One is the emergency medical expenses of the insured with Shanghai medical relationship in medical institutions in other provinces and cities, the medical expenses incurred in pre-hospital emergency in Shanghai, and the emergency medical expenses during the loss of medical insurance card or social security card;
The second category is the outpatient and emergency medical expenses incurred by the insured in his place of residence in other provinces and cities, the hospitalization expenses in the emergency observation room and the hospitalization expenses.
After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, and the reimbursement rate is 50%. For retirees under 70 years old, expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed.
No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 700 yuan can reimburse 50%, that is, 350 yuan.
First, in line with the basic medical insurance drug list, diagnosis and treatment matters, medical service facilities guide and emergency, rescue medical expenses, in accordance with national restrictions from the basic medical insurance fund to pay.
The specific emergency expenses that can be reimbursed include three types:
1, emergency medical expenses incurred by the insured who died after being rescued in a designated hospital in this city;
2, the insured in the city designated hospital emergency rescue treatment, after diagnosis, need to be transferred for further treatment, emergency medical expenses;
3, the insured in the city's designated hospitals for emergency treatment, due to the limited medical requirements of designated hospitals, patients transferred to other designated hospitals, emergency medical expenses.
4, the insured emergency medical expenses, which belong to the scope of the medical insurance reimbursement catalogue, Qifubiaozhun above and below the maximum payment limit, medical insurance reimbursement 70%, individual pays 30%.
5. Emergency expenses incurred during the period when the unit owes medical insurance premiums can be reimbursed after the unit makes up the arrears, and the time to stop accepting emergency expenses in that year is the end of March of the following year.
Two, emergency medical insurance reimbursement insured due to visit relatives or travel in different places, should choose the local qualified medical insurance designated public hospitals for hospitalization, and solve the application within 3 working days; Insured persons should register in real-name registration system for medical treatment in different places, and their ID card information should be filed in inpatient departments of different hospitals; Hospitalization in different places shall not exceed 30 days. Emergency hospitalization, transfer to Dalian for follow-up treatment after the condition is stable. If the patient is at high risk, can't be discharged from hospital or needs to be transferred on the spot, the second application should be solved in time, and the hospitalization summary and doctor's advice should be provided when applying.
Three or five cases of first aid expenses are reimbursed separately.
1. Emergency treatment and hospitalization are in the same hospital: employees' medical insurance and residents' medical insurance insured persons are transferred to the hospital for further treatment due to critical, acute and serious diseases in the same designated medical insurance hospital, and the emergency expenses can be merged into the hospitalization expenses and settled in real time through the information network.
2. Emergency treatment and hospitalization are in the same non-designated hospital: if emergency treatment and hospitalization are carried out in the same non-medical insurance designated hospital, the emergency outpatient expenses of employees' medical insurance will not be reimbursed. In terms of residents' medical insurance, if the emergency and hospitalization are confirmed as the same disease by the county (city, district) urban medical insurance center at the time of reimbursement, the emergency outpatient expenses can be measured together with the hospitalization expenses, and the medical insurance reimbursement is 50%, and the individual pays 50%.
3. Only the emergency department was not hospitalized for further treatment: if the insured person did not transfer to the emergency department for further treatment, neither the employee medical insurance nor the resident medical insurance would reimburse the expenses of the emergency department.
4. Transfer to other hospitals for hospitalization after emergency: If the insured person is transferred to other hospitals for further hospitalization after emergency, the employee's medical insurance will be reimbursed at the designated hospital where emergency expenses occur, with 70% of medical insurance reimbursement and 30% of the individual paying.
In this case, residents' medical insurance will not be reimbursed.
5. Death after emergency: If the insured person dies in the emergency clinic of a designated medical insurance hospital due to critical, acute or serious illness, the employee shall be reimbursed for medical insurance in the designated hospital where the emergency expenses occur, with 70% of medical insurance reimbursement and 30% paid by the individual; Residents' medical insurance emergency outpatient expenses, after the county (city, district) urban medical insurance center audit confirmation, medical insurance reimbursement 50%, 50% of the individual pays.
Legal basis: Article 28 of the Social Insurance Law of People's Republic of China (PRC) conforms to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue medical expenses, and shall be paid from the basic medical insurance in accordance with state regulations.