Hey friends, if you have basic medical insurance, what expenses can be reimbursed? How much can be covered? And what cant be reimbursed? You might be curious but not quite sure. Let me help you sort it out~
First, let me share a few small pieces of knowledge with you:
1. Can medical expenses be reimbursed at any hospital?
Only when you seek medical treatment and purchase medicine at designated medical institutions can you get reimbursement. For common minor illnesses, it is more cost-effective to visit primary-level medical institutions, as you can get more reimbursement.
Tips:
Which are the designated medical institutions?
Friends can search for "Hainan Designated Medical Institutions" at the bottom of the homepage in the "Hainan Medical Insurance" WeChat mini-program.
For instance, Hainan Chengmei Hospital is a tertiary specialized hospital for geriatric diseases. Insured individuals who receive medical treatment at this hospital can enjoy medical insurance benefits such as reimbursement for inpatient care and outpatient chronic and special diseases within the scope of medical insurance policies.
2. What can be covered by medical insurance?
The key lies in whether it is included in the medical insurance directory, which includes the medical insurance drug directory, the medical treatment project directory and the medical service facility scope directory. Medical expenses within the three directories, which we often refer to as "compliant expenses", can be reimbursed.
3. What is the deductible?
It refers to the deductible of the medical insurance fund. For the compliant expenses actually incurred by the insured person at designated medical institutions, they have to bear the expenses below the deductible themselves, and the portion above the deductible will be reimbursed by the medical insurance fund in accordance with the regulations and at a certain ratio.
4. What is the cap line?
It refers to the maximum payment limit of the medical insurance fund, that is, the maximum limit that insured persons can obtain reimbursement from the medical insurance fund within a year. In other words, it is the maximum amount that can be reimbursed.
5. What cannot be reimbursed by medical insurance?
Medical expenses not within the three directories;
Medical expenses that should be paid from the work-related injury insurance fund;
Medical expenses that should be borne by a third party, such as those resulting from traffic accidents involving a third party;
Medical expenses incurred while seeking medical treatment abroad.
Lets take an example to have a look. It will be much clearer then~
Mr. Wang is an insured person under the employee medical insurance. He received medical treatment at Hainan Chengmei Hospital, with a total medical expense of 1,000 yuan, of which 900 yuan was compliant. According to the policy, for outpatient treatment at a tertiary hospital, the deductible for employee medical insurance is 100 yuan, and the reimbursement ratio is 50%. Therefore, the amount that Mr. Wang can be reimbursed is (900 - 100) * 50% = 400 yuan, and he only needs to pay 1,000 - 400 = 600 yuan out of pocket.
The reimbursement standards for various medical insurance situations have all been sorted out by our editor for you~
Specifically, as follows:
Hospitalization
Medical insurance reimbursement for in-service employees during hospitalization
Medicare coverage for retired employees hospital stays.
Reminder:
Male retirees must have accumulated 30 years of contributions and female retirees 25 years to be eligible for a 90% reimbursement. For those who have not met the required contribution years, the reimbursement rate will decrease by 3% for each year short of the requirement. For example, if Mr. Li had accumulated 25 years of contributions before retirement and did not make up the shortfall, his reimbursement rate for hospitalization would be 90% - 3% * 5 = 75%.
Reimbursement for Hospitalization under Urban and Rural Residents Medical Insurance
Note
Persons in extreme poverty, orphans, recipients of the minimum living allowance, people who have fallen back into poverty in rural areas, and persons with severe disabilities of grade one or two, minors (under 18 years old), and the elderly (60 years old and above) in low-income families are not subject to a deductible.
Reminder
Pregnant women, children under 5 years old, the elderly over 65 years old, and insured patients with malignant tumors, critical illnesses, emergency conditions, postoperative follow-up visits, ophthalmic diseases, tuberculosis, infectious diseases, mental disorders, etc. do not need to go through referral procedures and can directly receive treatment at provincial-level tertiary designated medical institutions, with their medical expenses reimbursed as per regulations. For other insured persons seeking inpatient treatment at provincial-level tertiary designated medical institutions, they must obtain a referral from a secondary designated medical institution in their place of insurance or place of treatment. Failure to do so will result in a 10% reduction in the reimbursement ratio.
General outpatient services
General outpatient services for employed workers
Medical insurance reimbursement
Ordinary outpatient services for retired employees
Medical insurance reimbursement
Reminder
For retired individuals whose cumulative payment years for basic medical insurance for retirees have not reached 30 years for men and 25 years for women, for each year less, the payment ratio of the general outpatient pooling fund will be reduced by 3%.
General outpatient services for urban and rural residents
Medical insurance reimbursement
Outpatient chronic special diseases
In our province, outpatient chronic special diseases are divided into two categories. One category is determined by a fixed quota (monthly/quarterly/time) and then reimbursed according to the inpatient ratio (such as hypertension), while the other category is not set with a quota and is directly reimbursed according to the inpatient ratio (such as chronic renal failure hemodialysis).
Reimbursement for chronic and special diseases under the medical insurance for employed workers.
Reimbursement for chronic disease medical insurance for retired employees
Reminder
For retired individuals whose cumulative payment years for basic medical insurance for retirees have not reached 30 years for men and 25 years for women, for each year less, the payment ratio of the general outpatient pooling fund will be reduced by 3%.
Medical insurance reimbursement for chronic and special diseases among urban and rural residents at the outpatient level
Reminder
Persons in extreme poverty, orphans, children who are actually without guardianship, recipients of the minimum living allowance, people who have fallen back into poverty in rural areas, and severely disabled persons (Grade I and II) in low-income families, minors, and the elderly (aged 60 and above) are not subject to the deductible.
Repost: Hainan Social Security and Medical Insurance Official Account