In the current social security system, health insurance is an important mechanism to ensure that every citizen receives the necessary help in the face of illness. However, for many people who have paid social security, there seem to be many people who are confused about the medical insurance account.
Why is it that when we pay the money on time every month, when we need it urgently, we find that the balance of the medical insurance account is completely zero?
01
The type of health insurance affects the health insurance account
First of all, it should be made clear that the mainland's medical insurance system is mainly divided into two categories: employee medical insurance and resident medical insurance.
1. Basic medical insurance for urban employees
There is a personal account for the medical insurance of urban employees, and a part of the monthly premiums we pay will be deposited into this account.
2. Medical insurance payment for flexible employees
Flexible employment is a new type of employment model, and more and more people are choosing this way of working. However, this group of people often encounters difficulties in social security contributions. If the flexible employee chooses to pay medical insurance at a low level, then the medical insurance personal account will not be rich.
3. Medical insurance for urban and rural residents
Resident medical insurance generally does not set up a personal account. All premiums paid are transferred to the public account to cover hospitalization and other major medical expenses.
02
Regional differences affect health care accounts
In the case of health insurance contributions in different regions, the issue of health insurance accounts may be more complicated.
For example, in Shenzhen, employee medical insurance is divided into different grades according to the level of payment. The most upscale health care holders will have a personal health insurance account, and the funds in the account can be used to pay for routine outpatient services.
However, if you only participate in the second and third levels of Shenzhen basic medical insurance, you do not have a medical insurance personal account, and all expenses are paid by the pooled fund in accordance with the relevant provisions of the medical insurance measures.
Dongguan's social security system is similar, divided into gold and silver cards according to different levels – only gold card holders have a personal account, while silver card holders do not.
To put it simply, the Gold card corresponds to a higher level of supplementary health insurance, while the Silver card is the basic medical insurance. Gold card holders have access to benefits including supplemental hospital medical insurance, a medical insurance personal account, and specialized outpatient services.
Of course, except for Shenzhen and Dongguan, most cities still have personal accounts for employee medical insurance. If you find that you still have no money in your medical insurance account, it is recommended to check with your employer first to see if you have made medical insurance contributions and received them.
If the payment is successful but the payment cannot be queried, it may be that the query method is incorrect or there is a problem with the medical insurance system, and it is good to check again after a period of time.
03
If I don't have any money in my medical insurance card, can I still be reimbursed for medical treatment?
First of all, please rest assured: even if the account balance in the medical insurance card is zero, this will not interfere with our normal right to enjoy medical insurance reimbursement.
This situation needs to start with two types of accounts for employee medical insurance: personal accounts and pooled funds.
Usually when we refer to the funds in the medical insurance card, we actually refer to the funds in the personal account, which comes from the medical insurance fees paid by the employer and the individual, and is distributed according to a certain percentage, mainly used to pay for some medical expenses that need to be borne by the individual.
(It is worth mentioning that the mainland medical insurance can be divided into two systems: urban employee medical insurance and urban and rural residents' medical insurance, the latter is funded by individual contributions plus government subsidies, all of which are remitted to the overall account, and there is no personal account.) ）
About the pooled account: it mainly handles the reimbursement of medical expenses, and as long as the reimbursement standard is met, the funds can be transferred from the pooled account to the hospital.
Therefore, the funds used in the reimbursement process are the funds of the pooled account, and as long as the medical insurance status is kept normal, regardless of whether the individual account has a balance, it will not affect our medical insurance reimbursement according to the regulations.
04
Will the money in the pooled account run out?
The pooled fund for health insurance is a public fund that receives financial support from the state, so it is not depleted.
However, the reimbursement system has a number of restrictions that affect the upper limit of reimbursement:
1. Restrictions on the medical insurance catalog
Only medical expenses covered by the three categories of Medicare Drugs, Diagnosis and Treatment Items, and Medical Services are reimbursed.
2. Restrictions on Designated Medical Institutions
In most cases, the cost is reimbursed only if you receive treatment at a designated medical facility.
3. Restrictions at the level of medical institutions
According to the level of medical institutions, "minor illnesses to the community, major illnesses to the hospital", the medical insurance system sets different reimbursement ratios.
4. Restrictions on out-of-pocket lines and reimbursement caps
Only medical expenses above the out-of-pocket line and below the reimbursement ceiling are reimbursable.
Write at the end
The zero balance of the medical insurance account is not a single system error, but the result of multiple factors such as the type of medical insurance paid, regional policy, and even the form of employment. It is very important for each insured person to understand the policy environment and the corresponding rights and interests in which they are located.