1. 85% reimbursement for the period of 0-40,000 yuan;
2. 90% reimbursement for the period of 40,000 yuan to 80,000 yuan;
3. 95% reimbursement for the period of 80,000 yuan or more.
The scope of treatment items that are not covered by the Employee Health Insurance is as follows:
1. Services
(1) registration fee, out-of-hospital consultation fee, and cost of medical records;
(2) consultation fee, expedited examination and treatment fee (except for emergencies), surcharge on named surgeries, high quality premium fee, and fee for special nurses for special needs medical services;
2, non-disease treatment programs
(1) a variety of cosmetic (cosmetic life, medical aesthetics) and fitness programs, as well as non-functional cosmetic surgery, orthopedic surgery, etc.;
(2) a variety of weight loss, weight gain, height increase program;
(3) a variety of health checkups;
(4) a variety of preventive, health care diagnostic and therapeutic programs;
(5) dental orthodontics, dental porcelain;
(6) a variety of medical consultation (excluding psychiatric consultation), medical appraisal;
3, diagnostic and therapeutic equipment and medical materials
(1) the application of positron emission tomography scanner, electron-beam CT, ophthalmology, excimer laser therapy and other large-scale medical equipment for examination and treatment programs;
(2) Eyeglasses, prosthetic teeth, prosthetic eyes, prosthetic limbs, hearing aids and other rehabilitative devices;
(3) a variety of self-use of health care, massage, checkup and rehabilitation and treatment equipment;
4, the category of therapeutic items
(1) all types of organ transplantation or tissue transplantation of organ sources or tissue sources;
(2) in addition to kidneys, heart valves, corneas, skin, blood vessels, bone, Bone marrow transplantation other than organ or tissue transplantation;
(3) myopic eye orthopedics;
(4) qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary therapeutic projects;
5. Other
(1) a variety of infertility (pregnancy), sexual dysfunction of the diagnostic and treatment programs;
(2) a variety of scientific research, Clinical verification of the diagnosis and treatment program.
Employee health insurance to pay part of the cost of the treatment program scope is as follows:
1, diagnostic and therapeutic equipment and medical materials
(1) the application of X-ray computed tomography (CT), stereotactic radiography (γ-knife, χ-knife), cardiography and angiography X-ray, X-ray and angiography (γ-knife, χ-knife, χ-knife, χ-knife). ), cardiac and angiographic X-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (MEI), single-photon emission computer scanning device (SPECT), color Doppler, medical linear gas pedal and other large-scale medical equipment for the examination, treatment programs;
(2) extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy;
(3) pacemakers
(4) Provincial price department regulations can be charged separately for disposable medical materials
2, treatment program category
(1) hemodialysis, peritoneal dialysis;
(2) kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplantation;
(3) cardiac laser perforation, anti-tumor cellular immunotherapy and fast neutron therapy programs;
3. Examination and treatment programs of medical instruments and equipment and medical materials with a single cost of more than 400 yuan.
In summary, the maximum reimbursement amount for employee health insurance is 85% for medical expenses incurred above the maximum payment limit of the Basic Medical Care Coordination Fund by the social insurance department at the following rates: 85% for medical expenses incurred between 0 and less than 40,000 yuan, 90% for medical expenses incurred between 40,000 yuan and less than 80,000 yuan, and 95% for medical expenses incurred above 80,000 yuan. The maximum payment limit is 150,000 yuan in each medical year.
Legal basis:
Article 28 of the Social Insurance Law of the People's Republic of China
Medical expenses that conform to the basic medical insurance drug catalog, diagnostic and therapeutic items, medical service facility standards, as well as those for emergency and rescue, shall be paid out of the basic medical insurance fund in accordance with state regulations.
Article 29
The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.