Social insurance (1) (referred to as social security for short) is a social and economic system that provides income or compensation for people who are unable to work, temporarily unemployed or suffer losses due to health reasons. The main items of social insurance include old-age insurance, medical insurance, unemployment insurance, industrial injury insurance and maternity insurance, which guarantees citizens' right to get material help from the state and society in case of old age, illness, industrial injury, unemployment and maternity.
Among them, social security can reimburse basic medical expenses, work-related injury medical expenses and maternity medical expenses.
Medical expenses reimbursed by social security
(1) basic medical expenses
Taking Zhuji City (II) in Zhejiang Province as an example, employees can reimburse outpatient and inpatient medical expenses through the basic medical insurance in social security.
1。 Outpatient co-ordination fund reimbursement
In a medical insurance year, the expenses incurred by the insured in the general outpatient service of the second-level medical insurance unit within the scope of the policy, from the Qifubiaozhun to the maximum payment limit, will be reimbursed by the overall fund according to the following proportions: for those who seek medical treatment in primary medical and health institutions, the on-the-job employees will be reimbursed 75%, and the retirees will be reimbursed 80%; In other designated medical institutions or retail pharmacies in the city, 65% of employees are reimbursed and 70% of retirees are reimbursed. The qifubiaozhun for general outpatient service is 400 yuan, and the maximum payment limit is 5,000 yuan;
2。 Inpatient and special outpatient services
Medical expenses within the scope of hospitalization and outpatient policies for special diseases shall be reimbursed by the overall fund according to the following proportions: 85% of employees and 90% of retirees will be reimbursed in primary medical and health institutions if the minimum deductible is more than 50,000 yuan; In other medical institutions, employees are reimbursed 80% and retirees 85%. The part of more than 50,000 yuan to 654.38+10,000 yuan is treated in primary medical and health institutions, and 90% of the employees are reimbursed and 95% of the retirees are reimbursed; In other medical institutions, employees are reimbursed 85% and retirees are reimbursed 90%. For the part exceeding 654.38+10,000 yuan to 250,000 yuan, 90% of the employees are reimbursed and 95% of the retirees are reimbursed. For the part exceeding 250,000 yuan, 90% will be reimbursed, and there is no upper limit. ?
In addition, social security can also go to local designated pharmacies and health centers to buy medicines for reimbursement.
(2) Maternity medical expenses
Taking Foshan City as an example, according to the provisions of the Notice on Printing and Distributing the Implementation Measures of Maternity Insurance for Employees in Foshan City (III), employees can reimburse maternity medical expenses (including maternity medical expenses, family planning medical expenses and other project expenses stipulated by laws and regulations) through social security cards;
1。 Maternity medical expenses
Maternity medical expenses mainly refer to the medical expenses incurred by female workers during pregnancy and childbirth, including the expenses of prenatal examination and termination of pregnancy, and the medical expenses during childbirth and hospitalization.
① Prenatal check-up expenses
The project scope of prenatal examination includes:
Routine items: prenatal examination, blood routine, blood type, blood sugar, urine routine, liver function, renal function, hepatitis B surface antigen, syphilis serological detection, HIV screening, electrocardiogram, fetal heart monitoring, B-ultrasound;
Items for future reference: maternal aneuploidy serological screening, hepatitis C antibody determination, hemoglobin electrophoresis test, anti-D titer screening (Rh negative), thyroid function screening, vaginal discharge examination, cervical exfoliative cytology examination, cervical secretion Neisseria gonorrhoeae detection and cervical secretion Chlamydia trachomatis detection.
(2) the cost of terminating pregnancy.
Medical expenses that meet the prescribed scope when terminating pregnancy;
(3) Medical expenses for delivery hospitalization.
Expenses for delivery, operation, hospitalization, medicine, diagnosis and treatment of pregnancy complications, complications and other medical expenses within the prescribed scope.
