What is the scope of medical insurance reimbursement in Shenzhen?
Medical insurance reimbursement is the medical insurance checkout window to the local medical insurance management center or designated medical institutions. Shenzhen Medical Insurance has a series of relevant regulations on medical insurance reimbursement, and there are different regulations on the scope of reimbursement to municipal social security institutions and medical institutions, such as reimbursement conditions and materials needed for reimbursement. The specific provisions are as follows:
Article 78 [Reimbursement Scope of Municipal Social Security Institutions]
The medical expenses incurred by the insured for medical treatment, in any of the following circumstances, shall be paid in cash first, and then an application shall be submitted to the municipal social insurance institution with relevant documents and materials, and the municipal social insurance institution shall review and reimburse according to the regulations:
(a) comprehensive medical insurance, hospitalization insurance insured in other cities in China emergency or approved referral to other cities in China hospitalization expenses;
(2) The medical expenses incurred by the insured in the medical institution for filing in other cities in China for a long time or living in other cities in China after retirement;
(3) Medical expenses incurred by the insured in outpatient dialysis of chronic renal failure, outpatient use of anti-rejection drugs after organ transplantation, outpatient chemotherapy of malignant tumor, interventional therapy, radiotherapy or radionuclide therapy in designated medical institutions;
(four) medical expenses incurred by the insured for migrant workers' medical insurance in the emergency department of non-settlement hospitals due to going out or going on business trips;
(five) with the consent of the hospital, the expenses incurred by the insured in the catalogue of medical treatment projects outside the hospital;
(six) maternity medical expenses that meet the requirements in other cities in China.
Article 80 [Scope of reimbursement for medical treatment by medical institutions]
Under any of the following circumstances, the medical expenses incurred by the insured person in the hospitalization of comprehensive medical insurance or the medical expenses incurred by the insured person in the outpatient service may be paid in cash first, and the relevant documents and materials shall be submitted to the medical institution at the place of medical treatment for review and reimbursement according to the regulations:
(a) the designated medical institution for medical treatment has a computer failure or is unable to keep accounts due to the damage of the social security card;
(two) with the consent of the hospital, the prescription drugs within the scope of the basic medical insurance catalogue are purchased outside the hospital;
Article 8 1 [Payment Term and Required Information]
The insured shall submit the following materials for reimbursement within 0/2 months from the date of medical expenses (hospitalization from the date of discharge):
Transfer-out hospital referral certificate, copy of outpatient or inpatient medical records with hospital seal, disease diagnosis certificate (outpatient), discharge diagnosis certificate or discharge summary (hospitalization), detailed list of expenses, original expense receipt, employer's certificate and social security card.
The specific information required for reimbursement of hospitalization expenses is as follows:
(1) outpatient medical records (original and copy); (2) Hospital medical records stamped with the official seal of the hospital (including admission records, doctor's orders, operation records, discharge records and related inspection reports) (copies);
(3) A valid invoice (check the original and receive a copy); (4) Detailed list of expenses (copy received); (5) disease diagnosis certificate (original); (6) unit certificate (on-the-job employee) (original);
(7) My medical card (check the original and receive a copy); (8) My bankbook in this city (limited to the four major state-owned banks) (check the original and receive a copy).
Have all the money in the medical insurance been used up?
If you don't run out, medical insurance will help you pay 80%, but the medicine you want to prescribe is within the scope of medical insurance.
When it is used up, it will be transferred to local supplementary medical insurance, that is, 75% of 80%.
If you have used up all the supplements, you can only collect them all (make a list) and report them uniformly in July of the following year. These will be reported as% of the average salary of the previous year, but you can leave it out. You can ask the Social Security Bureau yourself. They are very nice.
