I. The scope of diagnostic and treatment programs for which the basic medical insurance does not pay the fees
(1) Service categories
1. Registration fees, out-of-hospital consultation fees, and the cost of medical records.
2. Special medical services such as visit fee, expedited fee for examination and treatment, surcharge for named surgery, quality premium fee, and self-invited special nurse.
(2) Non-disease treatment program category
1. All kinds of cosmetic and body-building programs as well as non-functional cosmetic and orthopedic surgeries.
2. All kinds of weight loss, fat gain, height increase program.
3. All kinds of health checkups.
4. Various preventive and health care treatment programs.
5. All kinds of medical consultation, medical appraisal.
(C) diagnostic and therapeutic equipment and medical materials
1. Application of positron emission tomography (PET), electron beam CT, ophthalmic excimer laser therapy and other large-scale medical equipment for the examination and treatment program.
2. Eyeglasses, dentures, eye prostheses, prosthetic limbs, hearing aids and other rehabilitative devices.
3. A variety of self-use health care, massage, examination and treatment equipment.
4. Provincial pricing department regulations can not be charged separately disposable medical materials.
(D) therapeutic project category
1. All kinds of organ or tissue transplantation of organ source or tissue source.
2. Transplantation of organs or tissues other than kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow transplantation.
3. Orthopedic surgery for myopia.
4. Complementary therapeutic programs such as qigong therapy, music therapy, nutrient therapy for health care, and magnetic therapy.
(E) other
1. Various infertility (pregnancy), sexual dysfunction treatment program.
2. A variety of scientific research, clinical verification of the treatment program.
Basic medical insurance to pay part of the cost of the scope of treatment programs
(a) diagnostic and treatment equipment and medical materials
l. Application of χ-ray computed tomography (CT), stereotactic radiography (γ-knife, χ-knife) , cardiac and angiography χ-line machine (including digital subtraction equipment), magnetic **** vibration imaging device (MRI), single photon emission computerized scanning device SPECT), color Doppler, medical linear gas pedal and other large-scale medical equipment for examination and treatment projects.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy.
3. Cardiac pacemakers, artificial joints, artificial crystals, vascular stents and other artificial organs and materials for internal replacement.
4. Disposable medical materials that can be charged separately as stipulated by the price departments of each province.
(B) treatment program category
1. Hemodialysis, peritoneal dialysis.
2. Kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow transplantation.
3. Cardiac laser perforation, anti-tumor cellular immunotherapy and fast neutron therapy programs.
(3) the provincial labor security department of the expensive medical instruments and equipment for inspection, treatment projects and medical materials.
China's medical insurance is divided into two parts: individual account and social coordinated fund, which is funded by the unit and individual in the prescribed proportion **** the same, to protect the basic medical needs of the public. Among them, the co-ordinated fund is used to pay for hospitalization expenses, the individual account is used for outpatient and emergency expenses and the purchase of medicines at designated retail pharmacies, and the costs to be borne by individuals in the costs of hospitalization and outpatient specific items are also paid for by the individual account, or by the individual if the individual account has insufficient funds.
At the same time, the relevant policies on medical insurance also stipulate that the principal and interest of the individual account are owned by the individual, and can be inherited in addition to being used to settle accounts.
Medicare reimbursement rates and medication coverage vary slightly from place to place, but are based on national standards.
Medical insurance reimbursement regulations are basically the same, in the local hospitalization, according to the level of hospitals, different ratios are also different (generally required to the county level or above the public health insurance designated medical institutions), but the same procedures, hospitalization, hospitalization card, medical insurance book, to the hospital medical insurance office to register for the admission formalities, pay a certain amount of deposit, you can be hospitalized. When you are hospitalized, if the cost is too high, you will be asked to pay another deposit. When you are discharged from the hospital, you will be required to pay a portion of the deposit according to the regulations of the medical insurance, and if the deposit is insufficient, you will be discharged with the full amount of the deposit.
If you are hospitalized in a foreign country, you will have to pay for the hospitalization expenses yourself, and after you are discharged, you will have to submit the relevant hospitalization data according to the regulations and be reimbursed by the unit to the health insurance center in accordance with the proportion of the hospitalization expenses.
The basic medical insurance in social security consists of a personal medical account and a comprehensive fund. (The following specific data is based on the standard of Guangzhou City, and the standard base for other areas is based on the data prepared by the local social security bureau)
How is medical insurance reimbursed?
Social insurance can be reimbursed by presenting the medical record and the insurance card (bank card) at the time of medical treatment.
In the case of commercial insurance, the insured person, as the applicant, will apply to the insurance company for reimbursement of benefits within ten days after discharge from the hospital with the following certificates and documents. If it is handled by an agent, you need to have a power of attorney and a copy of your ID card.
1. Hospital admission and discharge certificate issued by the hospital;
2. Identity proof of the insured;
3. Other certificates and information that the insured can provide to confirm the nature and cause of the insurance accident.