2。 Family planning medical expenses
The medical expenses of family planning include the medical expenses incurred by workers in placing or taking out intrauterine devices, tubal ligation and recanalization, induced abortion and induction of labour.
3。 Other project expenses stipulated by laws, regulations and rules.
Maternity medical expenses enjoyed by unemployed spouses of employees shall be implemented according to the subsidy standard of maternity medical expenses of local residents' basic medical insurance.
(3) Medical expenses for work-related injuries
According to Article 30 of the Regulations on Work-related Injury Insurance (IV), employees who suffer from accidents or occupational diseases due to work shall enjoy medical treatment for work-related injuries.
Workers can reimburse medical expenses for accidental injuries and occupational diseases through industrial injury insurance. The premise of reimbursement is that accidents or occupational diseases suffered by employees should be recognized as work-related injuries.
What diseases can be reimbursed in Bao Hui?
1, dialysis of severe uremia;
2. Anti-rejection after renal transplantation;
3. Malignant tumor treatment: chemotherapy, endocrine specific therapy, radiotherapy, isotope therapy, interventional therapy and traditional Chinese medicine treatment;
4. Treat some mental diseases: schizophrenia, moderate and severe depression, mania, obsessive-compulsive disorder, mental retardation with mental disorder, epilepsy with mental disorder, paranoid psychosis;
5. College students in Shanghai suffer from hemophilia and aplastic anemia;
6. Specific major diseases: including lung cancer, head and neck cancer, gastric cancer, melanoma, esophageal cancer, liver cancer, breast cancer, prostate cancer, ovarian cancer, lymphoma, nasopharyngeal cancer, brain tumor and leukemia;
7. Rare diseases: including Fabry's disease, mucopolysaccharide storage disease and transthyroxine amyloidosis polyneuropathy.
Reimbursement ratio:
1, individual pays the proportion.
Including hospitalization expenses and specific outpatient expenses, after deducting the deductible of 6,543,800 yuan, it will be reimbursed by 95%, with a maximum reimbursement of 6,543,800 yuan per year.
2, the proportion of self-sufficiency and self-funded part of the guarantee
Medical expenses 1 can be reimbursed for hospitalization expenses outside medical insurance. 20,000-6,543,800 yuan, 50% reimbursement, and 70% reimbursement for medical expenses above 6,543,800 yuan. The deductible is RMB 654.38+10,000, and the maximum annual reimbursement is RMB 1 10,000. Participating in residents' medical insurance, if the medical expenses exceed the maximum payment limit of residents' medical insurance fund, the medical expenses will be reimbursed 10%.
3. "Prevention of disease" in TCM
If the medical expenses incurred by the insured in the "Prevention of Diseases" department of the agreed Chinese medical institution meet the requirements of the Catalogue of Special Items of Chinese Medical Diagnosis and Treatment Services, and the individual pays more than RMB 1 000 during the year, they will be reimbursed according to the prescribed standards, with the highest reimbursement for 70 yuan in a single time and 500 yuan in the whole year. Include joint dislocation, acupoint application and scapulohumeral periarthritis massage.
General outpatient expenses for children under 4.6 years old.
The medical expenses incurred by the insured under the age of 6 in the designated medical institutions agreed by the general outpatient department can be reimbursed by 55% after exceeding 800 yuan, and the maximum payment is 70 yuan at a time, and the cumulative maximum payment is 500 yuan.
5. Nursing care of patients with special diseases
For patients with specific diseases such as disability and semi-disability, the nursing expenses incurred by professional nursing institutions contracted by Bao Hui insurance can enjoy a 10% discount, and the highest discount is 500 yuan every year.
I hope the above content can help you. If in doubt, please consult a professional lawyer.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 25 The state establishes and improves the basic medical insurance system for urban residents.
The basic medical insurance for urban residents combines individual contributions with government subsidies.
People who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people and minors over 60 years old in low-income families, etc. , subsidized by the government.
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(3) The public health burden should be discussed in turn;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.
Thirty-first social insurance agencies may, according to the needs of management services, sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior.