What Is a Medical Reimbursement Specialist?

Basic medical insurance is a social insurance system established to compensate workers for economic losses caused by disease risks. Through the payment by employers and individuals, a medical insurance fund is established. After the medical expenses incurred by the insured person during the medical treatment, the medical insurance agency will provide certain financial compensation to avoid or reduce the laborer's illness and treatment Economic risk.

basic medical insurance

Basic medical insurance is a social insurance system established to compensate workers for economic losses caused by disease risks. Established by employers and individuals

In December 1998, the State Council issued

Urban employee basic medical insurance

China has established a basic medical insurance system for urban employees, a new rural cooperative medical system, and a basic medical insurance system for urban residents. Among them, the basic medical insurance for urban employees consists of employers and employees jointly paying basic medical insurance premiums in accordance with state regulations, establishing a medical insurance fund, and medical insurance agencies to provide certain financial compensation after medical expenses incurred by insured patients. To avoid or reduce the economic risks of workers due to illness, treatment, etc. The new rural cooperative medical system and the basic medical insurance for urban residents are combined with individual contributions and government subsidies, and treatment standards are implemented in accordance with state regulations.

According to the requirements of the State Council's Decision on Establishing a Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No. 44) ^[3] , the framework of the basic medical insurance system for urban employees includes six parts:

Establish a co-payment mechanism with reasonable burden

The basic medical insurance premiums are jointly paid by employers and individuals, reflecting the compulsory characteristics of national social insurance and the unification of rights and obligations. The medical insurance premiums are paid by the unit and the individual, which can not only expand the source of medical insurance funds, but more importantly, clarify the responsibilities of the unit and employees, and enhance the awareness of personal self-protection. In this reform, the state has stipulated the employer's contribution rate and personal contribution rate control standards: the employer's contribution rate is controlled at about 6% of the total wages of employees, and the specific proportion is determined by the localities. The employee's contribution rate is generally 2% of the employee's wages .

Set up pool funds and personal accounts

The basic medical insurance fund is composed of a pooled fund for social pooling and a personal account fund for personal use. All personal contributions are transferred to personal accounts, and unit contributions are transferred to personal accounts at about 30%, and the remaining part is established as a unified fund. The personal account is used exclusively for personal medical expenses and can be carried forward and used and inherited. The principal and interest of the personal account belong to the individual.

Establish a clear and separate payment mechanism for unified accounts

The unified fund and personal account determine the respective payment scope. The unified fund mainly pays large amounts and inpatient medical expenses, and the personal account mainly pays small amounts and outpatient medical expenses. The unified fund shall determine the minimum payment standard and the maximum payment limit in accordance with the principle of "determining expenditures and balancing expenditures", according to the actual conditions in various places and the fund's affordability.

Establish effective medical service management mechanisms

The payment scope of basic medical insurance is limited to the medical expenses in the prescribed basic medical insurance drug catalogue, diagnosis and treatment programs, and medical service facilities standards; fixed-point management of medical institutions and pharmacies that provide basic medical insurance services; social insurance agencies and basic medical care Insurance service agencies (designated medical institutions and designated retail pharmacies) shall settle the expenses in accordance with the settlement methods stipulated in the agreement.

Establish a unified social management system

Basic medical insurance implements social management at a certain overall level. In principle, administrative units above the prefecture level (including prefectures, cities, states, and alliances) are used as coordinating units, and counties can also be used as coordinating units. The social insurance agency in the coordinating area is responsible The unified collection, use and management of the fund ensure the full collection, reasonable use and timely payment of the fund.

Establish a sound and effective regulatory mechanism

The basic medical insurance fund is managed by a special fiscal account; social insurance

Basic medical insurance (15 photos)

The insurance agency shall establish and improve rules and regulations; the overall planning area shall establish a basic medical insurance social supervision organization to strengthen social supervision. It is necessary to further establish and improve the fund's budget and final account system, financial accounting system, and internal audit system of social insurance agencies.

These contents basically determined the general framework of the new urban employee basic medical insurance system, laid the foundation for the unified national system in the future, and facilitated local governments to follow in formulating reform plans. At the same time, they also left local governments with specific regulations tailored to local conditions. space.