Special needs outpatient services are not within the scope of diagnosis and treatment items paid by basic medical insurance, so special needs outpatient services are not reimbursed by the medical insurance fund.
According to the Ministry of Labor and Social Security's "Notice on Issuing Opinions on the Management of Diagnosis and Treatment Projects, Scope of Medical Service Facilities and Payment Standards of Basic Medical Insurance for Urban Employees" [Labor and Social Security Bureau (1999) No. 22], the third The article stipulates: "The Ministry of Labor and Social Security is responsible for organizing the formulation of the scope of diagnosis and treatment items for the national basic medical insurance, and uses the exclusion method to separately stipulate the scope of diagnosis and treatment items for which basic medical insurance does not cover expenses and the scope of diagnosis and treatment items for which basic medical insurance pays part of the expenses."< /p>
The attachment to the document uses the exclusion method to clarify the scope of services that are not covered by basic medical insurance: “visit fees, expedited examination and treatment fees, named surgery surcharges, high-quality and premium services” Prices, self-recruitment of special nurses and other special medical services, etc. Therefore, special outpatient expenses cannot be reimbursed by medical insurance.
Reimbursement ratio:
Theoretically, the insured person can be reimbursed up to 170,000 yuan for medical treatment, of which the enterprise supplement and the individual have to bear 72,000 yuan. For example, if an employee participates in the insurance, the accumulated outpatient medical expenses exceeding 2,000 yuan (exclusive) in a year will go into the overall fund and be reimbursed at 50%; when he spends 42,000 yuan, the mutual aid fund can reimburse him. 20,000 yuan. Four reimbursement levels:
1. 80% reimbursement for 1,300 yuan to 10,000 yuan; 2. 85% reimbursement for 10,000 yuan to 30,000 yuan (inclusive);
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3. 90% reimbursement for RMB 30,000 to RMB 40,000 (inclusive); 4. 95% reimbursement for RMB 30,000 to RMB 40,000 (inclusive); When the cap is 58,000 yuan, the total *** can be reimbursed 50,000 yuan. The portion above the cap line will be reimbursed at 70%. In addition, in addition to mutual aid funds for large medical expenses, companies also have supplementary medical insurance, and employees can also reimburse a certain percentage.
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Extended information:
1. Scope of medical treatment items that are not covered by basic medical insurance
(1) Service items
1. Registration fee, out-of-hospital consultation fee, medical record cost, etc.;
2. Clinic fee, expedited examination and treatment fee (except emergency), Surcharges for roll-call surgeries, high-quality and low-price fees, self-recruitment special nurse fees and other special medical services.
(2) Non-disease treatment items
1. Various beauty (life beauty, medical beauty) and bodybuilding projects as well as non-functional plastic surgery, orthopedic surgery, etc.;
2. Various weight loss, fattening, and height-increasing programs;
3. Various health examinations;
4. Various preventive and health-care diagnosis and treatment programs; < /p>
5. Registration fee, out-of-hospital consultation fee, medical record cost, etc.;
6. Clinic fee, expedited examination and treatment fee (except emergency), roll call surgery surcharge, high quality and low price Fees, self-recruitment of special nurse fees and other special medical services.
(2) Non-disease treatment items
1. Various beauty (life beauty, medical beauty) and bodybuilding projects as well as non-functional plastic surgery, orthopedic surgery, etc.;
2. Various weight loss, fattening, and height-increasing programs;
3. Various health examinations;
4. Various preventive and health-care diagnosis and treatment programs; < /p>
5. Orthodontics, dental porcelain;
6. Various medical consultations (excluding psychiatric consultations) and medical appraisals.
(3) Diagnostic and treatment equipment and medical materials
1. Use large-scale medical equipment such as positron emission tomography scanning equipment, electron beam CT, ophthalmic excimer laser therapy equipment for examination and treatment Projects;
2. Rehabilitation equipment such as glasses, dentures, eyes, prostheses, and hearing aids;
3. Various self-use health care, massage, examination, rehabilitation and treatment equipment.
(4) Treatment Items
1. Organ sources or tissue sources for various organ transplants or tissue transplants;
2. Except for kidneys and heart valves , cornea, skin, blood vessels, bones, bone marrow transplants and other organ or tissue transplants;
3. Orthopedics for myopia;
4. Qigong therapy, music therapy, health care Nutritional therapy, magnetic therapy and other auxiliary treatment projects.
(5) Others
1. Various diagnosis and treatment items for infertility (pregnancy) and sexual dysfunction;
2. Various scientific research, Clinically verified diagnosis and treatment items;
2. Scope of diagnosis and treatment items for which basic medical insurance pays part of the cost
(1) Diagnostic and treatment equipment and medical materials
1 , applied X-ray computed tomography device (CT), stereotactic radiation device (γ-knife, χ-knife), cardiac and angiography X-ray machine (including digital subtraction equipment), magnetic resonance imaging device (MEI), single photon emission electron scanning equipment (SPECT), color Doppler, medical linear accelerator and other large medical equipment for examination and treatment projects;
2. Extracorporeal shock wave lithotripsy and high pressure Oxygen therapy;
3. Pacemakers, artificial joints, intraocular lenses, artificial organs for internal replacement of vascular stents, and materials placed inside the body;
4. Regulations prescribed by the provincial price department Disposable medical materials available for separate charge.
(2) Treatment items
1. Hemodialysis, peritoneal dialysis;
2. Kidneys, heart valves, cornea, skin, blood vessels, bones, Bone marrow transplantation;
3. Heart laser drilling, anti-tumor cell immunotherapy and fast neutron therapy projects.
3. Various personal health care, massage, examination, rehabilitation and treatment equipment.
(3) Treatment items
1. Organ sources or tissue sources for various organ transplants or tissue transplants;
2. Except for kidneys and heart valves , cornea, skin, blood vessels, bones, bone marrow transplants and other organ or tissue transplants;
3. Orthopedics for myopia;
4. Qigong therapy, music therapy, health care Nutritional therapy, magnetic therapy and other auxiliary treatment projects.
(4) Others
1. Diagnosis and treatment items for various infertility (pregnancy) diseases and sexual dysfunction;
2. Various scientific research, Clinically verified diagnosis and treatment projects;