"Obviously, the self-paid part meets the standard, why don't you report the medical insurance?" The medical insurance account pays normally, and the medical expenses exceed the minimum payment line, but the overall reimbursement amount is far lower than expected, or even zero reimbursement? What's going on?
In this case, it is likely that a key factor is overlooked - MedicalGuaranteed Records 。
In fact, basic medical insurance has a medical insurance catalog, and the expenses in the medical insurance catalog can be reimbursed according to regulations. So how is the medical insurance catalogue determined? What's included? Let's find out with Yu Xiaobao!
Before you get to know the "Medicare Catalog", you may have these questions that you want to ask:
1. What medical expenses can be reimbursed?
The scope of payment of basic medical insurance shall be managed by the catalogue, and the medical expenses incurred by the insured in the use of drugs, diagnosis and treatment items and medical service facilities in designated medical institutions shall be paid by the medical insurance fund in accordance with the regulations.
The catalogue of medical insurance drugs, diagnosis and treatment items and medical service facilities that regulate the scope of payment of medical insurance funds are what we often call the "three major catalogs" of medical insurance.
2. Why do we need to implement the management of the "three major catalogs" of medical insurance?
It is a common practice in all countries to manage the coverage of medical insurance through the development of health insurance catalogs:
First, it is conducive to the establishment of a medical security system commensurate with the level of economic and social development to prevent the "welfare trap";
Second, it is conducive to adhering to the principle of "guaranteeing the basics" and curbing excessive medical demand;
Third, it is conducive to improving the efficiency of the use of medical insurance funds and promoting the coordinated development and governance of the "three medicines".
3. How are the "three major catalogs" of medical insurance determined?
The medical insurance drug catalogue adopts the access method, which is mainly formulated and dynamically adjusted by the state, and in principle, it is adjusted once a year.
On this basis, the provincial medical insurance department may, in accordance with the authority and procedures, include eligible ethnic medicines, preparations of medical institutions, and traditional Chinese medicine decoction pieces into the payment scope of the local medical insurance catalog.
The catalogue of diagnosis and treatment items and the catalogue of medical service facilities shall be formulated by the state for medical insurance access and management, and in principle, the provincial medical insurance department shall adopt the access method and the exclusion method in accordance with national regulations.
⬇️ One picture to understand the three major catalogs ⬇️
Among them, the drug list can be divided into: Class A drugs and Class B drugs.The full amount of Class A drugs is included in the reimbursement, and the part of Class B drugs is included in the reimbursement.Out-of-catalogue drugs are not reimbursable.
In order to make it easier for everyone to understand, let's take a simple example: if the drugs used by Yu Xiaobao when he is hospitalized are all outside the drug list, then this part of the cost cannot be reimbursed, and he can only pay for it completely.
We can't simply take the total cost of inpatient care minus the threshold and multiply it by the reimbursement percentage.
Basic medical insurance mainly protects the insured person's disease treatment costs, in accordance with the provisions of the Social Insurance Law and the national medical insurance treatment list system, the scope of medical insurance fund does not pay the following situations:
1. It should be paid from the work-related injury insurance fund;
2. It should be borne by a third party;
3. It should be borne by public health;
4. Seeking medical treatment abroad;
5. Sports and fitness, health care consumption, health examination;
6. Other expenses that are not paid by the basic medical insurance fund stipulated by the state. If the population screening of tumors belongs to the scope of public health, it should be solved through public health services and other channels, so the medical insurance fund will not pay for the cost of tumor screening.
1. Try to go to primary medical institutions for minor illnesses
Many people like to go to big hospitals to see a doctor. But you know what? Judging from the situation in most areas, whether it is employee medical insurance or urban and rural residents' medical insurance, the minimum payment line is lower and the reimbursement ratio is higher when they see a doctor in primary medical institutions. Therefore, it is more cost-effective to go to primary medical institutions for some common minor diseases, such as colds, coughs, diarrhea, etc.
Attention! At the grassroots level, you can pay zero for outpatient treatment of special diseases, and you can use basic drugs! Zero minimum payment means that there is no starting line for medical treatment, and it directly enters the medical insurance co-ordination and is reimbursed according to the regulations.
2. Carefully choose designated hospitals
In many cities, reimbursement is only possible if you go to a designated hospital. If you go to a non-designated hospital for medical treatment, the medical insurance will not reimburse you. Therefore, it is recommended to choose a primary medical institution close to home for medical treatment, which is convenient and saves money!
3. Try to use the drugs in the medical insurance catalog
As we all know, the use of drugs in the medical insurance catalogue can be reimbursed according to the regulations, if there are alternative varieties of drugs in the medical insurance catalogue, you should try to use the drugs in the medical insurance catalogue!
4. For some serious and chronic diseases that can be treated in the outpatient clinic, remember to handle the outpatient special diseases
In order to reduce the burden on the insured and solve the problem of outpatient serious illness medical expenses, various localities have established a system of outpatient special diseases, and some serious and chronic diseases that can be treated in outpatient clinics are included in the scope of payment of the medical insurance pooling fund.
That is to say, if you can handle outpatient special diseases, major and chronic diseases, you can enjoy the medical insurance reimbursement treatment for outpatient special diseases.
Source: Chengdu Medical Insurance