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I. Scope of drug reimbursement
According to the drug list of basic medical insurance, industrial injury insurance and maternity insurance (including 2373 kinds of western medicine, Chinese patent medicine and ethnic medicine, including Class B drugs 18 17), reimbursement is divided into Class A and Class B, which are adjusted regularly. All Class A drugs are included in the scope of reimbursement, and Class B drugs are included in the scope of reimbursement after paying a certain proportion (class B drugs pay 10%, and the minimum package price of class B drugs exceeds 100 yuan, which is 15% according to special drugs).
Second, the scope of reimbursement for diagnosis and treatment projects
According to the catalogue of urban workers' basic medical insurance diagnosis and treatment projects, the basic medical insurance allows payment of fees, allows payment of some fees and does not pay some fees. Attached to the basic medical insurance diagnosis and treatment project directory:
The basic medical insurance will not pay for the diagnosis and treatment projects.
(1) service items:
1. Registration fee, consultation fee, home visit fee, outpatient fee, remote consultation fee, medical guidance service fee, etc.
2. Special medical service fees such as examination and treatment expedited fee, roll call (appointment) medical service fee, ward round fee, self-invited intensive care fee, door-to-door service fee, discharge follow-up fee, and full-service of maternal and child system.
3. Medical record fees, computer query management fees, and various bills.
(2) Non-disease treatment items:
1. Freckles, acne, dark spots, warts, acne, freckle removal, pigmentation, alopecia (including alopecia areata), white hair, mole removal, ear piercing, saddle nose, breast augmentation, single eyelid to double eyelid, massage and beauty.
2. All kinds of cosmetic surgery, orthopedic surgery (except polio sequelae) and the treatment of physical defects, such as cutting body odor, repairing rabbit lips, stuttering, correcting strabismus, multi-finger (toe) cutting, circumcision, O-leg, X-leg, ametropia, vision correction, etc.
3. Diabetes decision support system, sleep and respiratory monitoring system, trace element detection, bone mineral density determination, human information diagnosis, computer selection of the best pregnancy, fetal sex and fetal development examination and other diagnosis and treatment projects.
4. Various diagnosis and treatment projects for weight loss, weight gain, height increase, bodybuilding and smoking cessation.
5. Various health checks. 6. Various prevention and health care diagnosis and treatment projects.
7. Various medical consultations (including psychological prediction, health prediction, diet consultation and disease consultation), various predictions (including stroke prediction, health prediction and disease prediction), various appraisals (judicial appraisal, work injury appraisal, labor appraisal, medical appraisal, paternity test), health guidance and other projects.
(3) Treatment equipment and medical materials:
1. Examination and treatment items carried out by large medical equipment such as cell knife, positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic instrument.
2. Glasses, artificial eyes, dentures, prosthetic limbs, hearing AIDS, brain-strengthening devices, leather (steel) vests, steel vests, steel head and neck, stomach supports, kidney supports, scrotum supports, uterine supports, crutches, wheelchairs, deformed insoles, medicated pillows, pads, hot compress bags, pulse compression belts, infusion nets, testicular lifting belts and hernia belts.
3. Home inspection detectors (instruments), therapeutic instruments (instruments), physiotherapy instruments (instruments), massagers, magnetic therapy supplies and other therapeutic instruments.
4. Medical devices, equipment and medical materials that do not meet the national or provincial regulations on the management and supervision of medical devices, equipment and medical materials are used for diagnosis and treatment projects.
Disposable medical materials that cannot be charged separately as stipulated by the provincial price department.
(4) Treatment items:
1. Organ source or tissue source of various organ or tissue transplants and related operations to obtain organ source and tissue source, etc.
2. Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow.
3. Microwave (radio frequency) therapy for benign prostatic hyperplasia, He-Ne laser intravascular irradiation (blood therapy), new analgesic technology after anesthesia operation (analgesic bed), endoscopic retrograde appendectomy with dry cavity, etc.
4. Orthodontic treatment projects such as dental inlay, dental implant, tooth selling, dentition defect, yellow and black teeth, tooth defect, colored teeth, porcelain teeth, etc.
5. Qigong therapy, music therapy, hypnosis therapy, magnetic therapy, water bar therapy, oxygen bar therapy, posture therapy, psychotherapy and suggestion therapy (except mental patients), diet therapy, nutrition therapy and other auxiliary treatment projects.
6 all kinds of infertility (pregnancy), sexual dysfunction and family planning diagnosis and treatment projects.
7. All kinds of scientific research, teaching and clinical verification diagnosis and treatment projects.
The basic medical insurance pays part of the cost of diagnosis and treatment projects.
(a) diagnosis and treatment equipment and medical materials:
1. Use R knife, X knife, X-ray computed tomography (CT), cardiac and angiographic X-ray machine (including digital subtraction equipment), magnetic resonance imaging device (MRI), single photon emission computerized scanning device (SPECT), color Doppler instrument, medical linear accelerator and other large medical instruments for examination and treatment.
2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen treatment project.
3. Various clinical monitoring (except intraoperative and postoperative monitoring).
Disposable medical materials that can be charged separately as stipulated by the provincial price department.
(2) Treatment items:
1. Hemodialysis and peritoneal dialysis treatment project.
2. Kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow transplantation.
3. Pacemakers, artificial valves, artificial joints, intraocular lenses, various stents, various staplers, various catheters, implantable drug delivery devices and other artificial organs replaced in vivo, materials placed in vivo and the installation or placement of surgical items.
4. Cardiac bypass, cardiac catheter balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser drilling, T lymphocyte infusion in tumor biotherapy, transurethral resection of prostate, tumor hyperthermia and other diagnosis and treatment projects.
6 all kinds of microwave, spectrum, far infrared, photon (liquid therapy) and other auxiliary treatment projects.
Legal basis:
People's Republic of China (PRC) social insurance law
Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.