4. In addition to the above information,
(1) the application for the general hospitalization daily benefit should provide a certificate of disease diagnosis issued by the hospital.
(2) For Cancer Hospitalization Benefit, a certificate of diagnosis with pathology report issued by the hospital should be provided.
(3) The application for organ transplant insurance benefit should provide the disease diagnosis certificate, surgery certificate and original invoice of medical expenses issued by the hospital.
(4) Surgical certificates and original invoices of medical expenses issued by the hospital should be provided when applying for surgical medical insurance benefits.
If part of the cost of organ transplantation or surgery has been paid by other means (with social security), when the original invoice of medical expenses cannot be provided, the percentage and amount of the paid amount should be indicated on the copy of the invoice of medical expenses and the seal of the unit that paid for the expenses should be stamped on the copy of medical expenses, and with this copy, apply for the payment of benefits to the insurance company, which will bear the responsibility for the remaining part of the cost of the organ transplantation or surgery.
Another
Also:
The insurance company will issue a notice of refusal to pay the insurance benefit to the applicant within ten days after it receives the applicant's application for payment of the insurance benefit and the above mentioned certificates and information, if it does not belong to the insurance responsibility. The insurance company shall reach an agreement with the applicant on the amount of insurance premiums to be paid, and shall fulfill its responsibility to pay the insurance premiums within ten days after the agreement is reached.
The insurance company shall, within sixty days from the date of receipt of the relevant certificates and information listed in this article, pay the minimum amount that can be determined according to the existing certificates and information if the amount of insurance premiums cannot be determined as a result of the insurance liability, and the insurance company shall pay the corresponding difference after the amount of insurance premiums is finally determined.
The right of the insured person to request the insurance company to pay the insurance benefit shall be extinguished if it is not exercised for two years from the date when he/she knew or should have known of the occurrence of the insurance accident.
(I) Individual Account
1. Under the age of 35
Part I: After 100 yuan is transferred in the following month of enrollment. Afterwards, the cumulative contributions for 12 months will be transferred to 100 yuan;
The second part: 3% of the employee's own contribution base (of which 1% is the number of unit contributions and 2% is the number of my own contributions)
According to the 2000 average salary of Guangzhou workers of 1,581 yuan, each year, the individual health care account will should be 100 yuan + 1,581 * 2% * 12 (months) + 1,581 * 1% *12 (months) = 669.16 yuan.
2. 35~45 years old
The first part: after 100 yuan is allocated in the next month of enrollment. Afterwards, the cumulative contribution of 12 months is transferred to 100 yuan;
The second part: 4% of the employee's own contribution base (of which 2% is the number of unit contributions and 2% is the number of my own contributions)
Based on the 2000 average salary of 1581 yuan for employees in Guangzhou City, each year, the individual health care account will should be 100 yuan + 1581*2%*12 (months) + 1581*2% *12 (months) = 858.88 yuan.
3, 45 ~ pre-retirement
The first part: after the next month of enrollment transferred to 100 yuan. Afterwards, the accumulated contribution of 12 months is transferred to 100 yuan;
The second part: 4.8% of the employee's own contribution base (of which 2.8% is the number of unit contributions and 2% is the number of my own contributions)
Based on the 2000 average salary of 1581 yuan for workers in Guangzhou City, each year, the individual health care account will should be 100 yuan + 1581*2.8%*12 (months)+ 1581*2%*12 (months) = 1010.66 yuan.
4. Retirees
The first part: after 100 yuan is allocated in the following month of enrollment. Afterwards, the accumulated contributions for 12 months will be transferred to 100 yuan;
The second part: 5.1% of the average monthly salary of Guangzhou workers in the previous year
Based on the average salary of Guangzhou workers of 1,581 yuan in 2000, the individual medical account should have 100 yuan + 1,581 * 5.1% * 12 (months) = 1,067.57 yuan in each year.
The scope of payment of the individual medical account:
1. Outpatient medical expenses for common diseases and emergencies
2. Basic medical expenses for inpatient and outpatient specific items below the starting line
3. The part of inpatient and outpatient specific items that is above the starting line and below the ceiling line and is to be paid by the individual (ranging from 5 to 20%, depending on the grade of the inpatient hospital). (5~20%, depending on the level of hospitalization)
(2) Composition of the Coordinated Fund
Part I: the basic medical insurance premiums of active employees and the transitional basic medical insurance premiums of retirees, except for the portion that is allocated to the individual medical account;
Part II: the medical subsidies for major illnesses.
The scope of payment of the co-ordinated fund: the part of inpatient and outpatient specific items in the ***payment section (i.e., the part above the starting line and below the ceiling line) and the part paid by the co-ordinated fund (ranging from 80 to 95%, divided by the level of inpatient medical care
The part paid by the co-ordinated fund doesn't need the balance on your personal account, while the hospitals cut off the part from personal account below the starting line and the part which the individual should The first thing you need to do is to get the money from your account, and the second thing you need to do is to get the money from your bank account.