Shanghai Medical Insurance Guide
Reimbursement Ratio
Participants Outpatient Emergency
Participants Outpatient Emergency (including family hospital beds) incurred in the medical expenses set a starting standard, within a year, the accumulated medical expenses exceeding the starting standard part of the medical expenses, by the urban and rural residents of the medical insurance fund in accordance with a certain percentage of the remaining portion of the individual's responsibility.
The starting standard is:
300 yuan for people aged 60 and above, people with severe disabilities, and primary and secondary school students, infants and young children;
500 yuan for people who are over 18 years old and under 60 years old.
The urban and rural residents' health insurance fund pays 70% for outpatient emergency treatment at community health centers (or first-level medical institutions), 60% for outpatient emergency treatment at second-level medical institutions, and 50% for outpatient emergency treatment at third-level medical institutions.
The medical expenses incurred by the insured in outpatient clinics of village health centers are not counted as the starting standard, and will be paid 80% by the urban and rural residents' medical insurance fund.
Hospitalization of insured persons
The starting payment standard is set for the medical expenses incurred for each hospitalization of an insured person (including hospital observation in the emergency observation room). The portion exceeding the threshold will be paid by the Urban and Rural Residents' Medical Insurance Fund in accordance with a certain percentage, and the remaining portion will be borne by the individual.
The starting standard is:
50 yuan for first-level medical institutions, 100 yuan for second-level medical institutions, and 300 yuan for third-level medical institutions.
The urban and rural residents' medical insurance fund pays:
People aged 60 years and above, as well as those with severe disabilities, pay 90% of their hospitalization in community health service centers (or first-level medical institutions), 80% in second-level medical institutions, and 70% in third-level medical institutions;
People under the age of 60 years old pay 90% of their hospitalization in community health service centers (or first-level medical institutions). (or first-level medical institutions), 80% will be paid for hospitalization in second-level medical institutions, 75% will be paid for hospitalization in third-level medical institutions, and 60% will be paid for hospitalization in third-level medical institutions.
Reimbursement Scope
1 Active Employees
Active employees pay 2% of their monthly salary (11% for organizations) for health insurance. When visiting an outpatient or emergency clinic, they need to use up the amount credited to their health insurance for the year first, and then enter the deductible section after using up the amount, which is 1,500 yuan.
Hospitalization of active employees
If hospitalization is required, most of the medical expenses can be covered by medical insurance as long as medical insurance is paid.
First of all, they will be responsible for the 1,500 yuan starting line cost, and the cost exceeding the starting line can be reimbursed by the medical insurance on a proportional basis. If it exceeds the maximum payment limit, it can also be paid proportionally by the additional fund.
2Retirees
3Non-active retirees
4Undergraduates
More detailed information: 2016 Shanghai's latest health insurance policy Shanghai medical insurance reimbursement standards and scope of the complete list of
Not reimbursed:
According to the Social Insurance Law, the following medical costs are not included in the urban and rural residents' medical insurance fund Payment scope:
(i) Those that should be paid from the Workers' Compensation Insurance Fund;
(ii) Those that should be borne by a third party;
(iii) Those that should be borne by public **** health;
(iv) Those who seek medical treatment outside the country.
Medical expenses shall be borne by a third party in accordance with the law, and if the third party fails to pay or if the third party cannot be identified, the urban and rural residents' medical insurance fund shall pay in advance. The urban and rural residents' medical insurance fund shall have the right to recover the medical expenses from the third party after paying them first.
Conditions for reimbursement
1, insurance and normal contributions (refers to the state of insurance and contributions until the time of discharge) and the treatment review period (as a unit of insurance and contributions for 30 days, as an individual insurance and contributions for 6 months)
2, the disease type in line with the "basic medical insurance inpatient disease catalog.
3. Complete information
Reimbursement materials
Reimbursement of outpatient and emergency medical expenses
To apply for reimbursement of outpatient and emergency medical expenses, the insured person should bring along his/her valid ID card (ID card, household registration book, etc.), Social Security Card or Medical Insurance Card, special receipt for outpatient medical expenses, special receipt for emergency medical expenses, relevant medical history and copies, and the "Outpatient and Emergency Record Book" emergency page and copies. Emergency Medical Attendance Record Book" with a copy of the attached page (medical expenses incurred at local designated medical institutions for those whose medical relationship is with the city). If the Medical Insurance Card is reported damaged, the "Notice of Damage to Medical Insurance Card" is also required.
Reimbursement of Hospital Observation Expenses
To apply for reimbursement of hospitalization and emergency room observation expenses, the insured person should provide a special receipt for medical expenses, a list of medical expenses incurred during hospitalization (list of medical expenses incurred during hospitalization in the emergency room) and a copy of the same, and a copy of the discharge (observation) summary.
Sporadic reimbursement of outpatient medical expenses for serious illnesses
To apply for sporadic reimbursement of outpatient medical expenses for serious illnesses, the insured person should provide a special receipt for outpatient medical expenses, a copy of the certificate of diagnosis of the disease, and a copy of the relevant examination report.
Appointing others to make reimbursement
Participants can appoint others to make reimbursement on their behalf. The delegated person should bring along the valid documents (ID card, household register, etc.) of the participant and himself/herself.
Reimbursement Location
Pudong New District Medical Insurance Center
Address: No. 3059, Zhangyang Road, Pudong New District
Tel: (021)50353961
Minhang District Medical Insurance Center
Address: No. 530-546, Shuiching Road, Minhang District (near Baochun ...
Tel: (021)54135063
Changning Medical Insurance Center
Address: No. 702, Wuyi Road, Changning District
Tel: 021-52065400
Xuhui District Medical Insurance Affairs Center
Address: No. 999, Nanning Rd.
Medical Insurance Branch Center of Shanghai Pudong District Affairs Sub-center
Address: No.168 Hongshan Road, Pudong New Area (near South Pudong Road)
Tel:021-50567061
Tel:021-64164870
Shanghai Huangpu District Medical Insurance Affairs Center
Address: 1/F, Hualong Mansion, No. 343, Nanshou Road, Huangpu District (near Sichuan Middle Road)
Tel:021-63215132
Putuo District Medical Insurance Affairs Center
Address:No.1711, Daduhe Road
Tel:021-52804754
Hongkou District Medical Insurance Affairs Center-
Address:No.352-356, Chifeng Road
Tel:021-52804754
Hongkou District Medical Insurance Affairs Center -
Address:No.352-356, Chifeng Road
Yangpu District Medical Insurance Affairs Center
Address: No.1118 Lanzhou Road, Yangpu District
Tel:021-65890960
Shanghai Medical Insurance Center
Address: No.805-807, Kangding Road
Tel:021-62554838
Tel. 62554838
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