Medicare reimbursement is capped, except that the caps vary slightly from place to place, but they are generally the same.
What is the upper limit of medical insurance reimbursement:
1, outpatient
Village health clinics and village center health clinics are reimbursed 60% of the cost of prescription drugs per visit, with a limit of 10 yuan, and a limit of 50 yuan of the cost of temporary rehydration of the doctor's prescriptions in the hospitals; town health centers are reimbursed 40%, with a limit of 50 yuan of the cost of various tests and surgeries per visit, and a limit of 100 yuan of the cost of prescription drugs; 30% reimbursement for secondary hospital visits, with a limit of RMB 50 for each visit for each examination and operation and RMB 200 for prescription drugs; 20% reimbursement for tertiary hospital visits, with a limit of RMB 50 for each visit for each examination and operation and RMB 200 for prescription drugs; a limit of RMB 1 for each sticker of prescription attached to the Chinese herbal medicine invoice; and a limit of RMB 5,000 per annum for outpatient reimbursement for township-level cooperative medical care.
2. Hospitalization
Reimbursement scope: medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, MR*** vibration and other examination fees are limited to 200 yuan; surgical fees (with reference to the national standard, more than 1,000 yuan are reimbursed according to 1,000 yuan). 60 years of age or older hospitalized in a health center, the treatment and nursing care fees are reimbursed 10 yuan per day, limited to 200 yuan. 10 yuan, with a limit of 200 yuan.
Reimbursement rates: town health centers reimburse 60%; secondary hospitals reimburse 40%; tertiary hospitals reimburse 30%.
3. Major Diseases
Any hospitalized patient who participates in cooperative medical care will be reimbursed for the one-time or yearly cumulative reportable medical expenses of more than 5,000 yuan, i.e., 65% of 5,001-10,000 yuan, and 70% of 10,001-18,000 yuan. The annual limit of compensation for town-level cooperative medical care inpatient and outpatient blood dialysis for uremia, outpatient radiotherapy and chemotherapy for tumors is 11,000 yuan.
4. Exemption
Self-medical treatment (without designated hospitals for medical treatment or without referral orders), self-purchased medicines, medicines that cannot be reimbursed by the public medical care regulations, and medical expenses not in accordance with the family planning; outpatient treatment fees, consultation fees, hospitalization fees, meals, companion fees, nutritional fees, blood transfusion fees (except for those who have blood stored in their families, which are reimbursed in accordance with the relevant regulations), air-conditioning and heating costs, ambulance fees, special other expenses such as nursing fees; medical expenses for car accidents, fights, suicides, alcoholism, work accidents and medical accidents; orthopedics, plastic surgery, dentures, prosthetics, organ transplants, named surgery fees, consultation fees, etc.; reimbursement is within the scope of reimbursement, and the portion outside the limit.
Legal Objective:With the gradual establishment of the basic social medical insurance system in the city, the employees of enterprises and institutions are also faced with new medical insurance needs. Supplementary medical insurance has become an inevitable product of social development, by the social medical insurance management organization to run voluntary enrollment in supplementary medical insurance as a supplement to the basic medical insurance, in addition to having unique advantages, but also in line with the majority of employees and units of the desire. The following are the relevant provisions on reimbursement of supplementary medical insurance: Article 6: The scope and content of reimbursement of supplementary medical insurance are identical to the provisions of the basic medical insurance of Beijing Municipality. The medical expenditures of the insured shall be in accordance with the drug catalog, diagnosis and treatment catalog and service item catalog of the basic medical insurance stipulated by the city. The supplementary medical insurance shall not reimburse the out-of-pocket expenses or the part of out-of-pocket expenses stipulated by the basic medical insurance. Article 7: After the participants' outpatient (emergency) and hospitalization medical expenses are reimbursed by the basic medical insurance and/or the Large Medical Mutual Aid Fund, they shall be reimbursed by the supplementary medical insurance according to the reimbursement ratio, deductibles, limits and other standards of the supplemental medical insurance program agreed upon in the contract with the employer. Article 8 According to the contract with the employer, the maternity expenses (including general hospitalization fee, examination fee, operation fee, delivery fee, medicine fee, etc., except for self-paid medicine and self-paid items) of female employees in compliance with the relevant family planning regulations of the state and the government shall be reimbursed in accordance with the Beijing Maternity Insurance and other relevant regulations, and the total reimbursement limit of the Maternity Insurance and the Supplementary Medical Insurance shall be RMB 8000 Yuan (if there is another agreement in the contract, the reimbursement limit shall be handled according to the agreement). The total reimbursement limit of maternity insurance and supplementary medical insurance is 8000 RMB (if the contract has agreed on other reimbursement limit, it shall be handled according to the agreement). According to the contractual agreement with the employer, if the insured person has an only child (including twins or multiple births) under the age of 18 (including twins or multiple births) who complies with the national family planning regulations and has Chinese nationality, the medical expenses shall be reimbursed at a rate of 50%, and the reimbursement items and upper limit shall be carried out according to the contractual agreement. For children who need to seek medical treatment in hospitals above the second level or in public children's hospitals, and who are enrolled in the Beijing Students' and Children's Major Diseases Medical Insurance, the hospitalization medical expenses will be reimbursed by the supplementary medical care after the settlement of the Beijing Students' and Children's Major