Medical Insurance Savings Guide

China's medical insurance system is a vast network covering over a billion people, with 95% of individuals having medical insurance and having paid into it.

A few months ago, a friend asked us, "How can I use my medical insurance for reimbursement?" We realized that this is not a simple matter. Even among colleagues at Chai Si, few could clearly explain the details. Meanwhile, every month, a portion of our salary goes towards medical insurance. If we don't know how to reasonably use our medical insurance for reimbursement, isn't that money wasted?

Understanding this issue is like making money. So we decided to create a "Medical Insurance Savings Guide"—this will inevitably involve explaining some basic concepts, terms, and policies related to medical insurance, but the focus is that even if you don't understand the specific details, we will tell you exactly how to maximize your use of medical insurance and save money.

To clarify this matter, this video will be a bit lengthy. For your convenience, we have added segment information. Without further ado, let's get started!

Text version

If you want to use medical insurance for reimbursement, the first thing to remember is that whether you register online or in person, as long as you have a medical insurance card, regardless of whether there is money on it, you must choose to register with the "medical insurance card" instead of "self-pay." If you get this step wrong, unless it's an emergency, you can stop reading the rest of this content... This video ends here; you won't be able to reimburse.

If you haven't made a mistake, then now you take your medical insurance card to the hospital, and you might be able to register and pay directly. However, it may also be the case that you can only register but not pay, as the window requires you to pay by other means.

Why is that?

First of all, although everyone has a medical insurance card, not everyone's insurance is the same.

If you have a job that pays five insurances and one fund, then your medical insurance is "Urban Employee Basic Medical Insurance," abbreviated as "Employee Insurance." If you are a student, a farmer, or a rich second generation who has never worked, then your medical insurance is "Urban-Rural Resident Basic Medical Insurance," abbreviated as "Resident Insurance." Except for a few cities like Shenzhen, the medical insurance across the country is divided into these two types.

The simplest way to understand the difference between the two types of insurance is: "Resident Insurance" pays less and covers less, and it is paid annually. In contrast, "Employee Insurance" pays more, covers more, and after retirement, you still have medical insurance without paying.

Moreover, the accounts for Employee Insurance are divided into "personal accounts" and "pool funds." When we refer to "the money in the medical insurance card," we mean the money in the "Employee Insurance" personal account.

If you have Employee Insurance and there is money in your personal account, you can pay directly after registering. If the money in your personal account runs out, you will have to pay by other means. If you have Resident Insurance, you can only pay by other means.

But don't worry, regardless of how you pay for the registration step, it does not affect your subsequent enjoyment of medical insurance reimbursement.

If you can pay using the personal account of your medical insurance card, you might feel, wow, this is great, I made a profit? When we first used it, we thought the same, we were so happy.

However, we must regretfully correct a misconception that many people, including ourselves, once had: just because you swipe your medical insurance card to pay and didn't pay cash, it does not mean "medical insurance reimbursement."

As mentioned earlier, the accounts for Employee Insurance are divided into "personal accounts" and "pool funds." Since we are talking about "reimbursement," it must involve using "public funds." The personal account in Employee Insurance does not count as "public funds"; that is your own hard-earned money!

Look at your payslip; there will be an item for "medical insurance - unit deduction." This money is deducted from your salary, plus a portion directly deposited by your company, all of which goes into your personal account. The money in the personal account is earmarked for medical expenses; although it cannot be withdrawn, it is essentially your own money.

"Public funds" refer to the "medical insurance pool fund," which is a large account contributed by your company and other local companies.

Resident Insurance does not have a personal account. The medical insurance money paid by everyone, combined with government subsidies, creates a single large account.

But regardless of which type of insurance you have, only when you use the money from this "large account" can it be called "medical insurance reimbursement." Spending your own personal account money on medical expenses does not count as reimbursement!

The next question is, how much do you need to spend with your medical insurance card to get reimbursed?

First, the registration fee is calculated separately and has already been reimbursed when you paid.

