Workers can fill prescriptions at designated medical institutions or retail pharmacies in accordance with regulations.
Employees whose places of employment or residence are in other provinces and cities may go to local medical institutions for medical treatment in case of emergency in other provinces and cities.
The scope of non-reimbursement of medical insurance in Shanghai is as follows: under any of the following circumstances, funds from the overall fund, additional fund and individual medical account will not be paid:
(1) Medical expenses incurred by employees in seeking medical treatment and dispensing drugs in non-designated medical institutions or dispensing drugs in non-designated retail pharmacies;
(two) medical expenses incurred by employees in seeking medical treatment or dispensing drugs that do not meet the basic medical insurance diagnosis and treatment items, medical service facilities, drug use scope and payment standards;
(3) Medical expenses incurred by employees due to suicide, self-mutilation, fighting, drug abuse, medical accident or traffic accident;
(four) other circumstances stipulated by the state and this Municipality.
Q: When will the basic medical insurance for urban workers begin to enjoy medical security benefits?
Answer: The starting time of medical insurance benefits for on-the-job employees is 15 of the month following the payment of medical insurance premiums. After going through the retirement formalities in the social security department, retirees can enjoy the medical insurance benefits stipulated in the Medical Insurance Measures from 1 of the month when they receive their pensions, such as medical expenses paid by the basic medical insurance pooling fund and local additional funds.
If the employer and employees who should pay the medical insurance premium fail to pay or fail to pay in full, the employees will stop enjoying the medical insurance benefits from next month 15. Employers and employees can continue to enjoy basic medical insurance benefits from the fifth day of the month after they pay medical insurance premiums in full according to regulations.
Q: Under what circumstances can medical expenses paid by individuals in cash be reimbursed?
Answer: Reimburseable medical expenses include: ① Medical expenses incurred by the insured in the emergency department of the designated hospital for medical security in this city without diagnosis certificate or referral procedures. (2) Medical expenses incurred by the insured in emergency treatment and emergency hospitalization in hospitals in other provinces and cities. (3) The medical expenses incurred by the insured in other provinces and cities after going through the relevant formalities.
Q: How to pay for the medical treatment items paid by medical insurance?
Answer: The inspection fee or treatment fee incurred by using medical equipment shall be paid by the insured in cash at the rate of 10% first, and the rest shall be paid according to the medical security regulations.
1, intraocular lens, heart valve, catheter and intravascular stent for diagnosis and interventional therapy of coronary artery diseases, disposable and implantable medical materials for interventional therapy of peripheral vascular and neurovascular diseases. The expenses incurred by using domestic materials shall be paid by the insured in cash at the rate of 20%, and the rest shall be paid according to the provisions of basic medical insurance; The expenses incurred by using imported materials shall be paid by the insured in cash at the rate of 30%, and the rest shall be paid according to the provisions of basic medical insurance.
2. Disposable medical materials for pacemaker and artificial joint replacement. The maximum payment standard of disposable medical materials for installing pacemakers is 25,000 yuan; The highest payment standard of disposable medical materials for artificial joint replacement is 15000 yuan. The expenses below the highest payment standard (including the highest payment standard) shall be paid according to the relevant provisions of this Municipality's basic medical insurance; The city's basic medical insurance will not pay the fees above the highest payment standard.
3. Intraosseous fixation materials. The highest payment standard for the expenses of the internal fixation materials of the insured for spinal internal fixation treatment is 20,000 yuan per person; The highest payment standard of internal fixation materials for the treatment of other parts of the spine is per person 10000 yuan. If the maximum payment standard is below (including the maximum payment standard), it shall be paid in accordance with the relevant provisions of this Municipality's basic medical insurance, and the expenses exceeding the maximum payment standard shall not be paid by this Municipality's basic medical insurance.
4, congenital heart disease interventional therapy materials. The maximum payment standard for disposable and implantable medical materials of the insured due to interventional treatment of congenital heart disease is 25,000 yuan per person. If the maximum payment standard is below (including the maximum payment standard), it shall be paid in accordance with the relevant provisions of this Municipality's basic medical insurance, and the expenses exceeding the maximum payment standard shall not be paid by this Municipality's basic medical insurance.
5, outpatient decocting fee. Outpatient decocting expenses incurred by the insured in the designated medical institutions of medical security in this Municipality shall be included in the payment scope of basic medical insurance according to the standard of 1.5 yuan/post, and paid according to the relevant laws, regulations or policies of basic medical insurance, and the rest 1 yuan shall be paid by the insured in cash.
Within a year of medical security, the maximum payment standard for outpatient ostomy in which the insured person is included in the basic medical insurance is set at 2500 yuan. The expenses below the highest payment standard (including the highest payment standard) shall be paid according to the provisions of this Municipality's basic medical insurance; The city's basic medical insurance will not pay the fees above the highest payment standard.