"Policy interpretation · question and answer"
Original title: Outpatient and family mutual aid policy for more than 3 years in employee medical insurance personal account (introduction)
Can the money in the medical insurance card be used by the family? Subject
People's Daily reporter Sun Xiuyan
"My father is ill, and there is money in my personal medical insurance account. Can he use my payment? How should I operate?" Although the outpatient family mutual aid policy for personal medical insurance account of employees has been issued for more than three years, such questions are still common. Can the money in the medical insurance card be used by the family? Recently, the relevant person in charge of the National Health Insurance Bureau answered the question.
The balance of individual medical insurance account can be authorized to the insured spouse, parents and children
Q: Can the money in the medical insurance card be used by the family?
Answer: "Money in the medical insurance card" refers to the balance of the employee's personal medical insurance account. In April 2021, the General Office of the State Council issued the Guiding Opinions on Establishing and Improving the Outpatient Mutual Financial Security Mechanism of Basic Medical Insurance for Employees. The Opinions proposed to standardize the use scope of individual accounts. The individual account is mainly used to pay the self paid expenses incurred by the insured in the designated medical institutions or designated retail pharmacies within the policy scope. It can be used to pay the individual medical expenses incurred by the insured person and his/her spouse, parents and children in the designated medical institution, as well as the individual expenses incurred in purchasing drugs, medical devices and medical consumables in the designated retail pharmacy. Explore individual accounts for individual contributions of spouses, parents and children to participate in basic medical insurance for urban and rural residents.
After participating in the employee medical insurance, the balance of the individual account can be authorized to the insured spouse, parents and children, for example, to pay for the self paid part of the compliance medical expenses by handling the employee medical insurance personal account for family assistance.
For example, Li Xiaoming, Li Ming's son, is ill. Li Xiaoming needs to pay 100 yuan for medical treatment and medicine. There is still a balance in the personal account of Li Ming's employee medical insurance. After handling the family assistance, Li Xiaoming can use the money in the personal account of Li Ming's employee medical insurance to pay the 100 yuan, which is called family assistance.
Q: Can you use family almsgiving as long as you are a family member?
Answer: No. Only the family members who have handled the individual account of employee medical insurance can enjoy the family assistance policy. The personal account fund in the medical insurance card of the employee medical insurance participant can be used by the spouse, parents and children, but it must meet two preconditions: first, the spouse, parents and children have also participated in the basic medical insurance (including employee medical insurance and resident medical insurance); Second, we have handled the individual account of medical insurance for employees and the family assistance. At the same time, it should be noted that family members do not include the parents of their spouses; The aided person cannot enjoy the medical insurance reimbursement treatment of the aided person, that is, the money in the personal account can be used by parents, but how much parents can be reimbursed for medical treatment depends on the medical insurance system they participate in. Those who participate in the employee medical insurance will enjoy the corresponding treatment of the employee medical insurance; Those who participate in resident medical insurance shall enjoy the corresponding treatment of resident medical insurance.
23 provinces have achieved cross regional economic cooperation
Q: How to handle the individual account of employee medical insurance and family assistance?
Answer: The insured (generally the people who help each other) can go online through the functional module of "individual account and family assistance of employee medical insurance" in the local special area of the national medical insurance service platform APP, the WeChat official account of the local medical insurance department, the official website, etc. The specific way is disclosed to the public by the medical insurance department of each planning area. Special groups such as the elderly who are difficult to operate intelligent devices can also be handled in the offline medical insurance hall. It is understood that medical insurance departments across the country have successively developed WeChat applet or APP to facilitate more insured people to enjoy the family solidarity policy.
It can be handled on the national medical insurance service platform APP to prove the relationship between spouse, parents and children, which usually only requires the commitment of the handler. WeChat and Alipay can bind relatives by promise and uploading relevant supporting materials.
Usually, the binding is initiated by the employee medical insurance provider. In Fujian, Xinjiang and Xinjiang Production and Construction Corps, the aid recipients can also initiate binding.
Q: After the successful binding of the masonic relationship, does the mason need additional operations to use his family's masonic account for medical treatment?
A: Most provinces do not need additional operations. They only need to provide their own medical insurance code (card) when settling medical bills. In Guangxi and Sichuan, both the patient's medical insurance code (card) and the medical insurance code of the freemasons need to be displayed when seeking medical treatment. After the successful binding of the masonic relationship, the patient can call up the medical insurance code of the masonic person in the mobile phone.
In addition to mutual aid in the same basic medical insurance planning area (usually the same prefecture level city), 23 provinces, including Hebei and Shanxi, have realized mutual aid among families not in the same planning area; Zhejiang, Shandong, Henan and Guangdong have partially achieved mutual aid in the province, which will be fully realized by the end of the year; Anhui and Shaanxi will realize mutual aid in the province in the near future; Liaoning, Heilongjiang and Hubei will be realized before the end of the year.
The patient's medical insurance card must be used for medical treatment and drug purchase. The family can help the elderly with mobility problems buy drugs on behalf
Q: Whose medical insurance card should be used for medical treatment and drug purchase after family almsgiving?
A: In any case, the patient's medical insurance card must be used for medical treatment and drug purchase. The family mutual aid policy "mutual aid" refers to the money in the personal account of the employee medical insurance participant's medical insurance card, rather than the medical insurance card itself.
The medical insurance follows the principle of "I am insured and I enjoy treatment". This principle will remain unchanged after the family helps each other. The insured person will still use his/her medical insurance card to see a doctor and enjoy his/her medical insurance benefits according to regulations. It is generally understood that money can be shared, but cards cannot be shared.
Q: What are the consequences of not using your medical insurance card for medical treatment?
Answer: Not using your medical insurance card to register for medical treatment is "going to see a doctor under false name", which may cause suspension of online settlement of medical expenses, or even constitute a crime.
The so-called "medical treatment under false name" refers to the act of fraudulently using other people's medical insurance vouchers for the purpose of illegal possession, registering for medical treatment in designated medical institutions and enjoying medical insurance settlement treatment to defraud medical insurance funds. "Others" here refers to anyone other than the insured, including family members.
Article 17 of the Regulations on the Supervision and Administration of the Use of Medical Security Fund clearly stipulates that the insured shall take their own medical security certificates to seek medical treatment and purchase medicines, and take the initiative to present them for inspection. Article 41 also clearly states that if the medical security certificate is handed over to another person for use under a false name, which causes losses to the medical security fund, it shall be ordered to return it; For the insured, the online settlement of medical expenses will be suspended for 3 to 12 months. If the amount involved is large and the circumstances are serious, it will also constitute a crime of fraud.
Q: The elderly in the family have difficulty moving. Can children buy medicine for them?
Answer: Yes. Article 17 of the Regulations on the Supervision and Administration of the Use of Medical Security Fund clearly stipulates that if it is necessary to entrust others to purchase drugs for special reasons, the identity certificates of the trustor and trustee shall be provided. Children can buy medicine for the elderly under special circumstances such as mobility difficulties. However, when purchasing drugs, it is necessary to use the medical insurance card of the drug user and show the identity certificates of the client and trustee.