As for other expenses, you may have heard that medical insurance has a "deductible," which must be reached before reimbursement can occur; expenses below the deductible must be paid out of pocket.

In fact, there is not only a "deductible" but also a "ceiling," and expenses exceeding the ceiling cannot be reimbursed.

So the portion between the deductible and the ceiling is the reimbursable portion. The specific values of these two lines vary by region. The specific reimbursement ratio also varies by region.

However, the same is true: Resident Insurance has a lower deductible but also a lower reimbursement ratio; Employee Insurance has a higher deductible, but once the deductible is exceeded, the reimbursement ratio is also higher.

For outpatient visits, the deductible in most cities is accumulated annually. For example, an outpatient deductible of 100 yuan means that regardless of how many times you visit the hospital, reimbursement starts from the 101st yuan spent this year.

However, hospitalization is different; in most cities, the hospitalization deductible is accumulated per visit. So a hospitalization deductible of 100 yuan means that the first 100 yuan of each hospitalization is not reimbursed, and reimbursement starts from the 101st yuan each time.

It should be noted that the "deductible" policy varies by region. Most areas have a two-tier system, meaning that the portion before the deductible can be paid using personal accounts or cash. The portion after the deductible is reimbursed by the medical insurance pool fund at a certain ratio.

However, places like Shanghai and Hangzhou have a three-tier system, making the calculation more complex. We will provide a document at the end of the video detailing the medical insurance reimbursement rules across the country, which you can check out if you're interested.

But actually, you don't have to look at it... Because when you go to see a doctor, you will have to undergo examinations and prescriptions based on the doctor's judgment, so how much can be reimbursed is already determined. In most cases, the amount you pay at checkout is already the result after reimbursement, and you don't need to worry about which medications can be reimbursed or how the specific reimbursement ratio is calculated.

So what do you really need to pay attention to, which you can decide? It's which hospitals to go to for treatment, as that can lead to more reimbursement.

Taking Beijing as an example, look at these two charts showing the reimbursement ratios for Resident Insurance and Employee Insurance. The entire classification is very complex, but there are only two key points:

First, the reimbursement ratio for hospitalization is higher than for outpatient visits;

Secondly, and more importantly, the reimbursement ratio for small hospitals is higher than for large hospitals!

These two principles apply nationwide.

Whether you go for outpatient treatment or hospitalization is not something we can decide; it requires the doctor to judge based on the actual condition. However, whether to go to a small hospital or a large hospital is something you can decide!

Why is the reimbursement ratio higher at small hospitals? This is actually easy to understand.

The full name of medical insurance is "Basic Medical Insurance." It is not targeted at anyone in particular but aims to provide basic medical security for everyone present.

To accommodate so many people, the medical insurance system will naturally encourage everyone to go to small hospitals for minor ailments; if small hospitals cannot solve the problem, then go to large hospitals. If everyone rushes to the top-tier hospitals for every little ailment, wouldn't that overcrowd them?

Additionally, it should be noted that if the deductible for different levels of hospitals in your city is the same, then expenses incurred at these hospitals can be accumulated towards the deductible. However, if the deductibles are different, even if you have spent money at one level of hospital, you will have to start calculating the deductible from scratch when you go to a different level of hospital.

But please note that the deductible, reimbursement, large hospitals, small hospitals, etc., are all based on one foundation: you must go to a designated medical insurance hospital.

So the next important question is: how to choose your "designated medical insurance hospital."

First, what is a "designated medical insurance hospital"?

This designated hospital does not refer to the dozens or hundreds of hospitals in a city that are connected to medical insurance. Instead, it refers to the need for you to personally select a few hospitals from these dozens or hundreds of "designated hospitals" in places like Beijing, Guangzhou, and Shenzhen, and sign contracts with them as your exclusive designated medical institutions. If you go to the designated hospital you selected for treatment, you can enjoy medical insurance reimbursement once you reach the deductible.

