Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for financial losses caused by the risk of illness.
The medical insurance fund is established through the contributions of employers and individuals, and the medical insurance organization will give certain financial compensation to the insured after they have incurred medical expenses in the event of illness.
The establishment and implementation of the basic medical insurance system gathers the economic strength of the units and members of society, and together with the government's subsidies, it enables sick members of society to obtain the necessary material assistance from society, reduces the burden of medical expenses, and prevents sick members of society from "becoming poor because of illness".
Reimbursement conditions
Article 28 of the Social Insurance Law stipulates that medical expenses that are in line with the basic medical insurance drug list, diagnostic and therapeutic items, standards of medical services and facilities, as well as those for emergencies and resuscitations, shall be paid out of the basic medical insurance fund in accordance with state regulations.
According to the basic requirements for the payment of basic medical insurance benefits in China, the reimbursement of medical expenses incurred by the insured person to the medical insurance organization for his/her own visit to the doctor generally has to comply with the following conditions:
(1) The insured person must go to the designated medical institutions for the purchase of medicines of the basic medical insurance or go to the designated retail pharmacies determined by the social insurance organization with the medicine prescription issued by the doctor of the designated hospital. The purchase of medicines.
(2) Medical expenses incurred by insured persons in the course of seeking medical treatment must be in accordance with the scope and payment standards of the basic medical insurance drug catalog, diagnostic and therapeutic items, and standards of medical service facilities, in order to be paid by the basic medical insurance fund in accordance with the regulations.
(3) The portion of medical expenses incurred by a participant in accordance with the scope of payment of basic medical insurance that are above the starting standard and below the maximum payment limit of the social medical insurance fund shall be paid by the social medical insurance fund in a uniform proportion.
Reimbursement Ratio
1. Outpatient and Emergency Medical Expenses: the portion of the medical expenses that meet the scope of the basic medical insurance that exceeds 2,000 yuan in total during the year (January 1~December 31) of an active employee.
2. Settlement ratio: 50% reimbursement for the part of over 2,000 yuan for dispatched staff during the contract period, and 50% out-of-pocket payment by individuals; the maximum amount of outpatient and emergency reimbursement paid to dispatched staff is 20,000 yuan cumulatively in a year.
3. The insured personnel should keep the outpatient medical bills (including receipts and prescription bottoms, etc. for the part of the outpatient medical bills below the large amount) of the designated hospitals as the vouchers for reimbursement of medical expenses.
4, three kinds of special disease outpatient medical treatment: participants suffering from malignant tumors radiation therapy and chemotherapy, kidney dialysis, renal transplantation to take anti-rejection drugs need to be in outpatient medical treatment, by the participant's second and third-class hospitals for medical treatment of the designated hospitals to issue a "diagnosis of the disease certificate" and fill out the "medical insurance special disease declaration and approval form", reported to the regional medical insurance center for approval and filing. The medical insurance center of the district for approval and filing.
The outpatient medical treatment for these three special diseases and the collection of medicines are limited to the approved designated hospitals, and cannot be purchased at designated retail pharmacies. If the medical fees incurred are within the scope of outpatient special diseases, they will be settled with reference to hospitalization.
5. Inpatient medical care.
Medicare payment is enough for 20 years in order to enjoy the medical insurance reimbursement after retirement.
The range of reimbursement rates for medical insurance varies from place to place, so please refer to the local policy.