Shanghai basic medical insurance reimbursement scope
Shanghai basic medical insurance reimbursement scope includes:
1, general outpatient consultation fee, expert outpatient consultation fee and emergency consultation fee of designated medical institutions;
2, designated medical institutions general ward bed fee;
3, outpatient decocting fee;
4, designated medical institutions for medical treatment, dispensing or retail pharmacies dispensing medical expenses;
5, in line with the basic medical insurance treatment project, medical service facilities, medication scope and payment standard of medical expenses.
Medical insurance part of the payment of medical treatment projects include
1, diagnosis and treatment equipment:
Examination and treatment fee for magnetic resonance imaging equipment;
Examination and treatment fees for cardiac and angiographic X-ray machines (including digital subtraction equipment) (DSA);
Inspection fee for single photon emission electronic computer scanning device (SPECT);
Hyperbaric oxygen treatment fee (except rescue treatment);
Extracorporeal shock wave lithotripsy treatment fee.
2, disposable and implantable artificial organs and medical materials:
Material cost of intraocular lens;
The cost of heart valve materials;
Material cost of catheter and endovascular stent for diagnosis and interventional therapy of coronary heart disease;
Material cost of peripheral vascular and neurovascular interventional therapy.
The scope of medical insurance reimbursement for migrant workers in Shanghai: the medical expenses incurred in hospitalization or emergency observation room, as well as outpatient serious illness medical treatment, family beds and various medical insurance burden reduction treatments are temporarily excluded. However, its personal medical account is limited to outpatient service, which belongs to outpatient service only, and is used to pay the outpatient emergency medical expenses that meet the requirements of the basic medical insurance in this Municipality, as well as the expenses of purchasing medicines at designated retail pharmacies.
The reimbursement scope of the new rural cooperative medical system: outpatient co-ordination, hospitalization co-ordination, and serious illness burden reduction subsidy (secondary compensation) co-ordination fund expenditure.
Content description
Outpatient (including emergency) co-ordination fund expenditure: refers to the compensation expenditure of less than 5,000 yuan paid by the co-ordination fund to the insured who meet the basic diagnosis and treatment items and the list of essential drugs.
Expenditure of hospitalization co-ordination fund: refers to the compensation expenditure paid by the co-ordination fund for the hospitalization expenses of the insured who meet the basic diagnosis and treatment items and the list of essential drugs, or the list of drugs for outpatient serious diseases is more than 5,000 yuan.
Expenditure of serious illness relief subsidy (secondary compensation) as a whole fund: refers to the compensation expenditure of participants who enjoy hospitalization or outpatient compensation of more than 5,000 yuan, and their one-time self-funded medical expenses are still more than 50% of their annual family income. The compensation standard is the same as hospitalization compensation, which can be increased by 10-20 percentage points for low-income households, five-guarantee households and families with disabilities confirmed by civil affairs.
What does Shanghai medical insurance reimbursement not cover?
1, which shall be paid from the industrial injury insurance fund;
2, should be borne by a third person;
3, should be borne by public health;
4. Go abroad for medical treatment.
Answers to Frequently Asked Questions about Shanghai Medical Insurance Reimbursement
1. My mother is 45 years old this year, and I intend to help her join the new rural cooperative medical system. What is the scope of reimbursement for the new rural cooperative medical system in Shanghai?
A: The reimbursement scope of the new rural cooperative medical system in Shanghai includes outpatient co-ordination, hospitalization co-ordination, and serious illness relief subsidy (secondary compensation) co-ordination fund expenditure.
Our unit is located in Huangpu District, Shanghai. An employee of the unit is not responsible for a car accident during working hours. Now he is in hospital. Can he apply for medical insurance reimbursement in this case?
A: According to your description, this situation of your employees should be borne by a third party, so it is not covered by Shanghai medical insurance and should be paid by a third party.
I am from Hunan, but I have been working in Shanghai, and my company bought medical insurance for me. Can migrant workers enjoy medical insurance for serious illness outpatient treatment?
A: Migrant workers' medical insurance can only reimburse the medical expenses incurred in hospitalization or emergency observation room, and temporarily do not enjoy outpatient serious illness, family bed medical treatment and various medical insurance burden reduction treatments.
2065438+2007 New Policy of Shanghai Serious Illness Medical Insurance
Shanghai officially launched medical insurance for urban residents with serious illness, and four kinds of serious illness can be reimbursed by 50%. Anyone who participates in the basic medical insurance for urban residents in Shanghai can also enjoy the medical insurance for serious illness of residents on the basis of enjoying the basic medical insurance benefits, and there is no need to pay separately. The insured can enjoy serious illness insurance benefits through reimbursement.
Four serious diseases can be reimbursed 50%:
These four serious diseases refer to: severe uremia, kidney transplantation, malignant tumor and partial psychosis. Personal expenses paid by the basic medical insurance for dialysis treatment of severe uremia, anti-rejection treatment of renal transplantation, treatment of malignant tumor and treatment of some mental diseases will be reimbursed by the urban residents' serious illness insurance fund by 50%.
In addition, the medical expenses incurred by Shanghai college students due to hemophilia and aplastic anemia can also be included in the coverage of residents' serious illness insurance.
Insured residents suffering from serious illness, in the city's basic medical insurance designated medical institutions, in line with the provisions of the city's basic medical insurance costs (hereinafter referred to as "at their own expense"), included in the scope of payment of residents' serious illness insurance, by the residents' serious illness insurance fund for reimbursement of 50%. Among them, if the insured residents have participated in the medical mutual fund for primary and secondary school students and infants in this city, the part paid by the mutual fund shall be deducted first, and the remaining expenses shall be reimbursed by the residents' serious illness insurance fund by 50%.
How to reimburse:
65438 Insured residents who meet the scope of residents' serious illness insurance after June 30 this year should voluntarily choose one of the above-mentioned commercial insurance institutions to handle the reimbursement of residents' serious illness insurance within 6 months from the date of issuing the receipt of medical expenses. The commercial insurance institution selected by the insured residents when applying for reimbursement of residents' serious illness insurance for the first time shall be the designated institution for reimbursement of residents' serious illness insurance in that year; Once selected, it shall not be changed in principle during the year.
Hotline enquiry:
If you don't know about medical insurance for urban residents, you can call the Shanghai medical insurance service hotline 9622 18 for consultation.
Shanghai medical insurance reimbursement new policy article;
1.20 16 New reimbursement policy for serious illness in Shanghai medical insurance.
2. Shanghai medical insurance policy
3.20 16 What are the medical insurance policies in Shanghai?
4.20 17 What are the policies of Shanghai medical insurance?
5. New Deal of Shanghai Medical Insurance for Serious Illness
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.