Medical insurance refers to the insurance in which the insured suffers from an accident or illness, and the insurance institution reimburses the medical expenses or gives a certain amount of allowance according to the insurance contract or system. The form of social medical insurance is relatively simple, which is a medical insurance system enforced by the state through legislation, and employers and individuals pay insurance premiums in a certain proportion to establish a social medical insurance fund to pay medical expenses for employees. It is mainly composed of basic medical insurance and large medical insurance.

Medical insurance for urban residents is applicable to primary and secondary school students (including students from vocational high schools, technical secondary schools and technical schools) who have urban non-agricultural household registration and are not included in the coverage of the basic medical insurance system for employees. Children and other non-employed urban residents can voluntarily participate in the basic medical insurance for urban residents.

In 2007, "Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents" greatly expanded the coverage of medical insurance, stipulating that two or three cities should be selected in qualified provinces to start the pilot project in 2007, and the pilot project should be expanded in 2008, reaching more than 80% of the pilot cities in 2009, and it will be fully launched nationwide in 20 10, gradually covering all urban non-employed residents.

At the same time, it is clearly stipulated in the coverage of pilot cities that students, children and other non-employed urban residents in primary and secondary schools (including vocational high schools, technical secondary schools and technical schools) not covered by the basic medical insurance system for urban employees can voluntarily participate in the basic medical insurance for urban residents. By the end of 2007, the number of people participating in the basic medical insurance for urban residents was 429 1 10,000. In 2009, the medical insurance payment for urban residents was fully pushed forward, and all college students were included in the medical insurance scope. By the end of 2009, the number of urban residents participating in the basic medical insurance was 1, 8 1 10,000.

Medical insurance for urban residents requires the insured to seek medical treatment: the basic medical insurance for urban residents implements a designated medical system. When the insured residents get sick and seek medical treatment, they must go to the local designated medical institutions with medical insurance cards, ID cards or household registration books, and enjoy medical compensation treatment with vouchers. Patients can choose their own designated medical institutions without going through the referral procedures. Because of emergency, rescue or illness in different places, you can go to a qualified hospital nearby for treatment, but you must report to the agency and go through the relevant procedures within 7 days.

Because of illness or medical conditions need to be transferred to medical institutions at or above the municipal level for treatment, the designated medical institutions at the municipal level shall issue a certificate of referral, and go through the referral procedures at the local medical insurance agency. If you do not go through the referral procedures in accordance with the regulations and go directly to the provincial hospital for treatment, or go to a non-designated medical institution for treatment, the basic medical insurance fund for urban residents will not be reimbursed, and the medical expenses incurred will be borne by the insured himself.

How to calculate the payment period of basic medical insurance for employees?

The payment period of basic medical insurance consists of two parts: actual payment period and deemed payment period. The working years or continuous working years confirmed by the labor and social security department before participating in the basic medical insurance can be regarded as the payment period of the basic medical insurance.

What is the contribution ratio of employers and individuals in the basic medical insurance for employees?

The basic medical insurance premium for employees shall be paid jointly by the employer and individual employees. According to the State Council's Decision on Establishing the Basic Medical Insurance System for Employees, the employer's contribution rate should be controlled at about 6% of the employee's salary, and the employee's contribution rate is generally 2% of his salary. With the development of economy, the contribution rates of employers and employees can be adjusted accordingly. The payment ratio is determined by local conditions. In some developed areas, such as Shanghai, the unit payment ratio is 10%. At present, the national average unit payment rate is about 7.5%, and the national average individual payment rate is 2%. Personal contributions are all included in personal accounts. In addition, about 30% of the unit payment is also included in the personal account, and the specific proportion is determined according to the age of the employees. The older the employees, the higher the proportion, and the rest of the units are included in the social pooling fund. Some difficult areas and enterprises only set up overall funds, and temporarily do not set up personal accounts. For example, in 2003, Tianjin implemented a serious illness pooling fund system for difficult enterprises. The employer pays 6.5%, the individual does not pay, and no personal account is established. A separate pooled fund was established. Insured persons enjoy the same treatment as inpatient and outpatient special diseases stipulated in the current basic medical insurance, but do not bear the outpatient expenses. Article 23 of the Social Insurance Law stipulates that employees and employers have the same obligation to pay fees. At the same time, Article 27 stipulates that retired workers who have reached the legal retirement age and accumulated contributions have reached the number of years stipulated by the state will not pay after retirement.

How to use medical insurance card and its scope of use

(1) The medical insurance card can be used for further medical treatment. First of all, you must show your social security card when registering, and pay your own expenses and expenses in cash. The hospital will issue a bill for the insured; Secondly, you should take the initiative to show the social security card and the emergency medical record manual of Beijing medical institutions to the doctor when you see a doctor; Thirdly, the social security card and payment documents must be handed over to the settlement personnel to pay personal and self-funded expenses; Finally, after getting the settlement documents, carefully check the contents of the documents and recover the social security card. Insured persons who have received social security cards must show their social security cards when seeking medical treatment in designated medical institutions that have opened card-based medical settlement services. If the social security card is not presented, the expenses incurred shall be borne by the individual in full, and the medical insurance fund cannot pay it. If the insured person goes to the hospital for emergency treatment, family planning surgery, enterprise arrears, replacement of cards, failure to issue cards after enrollment, etc. The medical expenses incurred can be paid in cash by the individual first and then reimbursed by the medical insurance agency according to the original process.

