Recently, it is in the period of high incidence of winter diseases, and many friends frequently go to the hospital to "sign in and check in". Every time you go to the hospital, I believe that everyone will immediately think of bringing a medical insurance card, because you can reimburse a lot of medical expenses by using a medical insurance card to settle the settlement. However, many friends are confused about how much medical insurance can reimburse: why do others reimburse more than themselves for the same disease? Why can some drugs be fully reimbursed, some drugs can only be partially reimbursed, and some drugs are not even reimbursed?
Next, the editor will talk to you about medical insurance reimbursement, and figure out what factors will affect medical insurance reimbursement.
1. What is medical insurance?
1. Definition of medical insurance
Medical insurance, that is, basic medical insurance, is a social insurance system established to compensate the economic losses caused by the risk of disease for the majority of workers. In the mainland, basic medical insurance has the basic characteristics of mandatory, wide coverage, basic and so on, the medical insurance system is enforced by national legislation, the cost is jointly paid by the employer and the individual and the establishment of a medical insurance fund, so as to provide compensation for relevant medical expenses when workers are sick or injured.
2. Types of medical insurance
The basic medical insurance in mainland China is divided into two types: employee medical insurance and urban and rural residents' medical insurance. Employee medical insurance is usually paid by state organs, enterprises and institutions for their employees or employees on a monthly basis, while urban and rural residents' medical insurance is generally paid once a year, and the state finance gives a certain subsidy, which is applicable to children, farmers, unemployed and other people.
3. The account composition of medical insurance
The basic medical insurance fund consists of a pooled fund and an individual account. Among them, all the basic medical insurance premiums paid by individual employees are included in the personal account, and the basic medical insurance premiums paid by the employer are divided into two parts, one part is transferred to the personal account and the other part is allocated to the overall fund.
When used specifically, the money in the personal account of medical insurance can be used to pay for the purchase of drugs in designated pharmacies, outpatient and emergency medical expenses; the expenses that exceed the minimum payment standard of the basic medical insurance pooling fund and need to be paid by individuals in proportion to the expenses; and in some areas, they can be used to purchase insurance products designated by the insurance regulatory department, such as Huimin Insurance in various places. The pooled account mainly pays for the medical expenses of hospitalization, radiation therapy for malignant tumors, kidney dialysis, and outpatient medical expenses for anti-rejection drugs after kidney transplantation.
2. Keep these points in mind and report more medical insurance
1. Employee medical insurance> medical insurance for urban and rural residents
As mentioned earlier, there are two types of medical insurance in the mainland: employee medical insurance and urban and rural residents' medical insurance. The medical insurance for employees is paid once a month, with an average annual payment of several thousand yuan, and the medical insurance for urban and rural residents is paid once a year, with an average annual payment of only a few hundred yuan. Due to the different premiums, there are obvious differences in the reimbursement treatment of the two in the medical insurance, and the reimbursement ratio of the employee medical insurance is higher than that of the medical insurance for urban and rural residents in the designated medical institutions at the same level. Of course, for those who have a formal job, it is a legal obligation to pay employee health insurance. However, for some flexible employment and non-permanent employment, both types of insurance can be selected. If conditions permit, it is recommended that you pay employee medical insurance in the form of flexible employment, so that the protection is much higher than that of urban and rural residents.
2. Community hospitals> tertiary hospitals
Many people think that the doctors in big hospitals are professional, and the departments and facilities are complete, so once they get sick, they try their best to go to a tertiary hospital.
In fact, most of the minor ailments are enough to be cured by the community hospital. In order to guide people to go to community hospitals for minor illnesses and reduce the pressure on large hospitals, the mainland's medical insurance policy was designed to reduce the reimbursement ratio of large hospitals, so as to guide people to seek medical treatment at different levels and reduce the frequency of people going to large hospitals. Taking Shanghai's employee medical insurance as an example, it stipulates that the reimbursement ratio for in-service employees to seek outpatient and emergency medical treatment in first-, second-, and third-level hospitals is 80%, 75%, and 70% respectively, and is gradually decreasing. Therefore, if you have a minor illness and go to a big hospital to see a doctor, you not only have to queue up for all kinds of long queues, but also have a lot less money for reimbursement, so it seems that it is better to go to a community hospital.
3. Medical insurance payment, try not to interrupt
The duration of continuous medical insurance payment is an important factor affecting the reimbursement of medical insurance. Generally speaking, if we are interrupted due to resignation, unemployment, etc., and complete the supplementary payment and renewal within 3 months of interruption, the medical insurance treatment will not be affected;
4. Three major catalogs, the scope of reimbursement is exquisite
According to the policy of medical insurance, only the expenses that belong to the "three major catalogs" of medical insurance (medical insurance drug catalog, diagnosis and treatment project catalog, and medical consumables catalog) can be reimbursed by medical insurance. If you use self-financed drugs, diagnosis and treatment items and medical consumables that are not in the catalog, the medical insurance will not reimburse.
Not only that, for some drugs in the catalog, medical insurance also limits the scope of reimbursement payment, and not all cases can be reimbursed, which will also lead to differences in medical insurance reimbursement. For example, the medical insurance payment scope of entecavir granules is "hepatitis B only", if you get "hepatitis C", then the use of entecavir granules is a self-financed drug, and the medical insurance does not reimburse. Another example is albumin injection, which stipulates that the patient's albumin index must be lower than 30g/L to be used to be covered by medical insurance, and if it is exceeded, it can only be paid by himself.
3. Medical insurance + commercial insurance, the cost of seeing a doctor is more cost-effective
With the above points in mind, we can maximize the role of medical insurance. However, after all, medical insurance is only a basic medical security, and there are various restrictions on reimbursement ratios and scopes, and there are always many medical expenses that we need to pay for ourselves. At this time, it is the turn of commercial insurance to play a role, such as critical illness insurance, which can give hundreds of thousands of yuan of insurance money at one time when the insured suffers from a critical illness to help the insured tide over the difficulties. Or millions of medical insurance, the general compensation limit is as high as millions of yuan, which can effectively share the economic pressure of the insured's various out-of-pocket medical expenses, so that the cost of medical treatment is more economical.