What are the cases that medical insurance cannot be reimbursed?The treatment list gives you the answer

In August 2021, the State Medical Insurance Bureau and the Ministry of Finance issued the "Opinions on Establishing a System of Medical Guarantee Treatment List" (Medical Insurance Fa [2021] No. 5, hereinafter referred to as "Opinions"). The goal of continuous multi -level medical security system is aimed at maintaining the demand for basic medical security for the people.

What is the medical security treatment list includes, what is the fund payment scope, and what are the scope of the fund's non -payment?

Answer: In addition to the projects and standards for the medical insurance fund payment, the medical insurance treatment list also includes the scope of basic systems, basic policies, and the scope of medical insurance funds.

The treatment list is not static, and it will be released in a timely manner according to the decision -making deployment of the Party Central Committee and the State Council.

Answer: In addition to being paid by the Injury Insurance Fund, the "Opinions" clearly states that the scope of the fund's non -payment should also include the burden of the third party. Health care consumption, health examination, and other expenses that basic medical insurance funds stipulated by the state are not paid. Of course, in case of a significant impact on economic and social development, temporary adjustments can be made through legal procedures.

Therefore, the expenditure fund for purchasing health products and nutritional products is not paid.

Answer: The "Opinions" stipulates that the fund payment scope includes the scope of the pharmaceutical medical consumables and medical service items determined by the access method and exclusion method. The country uniformly formulates the catalog of basic medical insurance drugs, and strictly implements the national basic medical insurance drug directory in various places. Except for the country's clear stipulation, it is not allowed to formulate the directory or use the method of changing the directory to increase the drug in the directory. Supplementary medical insurance and medical assistance reference policies are implemented within the scope of expenses within scope of the policy.

Answer: The "Opinions" stipulates that the medical security administrative department of the State Council will uniformly formulate, adjust, and issue basic medical security policies in conjunction with relevant departments. The localities can adapt to local conditions and formulate standards, payment ratios and maximum payment limit within the scope of the state regulations. For example, in terms of hospitalization benefits policy, according to the national medical security treatment list (2020 edition), the starting standard of employee medical insurance is not higher than 10%of the average annual salary of the annual employee in the coordinating region, and the specific standards shall be determined according to local actual conditions.

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