According to national regulations: "Medical insurance, also known as health insurance, is a life insurance in which the insurer is responsible for the expenses incurred by the insured due to accidental injury or illness. In China, this kind of insurance is in its infancy. At present, it is mainly handled as an additional risk of the main insurance, such as an additional risk in personal accident insurance. Because whether it is group life insurance (insurance liability includes illness or accident) or group personal accident insurance (insurance liability only includes accident), the insurer only pays death insurance or disability insurance, and does not bear the resulting medical expenses. Therefore, in order to obtain more adequate insurance protection, it is necessary to apply for medical insurance. Medical insurance is responsible for the expenses incurred by the insured due to accidents within the scope of personal accident insurance's responsibility during the insurance period, but the deductible for each accident is 5 yuan. The total medical expenses accumulated during the insurance period shall not exceed the insured amount. If it is additional medical insurance in personal accident insurance, its exclusion liability includes medical treatment and medical expenses incurred by the insured due to illness; Drug expenses that should be purchased at one's own expense according to the provisions of public medical care; The cost of assembling artificial eyes, dentures, artificial limbs, etc. The insured must provide proof of accidental injury accident, diagnosis certificate of hospitals at or above the county level (including the county level) and receipt of medical treatment and medical expenses when claiming compensation. "
Does not belong to medical insurance coverage:
1. The medical expenses incurred by female employees participating in the social pooling of industrial injury and maternity insurance due to work-related (public) injuries, occupational diseases and maternity shall be paid from the industrial injury and maternity pooling fund respectively; Did not participate in the overall planning, by the employer according to the original provisions of the original funding channels to solve; (two) the basic medical insurance shall not pay the medical expenses incurred by the insured during his going abroad or going to Hongkong, Macao and Taiwan Province Province; (3) Medical expenses arising from traffic accidents, medical accidents and drug accidents shall be handled in accordance with relevant state regulations; (four) medical expenses incurred due to illegal crimes, alcoholism, fighting, suicide, self-mutilation, etc., shall be borne by myself; (five) other medical expenses that are not covered by the basic medical insurance as stipulated by the state and the province.
Medical insurance is not paid and personal diagnosis and treatment projects are roughly divided into fourteen categories:
1, non-medical diagnosis and treatment project;
2, a variety of teaching, scientific research and clinical verification of diagnosis and treatment projects;
3, belongs to the special medical service diagnosis and treatment project;
4, all kinds of organ or tissue transplantation, the cost of purchasing organ or tissue source (except skin transplantation of burn patients);
5, drug rehabilitation, smoking treatment costs;
6, Qigong therapy, music therapy, balanced medical therapy, health nutrition therapy, psychotherapy and various magnetic therapy and other auxiliary treatment project costs;
7, all kinds of infertility (education), sexual dysfunction diagnosis and treatment project costs, such as male infertility, female infertility examination and treatment costs;
8. All expenses for violating the family planning policy;
9. Other insurance premiums and various late fees collected during hospitalization;
10. Expenses borne by others such as medical expenses caused by traffic accidents and medical accidents;
1 1, medical expenses due to illegal crimes or personal mistakes, such as drug abuse, fighting, alcoholism, sexually transmitted diseases, self-injury and self-mutilation. ;
12, medical expenses covered by industrial injury and maternity insurance;
13, medical expenses incurred in going abroad or going to Hong Kong, Macao and Taiwan;
14, medical treatment items beyond the payment scope stipulated by national, provincial and municipal medical insurance policies.
■ There are four kinds of medical materials that are not covered by medical insurance:
1, various medical rehabilitation instruments, such as orthopedic shoes, booster, hearing aid, glasses, dentures, artificial eyes, prostheses, hearing AIDS, etc.
2. Various self-use health care, massage and therapeutic instruments: such as massagers, wheelchairs, crutches, leather steel carapace, neck supports, waist supports, stomach supports, kidney supports, scrotum supports, uterine supports, hernia belts, knee pads, testicular belts, belts, steel head and neck, hot compress belts, medicine belts, medicine pillows, medicine pads, magic vitality bags, etc.
3. Skin nails and skin seamless belts used in various operations;
Disposable medical materials that cannot be charged separately as stipulated by the provincial and municipal price departments.
■ Proportion of medical materials medical insurance payment within the scope of social medical insurance pooling fund:
1, commonly used clinical syringes, infusion tubes, blood vessels, scalp needles, cotton swabs, gauze, medical cotton, bandages, plaster bandages, surgical fees and other medical materials used for hemodialysis treatment, the medical insurance payment ratio is100%;
2. Various artificial organs and medical materials implanted in the body, such as artificial joints, intraocular lenses, artificial larynx, artificial femoral heads, artificial heart valves, pacemakers, various stents implanted in the body and absorbable medical materials. The proportion of medical insurance payment is 50%;
3, the provincial and municipal price departments can be charged separately for disposable medical materials, medical insurance payment ratio is 70%.