Diseases Medical Insurance. The reimbursement for children is based on the provisions of the Basic Medical Insurance Regulations, the Regulations on the Administration of Publicly-funded Medical Care in Beijing, the Provisions of the Beijing Municipal Medical Insurance for Students and Children with Major Diseases, and the CIIC Children's Drug Catalog and other policies and documents. Children's medical treatment shall comply with the principle of one place per year (based on the place where the child's first reimbursement of medical treatment is made in a natural year). Article 11 According to the contractual agreement with the employer, if the participant and his/her children choose the health return benefit, if they do not have medical expenses (including maternity and family planning expenses) within one supplementary medical year, they can apply to CIIC Employee Health Service Center within three months after the end of the supplementary medical year, and those who meet the requirements after examination and approval will be able to receive the health encouragement fee. Article 12 The Supplementary Medical Insurance shall not pay for the medical expenses incurred in the following cases: (a) out-of-pocket medicines, purchased medicines other than those required by the basic medical insurance; (b) expenses for medicines not in accordance with the diagnosis; (c) all the medical expenses for outpatient and inpatient hospitalization in a medical institution that is not the designated medical institution of CIIC; (d) medical expenses not in accordance with or in excess of the reimbursement scope and standard of the basic medical insurance; (e) all the medical expenses arising from traffic accidents, medical accidents and other liability accidents; (f) all the medical expenses incurred in a medical accident, traffic accident, medical accident and other liabilities. (e) all medical expenses caused by traffic accidents, medical accidents and other kinds of accidents; (f) all medical expenses caused by drug abuse, fighting and other illegal behaviors; (g) all medical expenses caused by suicide, self-injury, alcoholism, etc.; (h) all medical expenses incurred outside of the country (including Taiwan, Hong Kong and Macao); (i) all medical expenses incurred by the outpatient clinics and hospitalization in the wards of special needs; (j) all medical expenses incurred by the clinics for infertility and all medical expenses incurred by preconception examinations; (k) all medical expenses incurred by the clinics for infertility; and (l) all medical expenses incurred by the hospitals for pre-conception examination and treatment; and (m) all medical expenses incurred by the clinics for infertility. (j) All medical expenses for infertility treatment, pre-pregnancy examination, and preventive medicine; (k) Medical expenses that should be paid by individuals in accordance with national and municipal regulations. Article 13: The supplementary medical insurance shall implement the principle of first payment for basic medical treatment. Within a natural year, the medical expenses incurred by the insured person due to illness that exceed the starting standard of basic medical insurance for outpatient (emergency) consultation or hospitalization shall be reimbursed by the basic medical insurance first. With the split bill issued by the medical insurance center and a copy of the original bill or the split medical expense bill, detailed list, original diagnosis certificate and other related materials issued by the hospital, the supplementary medical insurance shall reimburse the medical expenses that belong to the scope of the basic medical insurance and are paid by the employee individually on a proportional basis. The settlement year is synchronized with the basic medical insurance (by natural year). Article 14: If the outpatient (emergency) medical expenses of the insured do not exceed the starting standard of the basic medical insurance at the end of the year, they shall be reimbursed by the supplementary medical insurance from the end of the year to the first quarter of the following year with the original medical bills, the bottom prescription of the special medical insurance, the outpatient medical records, the detailed list of expenses and other original materials; if the medical expenses are incurred in the same year after the reimbursement of the supplementary medical insurance, the part of the expenses that exceeds the starting standard, the supplementary medical insurance shall not reimburse them any more. The supplementary medical insurance shall not reimburse any more. Article 15 The insured person shall apply for reimbursement of hospitalized medical expenses at CIIC within one month after discharge from the hospital. Female employees shall go to CIIC for reimbursement of maternity expenses within three months after giving birth in accordance with national family planning regulations. Employee's children's medical expenses can be reimbursed at any time during the year. Article 16 Participants are required to provide relevant reimbursement materials in accordance with the provisions of basic medical insurance. If the reimbursement materials do not comply with the basic medical regulations, the supplementary medical insurance will not pay. Article 17 The reimbursement of medication shall be in accordance with the medication dosage stipulated by the basic medical insurance: the dosage of medication for acute diseases shall not exceed three days, the dosage of medication for chronic diseases shall not exceed seven days, and the topical medication shall be prescribed in three sticks or three boxes. If the quantity of medicine exceeds the prescribed quantity, the excess shall be paid by the insured person. The prescribed medicines should be consistent with the illnesses treated, and all the medical fees will not be reimbursed if any inconsistency is found. Article 18 Participants working abroad and participating in the local basic medical insurance shall first be reimbursed by the local basic medical insurance for outpatient (emergency) and hospitalization expenses, and then submit the materials to CIIC for supplemental medical reimbursement procedures after completion of the process; if the local basic medical insurance does not reimburse the outpatient and emergency expenses, it can be submitted to CIIC at any time for supplemental medical reimbursement procedures.