Reimbursement scope of urban and rural medical insurance

As of 2022, the reimbursement scope of basic medical insurance for urban and rural residents is as follows:

1. Drug reimbursement scope

According to the "Basic Medical Insurance, Work-related Injury Insurance and Maternity Insurance" The "Insurance Drug Catalog" (including 2,373 types of Western medicines, Chinese patent medicines, and ethnic medicines, including 1,817 Category B drugs) has standard reimbursement, divided into Category A and Category B, and is adjusted regularly. All Category A drugs are included in the scope of reimbursement, and Category B drugs are included in the reimbursement scope after paying a certain percentage out of pocket (10% for Category B drugs, and 15% for Category B drugs with a minimum package price of more than 100 yuan as special drugs).

II. Scope of reimbursement for diagnosis and treatment items

Basic medical insurance allows payment of expenses, partial payment of expenses and non-payment of expenses determined in the "Urban Employees Basic Medical Insurance Diagnosis and Treatment Item Catalog" Standard reimbursement for diagnosis and treatment items. Attached is a directory of diagnosis and treatment items under basic medical insurance:

Diagnosis and treatment items that are not covered by basic medical insurance

(1) Service items:

1. Registration fee , consultation fees, house call fees, outpatient diagnosis and treatment fees, remote diagnosis and treatment fees, medical guidance service fees, etc.

2. Special medical service fees such as expedited examination and treatment fees, roll call (appointment) medical service fees, ward round fees, self-recruited special nurse fees, door-to-door service fees, discharge follow-up fees, full mother-child system services, etc. .

3. Medical record production costs, computer query and management fees, various bill production costs, etc.

(2) Non-disease treatment items:

1. Various beauty treatments such as freckles, acne, dark spots, warts, acne, freckle removal, pigmentation and hair loss (including alopecia areata) , gray hair, mole removal, ear piercing, saddle nose, breast augmentation, single eyelid to double eyelid, massage and beauty and other projects.

2. Various plastic surgery, orthopedics (except for sequelae of poliomyelitis) and physical defects treatment such as body odor removal, hare lip repair, stuttering correction, squint correction, polydactyly (toe) removal, circumcision, " O" shaped legs, "X" shaped legs, refractive errors, vision correction and other surgical items.

3. Diabetes decision support system, sleep breathing monitoring system, trace element detection, bone density measurement, human body information diagnosis, computer selection of the best pregnancy period, fetal gender and fetal development examination and other diagnostic and treatment items.

4. Various diagnosis and treatment projects for weight loss, weight gain, height gain, bodybuilding, and smoking cessation.

5. Various health examinations. 6. Various preventive and health-care diagnosis and treatment items.

7. Various medical consultations (including psychological prediction, health prediction, diet consultation, disease consultation), various predictions (including stroke prediction, health prediction, disease prediction,) various identifications (forensic identification, Work-related injury identification, labor identification, medical identification, paternity identification), health guidance and other projects.

(3) Therapeutic equipment and medical materials:

1. Large medical devices such as cytosurgery, positron-emitting segmental device PET, electron beam CT, ophthalmic excimer laser therapy equipment, etc. Equipment inspection and treatment items.

2. Glasses, prosthetic eyes, dentures, prosthetic limbs, hearing aids, brain-boosting equipment, leather (steel) vests, steel waistbands, steel necks, stomach supports, kidney supports, scrotal supports, pessaries, crutches , wheelchairs, deformed insoles, medicated pillows, medicated pads, hot compress bags, tourniquets, infusion nets, cremasteric belts, hernia belts, knee braces, artificial anal bags and other equipment.

3. Various household inspection and testing instruments (devices), treatment instruments (devices), physical therapy instruments (devices), massagers, magnetic therapy supplies and other treatment equipment.

4. Diagnosis and treatment projects using medical instruments, equipment and medical materials that do not comply with national or provincial regulations on the management and supervision of medical instruments, equipment and medical materials.

5. Disposable medical materials that cannot be charged separately according to the provincial price department.

(4) Treatment item categories:

1. Organ sources or tissue sources for various types of organ or tissue transplantation and related operations to obtain organ sources and tissue sources, etc.

2. Other organ or tissue transplantation except kidney, heart valve, cornea, skin, blood vessel, bone, and bone marrow transplantation.

3. Diagnosis and treatment items such as microwave (radio frequency) treatment for prostatic hyperplasia, helium-neon laser intravascular irradiation (blood therapy), new analgesia technology after anesthesia and surgery (analgesic bed), endoscopic retrograde appendography, etc.

4. Dental dentures, dental implants, dental implants, orthodontics, yellow and black teeth, missing teeth, stained teeth, baked magnetic teeth and other diagnostic and treatment items.

5. Qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, posture therapy, psychotherapy and suggestion therapy (except for mental patients), dietary therapy, nutritional therapy and other auxiliary services treatment program.

6. Diagnosis and treatment items for various infertility (pregnancy) diseases, sexual dysfunction and ultra-family planning.

7. Various scientific research, teaching, and clinical verification diagnosis and treatment projects.

Diagnosis and treatment items for which basic medical insurance pays part of the cost

(1) Diagnosis and treatment equipment and medical materials:

1. Application of r-knife, x- Knife, , color Doppler, medical linear accelerator and other large medical instruments for inspection and treatment projects.

2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy projects.

3. Various clinical monitoring (except intraoperative and postoperative monitoring).

4. Disposable medical materials that can be charged separately as stipulated by the provincial price department.

(2) Treatment items:

1. Hemodialysis and peritoneal dialysis treatment items.

2. Perform kidney, heart valve, cornea, skin, blood vessel, bone, and bone marrow transplant operations.

3. Artificial organs and bodies for internal replacement such as pacemakers, artificial valves, artificial joints, intraocular lenses, various stents, various staplers, various catheters, implanted drug delivery devices, etc. Built-in placement materials and installation or placement of surgical items.

4. Surgical projects such as cardiac bypass, cardiac catheter balloon dilatation, and cardiac radiofrequency ablation.

5. Coronary angiography, laparoscopic and thoracoscopic surgery, cardiac laser drilling, T lymphocyte reinfusion method in tumor biological treatment, prostate resection, tumor thermal therapy and other diagnostic and treatment items.

6. Various microwave, spectrum, far-infrared, photon (liquid therapy) and other auxiliary treatment items.

Legal basis:

"Social Insurance Law of the People's Republic of China"

Article 27 Individuals who participate in the basic medical insurance for employees must meet the statutory If the accumulated contributions at retirement age reach the number of years prescribed by the state, they will no longer pay basic medical insurance premiums after retirement and enjoy basic medical insurance benefits in accordance with the provisions of the state; if they have not reached the number of years prescribed by the state, they can pay premiums up to the number of years prescribed by the state.

Article 28 Medical expenses that comply with the basic medical insurance drug catalog, diagnosis and treatment items, medical service facility standards, and emergency and rescue expenses shall be paid from the basic medical insurance fund in accordance with national regulations.

Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit.

The social insurance administrative department and the health administrative department should establish a medical expense settlement system for medical treatment in other places to facilitate insured persons to enjoy basic medical insurance benefits.

Article 30 The following medical expenses are not included in the payment scope of the basic medical insurance fund:

(1) Should be paid from the work-related injury insurance fund;

( 2) Should be borne by a third party;

(3) Should be borne by the public health department;

(4) Seek medical treatment abroad.

Medical expenses should be borne by a third party in accordance with the law. If the third party fails to pay or the third party cannot be identified, the basic medical insurance fund shall pay first. After the basic medical insurance fund has paid in advance, it has the right to recover compensation from the third party.