As mentioned earlier, going to a small hospital for treatment results in more reimbursement. Therefore, when choosing your designated medical insurance hospital, our advice is not to select only well-known large hospitals but to choose a combination of small and large hospitals.

Some cities have certain hospitals that do not require separate contracts and will allow you to use medical insurance for reimbursement, such as specialized hospitals and large hospitals in Beijing.

To clarify further, let's take Beijing as an example and assume a scenario:

Today, I am sick and need to go to the hospital. Previously, I selected three designated medical insurance hospitals. In addition, there are some specialized hospitals and large hospitals in Beijing that do not require selection for reimbursement. If I go to these hospitals today, I will have the opportunity to enjoy medical insurance reimbursement. However, if I randomly go to another hospital, then sorry, no matter how much I spend, no one will reimburse me. Moreover, the money I spent cannot be used to accumulate the deductible, so when I go to the designated hospital later, I will have to start accumulating the deductible from scratch. However, emergencies are an exception.

Some friends may be thinking, ah, I randomly selected my designated hospitals before and don't even remember which ones they were. In fact, if you want to change your designated hospital, you can do it directly on the official website of the social security bureau in your city or use a mini-program to handle it online. In places like Beijing, you can apply today and have it effective tomorrow, so there's no need to worry too much.

Moreover, many cities, such as Shanghai, Hangzhou, Nanjing, and Suzhou, do not require you to choose your designated hospital; as long as you go to a designated hospital in the city, you can be reimbursed.

But still, it is emphasized that regardless of whether you need to select a designated hospital, going to a small hospital makes it easier to reach the deductible, and once reached, the reimbursement ratio is higher. In some cities, ordinary outpatient visits can only be reimbursed at small hospitals.

Additionally, if you need to be hospitalized, the reimbursement differences between different levels of hospitals can be even greater. If a small hospital truly cannot treat you, being referred from a small hospital to a large hospital will also increase the reimbursement ratio.

Speaking of referrals, we want to give a special reminder to student friends.

We likely have many college students among our audience. As mentioned earlier, students also have Resident Insurance, but it is a customized "Youth Version" of Resident Insurance.

The difference between college student insurance and regular Resident Insurance is that your designated hospital is your school's health center. We checked several schools, and basically, if you need to see a doctor outside, you must be referred from the school health center to get reimbursement. You cannot go out directly to see a doctor and get reimbursed.

Are there any middle or primary school students among our audience? If so, give a 1; if you're pretending to be younger, give a 0. The customization for middle and primary school students is that their premiums differ from adults, as the medical insurance fee is essentially included when paying tuition. Here, we also want to remind:

Kids, don’t sneakily watch videos; have you finished your homework today?

After discussing this, most people should have a clear understanding of the process for maximizing medical insurance reimbursement. Let's summarize:

First, bring your medical insurance card;

Then go to your selected designated medical insurance hospital or another hospital that does not require selection for reimbursement, and register with your medical insurance card;

If the money you spent has not reached the deductible, you will need to pay with cash or the money in your personal account from Employee Insurance.

If you have reached the deductible, the smaller the hospital you go to, the higher the reimbursement ratio.

In most cases, the system will automatically calculate how much can be reimbursed, and the amount you pay at the end, whether by swiping the medical insurance card or cash, is already the result after reimbursement.

This is the most common process for ordinary people using medical insurance.

Next, we will briefly introduce some special situations involving students, chronic diseases, referrals to other places, and major illness insurance.

First, if you are a college student and are referred from the school health center to see a doctor outside, the reimbursement cannot be directly calculated in the system; you will need to pay upfront, keep your medical records and invoices, and manually apply for reimbursement from the medical insurance bureau or the school health center;

For medical treatment in other places, remember to submit an application for medical treatment in other places on WeChat or Alipay; you can get reimbursed for seeing a doctor outside. However, sometimes it cannot be reimbursed directly, so you will need to keep your medical records and invoices, pay upfront, and then apply for reimbursement from the medical insurance bureau later.

