Medical expenses incurred above the maximum payment limit of the Basic Medical Care Coordination Fund shall be reimbursed by the social insurance department at the following rates: 85% for up to 0-40,000 yuan, 90% for up to 40,000 yuan to 80,000 yuan, and 95% for more than 80,000 yuan. The maximum payment limit is RMB 150,000 in each medical year.
The scope of treatment items for which the Employee Medical Insurance shall not pay expenses:
1. Service items
(1) registration fee, out-of-hospital consultation fee, and cost of medical records;
(2) special medical services such as consultation fee, expedited fee for checkups and treatments (except for emergencies), surcharge on named surgeries, high quality and excellent price, and self-invited special nurse fee;
2, non-disease treatment program category
(1) a variety of cosmetic (life beauty, medical cosmetic) fitness program and messy non-functional cosmetic surgery, orthopedic surgery, etc.;
(2) a variety of weight loss, weight gain, height projects;
(3) a variety of health checkups;
(4) a variety of preventive, health care clinic 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 scanning device, electron-beam CT, ophthalmology, excimer laser treatment instrument and other large-scale medical equipment for the examination and treatment of the project;
(2) glasses, Prosthetic teeth, prosthetic eyes, prosthetic limbs, hearing aids and other rehabilitative devices;
(3) a variety of self-use of health care, massage, examination and rehabilitation and treatment equipment;
4, treatment program category
(1) all types of organ transplantation or tissue transplantation of organ source or tissue source;
(2) in addition to the kidneys, heart valves, corneas, skin, blood vessels, bone, bone marrow transplantation Other organ or tissue transplantation;
(3) myopic eye orthopedics;
(4) qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary therapeutic programs;
5. Other
(1) a variety of infertility (pregnancy), sexual dysfunction of the diagnostic and treatment programs;
(2) a variety of scientific research, clinical validation of the
In summary, the maximum limit for hospitalization under the Employee Health Insurance is RMB 150,000 yuan.
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 emergencies and salvages, shall be paid out of the basic medical insurance fund in accordance with state regulations.
Article 29
The portion of the medical expenses of the insured 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.