1, the scope of reimbursement: Shanghai health insurance outpatient reimbursement includes drugs, medical services, diagnostic and therapeutic equipment and other medical expenses, but does not include self-payment of medicines and high-grade medical services;
2, the reimbursement rate: Shanghai health insurance outpatient reimbursement rate of 60%, that is, 60% of the medical costs can be reimbursed, the remaining 40% of the medical expenses will be reimbursed, and the remaining 40% will be paid by the individual;
3. Reimbursement ceiling: Shanghai's outpatient reimbursement has a reimbursement ceiling, i.e., the annual outpatient reimbursement reaches a certain amount, and then the exceeding part of the outpatient reimbursement will be no longer enjoyable. The specific ceiling standard can be consulted in the local health insurance organization;
4, reimbursement restrictions: Shanghai health insurance outpatient reimbursement there are some reimbursement restrictions, for example, for certain medicines or medical services need to meet certain conditions in order to enjoy the reimbursement. Specific limitations can be in the local health insurance agency for consultation;
5, reimbursement process: Shanghai health insurance outpatient reimbursement process generally includes consultation, settlement, reimbursement of three steps. The specific process can be consulted in the local health insurance institutions.
Shanghai medical insurance outpatient reimbursement need to pay attention to:
1, the patient must be ready to residents of the medical insurance card, otherwise it can not apply for reimbursement;
2, the charge clerk may adjust the reimbursement standard according to the patient's condition, the patient should carefully check the charge sheet, so as not to incur additional costs;
3, in the pick up of the medicine, the patient needs to check the validity date of the medicine and the manufacturer and other information;
3, the patient needs to check the drug
4. According to the regulations, each resident can be reimbursed up to 15,000 yuan per year, and can apply for full reimbursement for the exceeding portion;
5. The reimbursement period is one year, and patients need to be careful not to overstay the period before applying for reimbursement.
Shanghai medical insurance outpatient reimbursement conditions include:
1, participate in the insurance and normal contributions, and the treatment review period expired (in the capacity of the unit to participate in the insurance contributions for 30 days, in the individual's capacity to participate in the insurance contributions for six months);
2, the type of disease in line with the "basic medical insurance inpatient disease catalog";
3. The reimbursement documents are well prepared. These include the identity card, social security card or medical insurance card, special receipt for outpatient medical expenses, special receipt for emergency medical expenses, relevant medical history and copies, "Outpatient and Emergency Medical Record Book" or "Settlement List of Inpatient Medical Expenses";
4. In the case of an emergency patient, it is necessary to provide information such as the first diagnosis record of the emergency clinic, emergency diagnostic certificates, outpatient medical records, and examination reports.
In summary, different types of health insurance and different cities may vary, the specific reimbursement conditions and processes can be consulted with the local social security department or relevant organizations.
Legal basis:
Article 28 of the Social Insurance Law of the People's Republic of China
Medical expenses that are in line with the basic medical insurance drug catalog, diagnostic and treatment items, and standards of medical service facilities, as well as those for emergency and rescue, shall be paid out of the basic medical insurance fund in accordance with state regulations.
Article 30
The following medical expenses shall not be included in the scope of payment by the basic medical insurance fund:
(1) those that should be paid from the Workers' Compensation Insurance Fund;
(2) those that should be borne by a third person;
(3) those that should be borne by the public ****health; and
(4) those that are sought outside the country. If the medical expenses should be borne by a third person according to law, and the third person does not pay or the third person cannot be identified, the basic medical insurance fund will pay first. The basic medical insurance fund shall have the right to recover from the third party after the first payment.