The following are the specifics of the Social Security Medicare reimbursement coverage.
1, the basic medical insurance drug reimbursement
China's drug categories can be divided into Class A, Class B and Class C. Class A girdle is basically included in the scope of the medical insurance fund, according to a certain standard to give reimbursement; Class B drugs reimbursement of 80%, and the other 20% of the self-reported; Class C drugs for the self-supporting drugs, will not be reimbursed.
The following medicines are excluded from the reimbursement scope of the basic medical insurance: (1) medicines that mainly play the role of nutritional tonic; (2) some of the animals and animal organs that can be used as medicines, dried (water) fruits; (3) all kinds of wine preparations made from Chinese herbal medicines and Chinese herbal medicinal herbs; (4) all kinds of medicines in the fruit-flavored preparation, oral effervescent preparations; (5) blood products, protein products (except for the special indications and first aid, rescue); (6) social security insurance, the social insurance fund will not provide any reimbursement for these medicines. (except for special indications and first aid and rescue); (6) other medicines that are not paid by the basic medical insurance fund as stipulated by the social insurance administrative department.
2. Reimbursement of Basic Medical Insurance Diagnostic and Treatment Programs
Basic Medical Insurance Diagnostic and Treatment Programs shall meet the following conditions: (1) Clinical diagnosis and treatment must be necessary, safe and effective, and the cost is appropriate; (2) Fees and charges have been set by the price administration department; and (3) The designated medical institutions will provide designated medical services for the insured within the scope of the designated medical services.
3. Reimbursement of basic medical service facilities
The reimbursement of basic medical insurance medical service facilities covers the living service facilities provided by the designated medical institutions, which are necessary for the participants in the process of receiving diagnosis, treatment and care, including inpatient hospitalization beds or outpatient (emergency) observation beds.
Two, medical reimbursement second reimbursement is what it means
Medicare second reimbursement is supplemental medical insurance reimbursement, six insurance in the supplemental medical insurance and and the general health insurance is not the same, because the health insurance is the social security of the insurance content, is the national welfare policy, but also is the cause of the mandatory payment of the employees, but supplemental medical insurance belongs to the non-compulsory and social security can not be reimbursed, the supplemental medical insurance can be reimbursed. The first thing to understand is that supplemental health insurance is not the same as general health insurance, supplemental health insurance is not a card, you can not use the card directly to reimbursement, and the second is the second reimbursement of supplemental health insurance is the need to go through the process of manual declaration. This means that if you want to use the secondary reimbursement, you have to keep all the payment documents when you are hospitalized, these are the vouchers for the secondary reimbursement.
The original purpose of the supplementary medical insurance is not to allow the general public to reimburse more and more expenses, but in special circumstances, the family's financial ability is limited, through the medical insurance can not solve the problem, then the secondary reimbursement can play a role. Therefore, it is not that the medical insurance can not be reimbursed with supplementary medical insurance for secondary reimbursement.
Three, medical insurance second reimbursement rate standard
According to the provisions of the current year for the first time using basic medical insurance to pay for hospitalization expenses, the amount of the starting line of the active, retired people are 1300 yuan.
For the second and subsequent hospitalization, the starting standard is set at 50 percent, at 650 yuan. The maximum payment from the Basic Medical Insurance Co-ordination Fund (for hospitalization expenses) in a year is currently 70,000 yuan.
The individual payment rate for retirees is 60 percent of the individual payment rate for active employees, but the same portion below the starting standard is paid entirely by the individual. The rate of reimbursement for hospitalization is related to the level of the medical institution where the participant is staying. Note: There are two thresholds for outpatient and hospitalization.
Medicare refers to social medical insurance. Social medical insurance is a social insurance system established by the state and society according to certain, in order to provide protection to the workers covered by the basic medical needs in case of illness. The basic medical insurance fund consists of a general fund and individual accounts. The basic medical insurance premiums paid by individual workers are all credited to their individual accounts; the basic medical insurance premiums paid by employers are divided into two parts, one of which is credited to the individual accounts, and the other is used to build up the integrated fund.
The specific medical insurance secondary reimbursement standard is based on the actual reimbursement amount in your area.
Medical reimbursement in general is the drug and hospitalization medical reimbursement, reimbursement within the scope of the classification is very detailed, many drugs in the reimbursement, have to check what the patient is sick, that is, in the scope of the indications. And hospitalization is not always directly reimbursable, there are conditions as well as limitations.
