you can get to the top of the list. Generally speaking, the reimbursement is made according to the cost of each level of hospital, of course, there are some areas will be more simple, just according to the level of hospital reimbursement, specifically, if there is a need for reimbursement in this regard, then you need to go to the local social security bureau, the specific reimbursement is how much, the employee medical reimbursement will be more, to reimburse about 80%, 80%, 80%, 90%.
Legal basis
The People's Republic of China Social Insurance Law
Article 30: The following medical expenses are not included in the scope of payment of the basic medical insurance fund:
(1) those that should be paid from the workers' compensation insurance fund;
(2) those that should be borne by a third party;
(3) those that should be paid by a third party.
(iii) should be borne by the public ****health;
(iv) medical treatment outside the country.
Medical expenses shall be borne by a third person in accordance with the law, and if the third person fails to pay or if the third person cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the costs from the third party after making the payment first.
Article 28: Medical expenses in accordance with the basic medical insurance drug list, diagnostic and therapeutic items, standards of medical service facilities, as well as emergency and rescue shall be paid from the basic medical insurance fund in accordance with national regulations.