(2) Medical insurance card reimbursement. After holding a card for medical treatment, the patient only bears the medical expenses that the individual should bear, and the expenses that should be reimbursed are directly settled by medical institutions and medical insurance departments. Cardholders encounter four special situations and need to pay medical expenses in full in cash before reimbursement: First, they don't bring social security cards in the emergency department; Second, family planning surgery; Third, enterprises owe medical insurance premiums; Fourth, during the replacement of social security cards.

The scope and guarantee of medical insurance reimbursement for urban workers

Medical insurance for urban workers is the medical security provided for urban workers. Medical insurance for urban workers not only protects employees of state-owned enterprises and non-state-owned enterprises, but also protects employees of enterprise-managed institutions. With the deepening of the reform of basic medical insurance for employees of urban enterprises, some provinces, autonomous regions and municipalities directly under the Central Government have also included employees of administrative institutions in the scope of reimbursement of basic medical insurance for employees of urban enterprises. Medical insurance for urban workers is mainly composed of basic medical insurance and supplementary medical insurance.

So what are the scope of medical insurance reimbursement? Some people can be reimbursed 80% for illness, while others can only be reimbursed 6%. The gap is so great that it brings joy or worry to different insured. Therefore, I suggest you be familiar with the provisions of medical insurance. Basic concepts such as reimbursement ratio, reimbursement scope, designated hospitals and medical insurance drugs are necessary. Medical insurance is fair to everyone. Whether we can enjoy the benefits it brings us depends on whether we are familiar with the "rules of the game"

Let's look at a case first. Netizen Mr. Li spent 2.5w on radiofrequency heart surgery, and the medical insurance reimbursement was only 4 K. Ms. Zhang is a Beijinger and has retired; Because of chronic diseases, she has to see a doctor and take medicine every month, and the cost is quite high, but her monthly medical expenses can be reimbursed by social security 88%. Why is the gap so big? What are the restrictions on the scope of medical reimbursement?

First of all, the difference between medical insurance drugs and non-medical insurance drugs, reimbursement deductible line is also different according to hospital level.

Generally, Class A drugs can enjoy full coverage, while Class C drugs need to bear all the expenses, while Class B drugs will be charged 80% and bear 20% of the expenses.

If a person spends 10000 yuan in a hospital, if he is hospitalized in a first-class hospital, then subtract 500 yuan first; If you are hospitalized in a secondary hospital, you will be reduced by 1000 yuan first; If you are hospitalized in a tertiary hospital, you can deduct 2000 yuan first, which is the difference of deductible.

Secondly, the medical insurance premium reimbursement policy for insured employees who travel, visit relatives and live in different places for a long time stipulates that:

1. The medical expenses incurred by the insured employees on business trips or visiting relatives in other places will only be reimbursed for emergency expenses in other places that meet the requirements of medical insurance, and all expenses incurred for hospitalization for non-emergency reasons will not be reimbursed.

2, the insured workers living in the field for more than 6 months, according to the nature of long-term living in the field of medical expenses.

3, long-term residents should provide proof by the unit, determine the secondary designated hospitals (should be designated medical institutions for local medical insurance), and timely handle the "Zhenjiang long-term residents medical expenses reimbursement card".

4. Employees who live in other places for a long time must adhere to the principle of economy and prescribe drugs in a limited amount according to regulations (the acute dosage is within 3 days, the chronic dosage is within 10 days, and the dosage of tuberculosis, hypertension and diabetes can be extended to 30 days). Those who exceed the above standards will not be reimbursed for medicine.

5. Referral of foreigners living for a long time shall be signed by local designated hospitals and referred step by step according to the principle of territoriality. Referral hospital is a special hospital designated by medical insurance for employees in our city. The individual pays 65438+ 00% of the total expenses first, and then reimburses the expenses according to the medical insurance regulations. Other hospitals and individuals pay 20% of the total expenses first, and then reimburse medical expenses according to medical insurance regulations.

Finally, medical insurance also has exclusions, and the following ten items are not within the scope of medical insurance reimbursement.

1. Special medical expenses include organ and tissue transplantation due to illness, organ and tissue purchase and use of anti-rejection drugs and immunomodulatory drugs beyond the scope of medical insurance reimbursement for Zhenjiang employees; 2. Work-related injuries and occupational diseases; 3. Female workers give birth; 4. Rogue fights; 5. Injuries caused by alcoholism; 6. Traffic accidents; 7. Others intentionally hurt; 8. Medical malpractice; 9. Beauty and health examination; 10, other expenses not paid by the social medical insurance fund.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.