Legal Objective:Medical insurance is a kind of insurance to compensate for medical expenses caused by illness. Employees due to illness, injury, maternity, social insurance by the community or enterprises to provide the necessary medical services or material help. Such as China's public medical care and labor insurance medical care. The medical expenses of Chinese workers are borne by the state, the organization and the individual **** together, in order to reduce the burden on enterprises and avoid waste. The scope of medical insurance is very wide, and medical expenses are generally differentiated according to the characteristics of their medical services, which mainly include doctors' outpatient expenses, medicine, hospitalization, nursing care, hospital miscellaneous expenses, surgical expenses, and various examination expenses. Medical expenses are the costs incurred by the patient for treatment, which include not only the doctor's medical and surgical fees, but also the costs of hospitalization, nursing care, and hospital equipment. The reimbursement ratio and scope of medical insurance: 1. Outpatient and emergency medical expenses: the accumulated medical expenses in line with the scope of basic medical insurance within the year of the active employee (January 1~December 31) are more than 2,000 yuan or more. 2. Settlement ratio: 50% reimbursement of the part of the dispatched personnel over 2,000 yuan during the contract period, and the individual pays 50% out of his own pocket; the accumulated payment of the dispatched personnel's outpatient and emergency medical expenses in a year is 30,000 yuan. The maximum amount of reimbursement is 20,000 yuan. 3, the insured person should properly keep the outpatient medical bills (including receipts, prescription bottoms, etc.) of the outpatient treatment in the designated hospitals as the proof of the reimbursement of medical expenses. 4, the outpatient treatment of three kinds of special illnesses: the insured person who suffers from malignant tumors radiation therapy and chemotherapy, renal dialysis, and kidney transplantation after the anti-rejection drugs need to be in the outpatient medical treatment, the second or third level designated hospitals for medical treatment by the insured person, issued a "Certificate" of the outpatient medical treatment, When the participant needs outpatient medical treatment, the second or third level designated hospital will issue a "Diagnosis Certificate of Disease" and fill in the "Medical Insurance Special Disease Declaration and Approval Form", and report it to the District Medical Insurance Center for approval and filing. Outpatient medical treatment and medicine collection for these three special diseases are limited to the approved designated hospitals, and cannot be purchased at designated retail pharmacies. Medical fees incurred in accordance with the scope of outpatient special diseases will be settled with reference to hospitalization.5. For inpatient medical treatment, the medical insurance payment is sufficient for 20 years in order to be eligible for post-retirement medical insurance reimbursement. Rural Cooperative Medical Insurance Reimbursement Ratio and Scope: 1. Outpatient Reimbursement: (1) 60% reimbursement for visits to village health centers and village central health centers, with a limit of 10 yuan for prescription drug costs per visit, and a limit of 50 yuan for temporary rehydration of prescription drug costs by doctors of health centers. (2) 40% reimbursement for visits to township health centers, with a limit of RMB 50 per visit for various examinations and surgical procedures, and a limit of RMB 100 for prescription drugs. (3) 30% reimbursement for secondary hospitals, with a limit of RMB 50 for each examination and operation and RMB 200 for prescription drugs. (4) 20% reimbursement for tertiary hospital visits, with a limit of RMB 50 for each examination and operation and RMB 200 for prescription drugs per visit. (5) Chinese medicine invoice with prescription attached is limited to $1 per sticker. (6) Township cooperative medical outpatient reimbursement annual limit of 5,000 yuan. 2, hospitalization reimbursement (1) reimbursement scope: A, medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic **** vibration and other examination fees limit of 200 yuan; surgical fees (with reference to the national standard, more than 1,000 yuan reimbursement according to 1,000 yuan). B, elderly people aged 60 years old or older in the hospitalized in Xingta Township Health Center, treatment and nursing fees are reimbursed at RMB 10 per day, with a limit of RMB 200. (2) reimbursement ratio: town health center reimbursement 60%; secondary hospitals reimbursement 40%. 3, compensation for major illnesses town risk fund reimbursement: all participate in the cooperative medical treatment of hospitalized patients with a one-time or yearly cumulative reimbursable medical expenses exceeding more than 5000 yuan segmented compensation, that is, 5001-10000 yuan compensation 65%, 10001-18000 yuan compensation 70%.