Cataract, glaucoma, fundus diseases, pterygium, artificial eye table and other eye operations can be reimbursed. Different types of surgery can enjoy different insurance coverage. Cataract surgery expenses belong to the scope of medical insurance, which can be reimbursed by medical insurance and commercial medical insurance. Myopia surgery, strabismus surgery, orbital plastic surgery, etc. It does not belong to the category of treatment, and medical insurance and commercial medical insurance are not reimbursed. Because myopia surgery is mainly corneal refractive surgery, including excimer laser and femtosecond laser, it belongs to the cosmetic treatment of myopia patients and does not belong to the scope of basic medical insurance reimbursement.
The scope of medical insurance reimbursement refers to ensuring the basic medical needs of the insured, and standardizing the management of medication and diagnosis and treatment of basic medical insurance. The basic medical insurance stipulates the scope of reimbursement for drug list, diagnosis and treatment items and medical service facilities.
First, the scope of medical insurance card reimbursement:
1, drug reimbursement for basic medical insurance:
Drugs included in the basic medical insurance payment scope are divided into Class A and Class B. ..
(1) Class A drugs refer to drugs that are basically unified in China and can meet the basic needs of clinical treatment. The expenses of such drugs are included in the payment scope of the basic medical insurance fund, and the expenses are paid according to the basic medical insurance payment standard.
(2) The list of Class B drugs shall be adjusted by the provinces, autonomous regions and municipalities directly under the Central Government according to their own conditions. Before such drugs are included in the payment scope of the basic medical insurance fund, the employees shall pay according to a certain proportion and pay according to the basic medical insurance payment standard.
(3) The following drugs do not belong to the reimbursement scope of basic medical insurance:
A. drugs that mainly play a nourishing role;
B. Some medicinal animals and animal organs and dried (watered) fruits;
C. Various wine preparations brewed with Chinese herbal medicines and Chinese herbal pieces; D. Fruity preparations and oral effervescent agents in various medicines;
E blood products and protein products (except for special indications and first aid and rescue);
(six) drugs that are not paid by other basic medical insurance funds as stipulated by the administrative department of social insurance.
2, the basic medical insurance treatment project reimbursement
The basic medical insurance treatment project shall meet the following conditions:
(1) Clinical diagnosis and treatment must be safe and effective, and the cost should be appropriate;
(2) The price department has set the charging standard;
(3) within the scope of designated medical services provided by designated medical institutions for the insured.
The scope of basic medical insurance to pay part of the cost of diagnosis and treatment projects is determined in accordance with the scope of basic medical insurance diagnosis and treatment projects stipulated by the state. Belong to the basic medical insurance payment part of the directory of medical treatment project costs, first by the insured according to the provisions of the proportion of self pay, and then pay according to the provisions of the basic medical insurance. Belonging to the basic medical insurance for employees, belonging to the catalogue of medical treatment projects that are not paid, the basic medical insurance fund for employees will not pay.
3. Reimbursement of basic medical service facilities
The reimbursement scope of medical service facilities in the basic medical insurance includes the living service facilities provided by designated medical institutions and necessary for the insured to receive diagnosis, treatment and nursing, mainly including the hospitalization bed fee or outpatient (emergency) observation bed fee.
The basic medical insurance fund does not pay for living services and service facilities, mainly including:
(1) outpatient and first aid (transfer) transportation expenses;
(2) Air conditioning fee, TV fee, telephone fee, baby incubator fee and food incubator fee;
(3) Escort fee, nursing fee, washing fee and outpatient decocting fee;
(4) meals;
(5) Hospitality and other special life service expenses.
legal ground
People's Republic of China (PRC) social insurance law
Eighth social insurance agencies to provide social insurance services, responsible for social insurance registration, personal rights and interests records, social insurance benefits payment and other work.
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, 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.
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.