If you have a chronic illness, remember to register for "outpatient chronic special diseases." This will allow you to get more reimbursement during subsequent treatments, almost as if you are being treated as an inpatient. You can find the specific registration process in your city's medical insurance public account.

Finally, if you have spent a lot of money on medical treatment, you might be able to get reimbursed again. This is because the premium you pay each year includes a "major illness insurance" policy, also known as "secondary reimbursement." Please note that although it is called "major illness" insurance, it does not limit the specific types of illnesses; it only looks at the amount spent on treatment. If the out-of-pocket portion after medical insurance reimbursement exceeds the "major illness insurance" deductible, you can apply for secondary reimbursement.

The discussion about using medical insurance for reimbursement is nearly complete. However, you see the progress bar still has a bit left, right? Because besides medical treatment, medical insurance has other uses: it can be used to buy medicine, get vaccinations, purchase commercial insurance, and even be shared with family members. These are all practical ways to save money. If you spend less at the hospital, you should definitely keep reading.

First, let's talk about buying medicine.

People generally think that reimbursement is only possible when buying medicine at the hospital, but in the past two years, various places have been trying to include purchasing medicine at pharmacies under outpatient coverage. This means that in pilot areas, if you take a prescription from the hospital to a pharmacy, it will also count towards this year's outpatient expenses, and once you reach the deductible, you can get reimbursed just like for outpatient visits.

Even if your city has not started the pilot program, as long as you have Employee Insurance, you can use the balance in your personal account to pay for medications listed in the medical insurance directory at designated pharmacies—yes, although the money in the personal account is your own, it cannot be withdrawn, so it feels better than paying cash directly. Currently, most cities only support offline card swiping, while places like Hangzhou and Jinhua have recently started piloting online purchases of medicine using medical insurance.

In addition to buying medicine, you can also use it for vaccinations. For example, if you go to get a flu vaccine or HPV vaccine, although they are not included in the medical insurance reimbursement directory, you can still use the money in your personal account to pay.

Another use that many people do not know about is that in some places, medical insurance can also be used to purchase commercial insurance. This is not yet possible in Beijing, but many other places support it. For example, if you are in a free shipping zone and feel that you or your family need to buy some commercial insurance in addition to basic medical insurance, and if your personal account balance is sufficient, you can use it to pay the premium, which is a good use of resources.

Another great feature is that the money in your personal account can also be used for family members. By binding accounts, family members can transfer money from the main account. This avoids situations where some family members have a lot of money in their personal accounts that they cannot use, while others do not have personal accounts or have exhausted their balances and can only pay cash. This policy is called "family pooling." As long as parents, children, and spouses, who are direct relatives, participate in basic medical insurance, whether Employee Insurance or Resident Insurance, they can pool resources as a family.

We have discussed so much, such as your own insurance information, personal account balance, and various functions like family pooling. Most of these can be found in apps like WeChat, Alipay, and the National Medical Insurance Service Platform. Some operations may require logging into the local government service platform on a computer. With a little exploration, you should be able to find most of it.

Additionally, a reminder: do not use medical insurance in certain situations.

For example, if you have a work-related injury, you should use work injury insurance; if you are involved in a liability accident, the responsible party should cover the medical expenses. In situations where someone else can pay, using your own medical insurance card would be a significant loss.

Finally, according to the standards of a health-related topic, we should wish you good health and never need to understand this knowledge or step into a hospital. However, as a popular science media outlet, we must acknowledge that everyone will need to go to the hospital and face unexpected situations. We cannot help you prepare physically or mentally, but we hope this video can help you prepare financially as much as possible.

Quick look! Six tips for saving money with medical insurance - Tencent News Medical insurance cards are essential for everyone, as important as ID cards! Many people have only a vague understanding of how to use medical insurance cards! For example, what is a designated hospital, how to register for medical treatment in another place, how to apply for secondary reimbursement, etc.! Based on everyone's inquiries, we have summarized six major tips for saving money on medical insurance reimbursement to help you save a significant amount! Let's take a look one by one!

01 Choose the right designated hospital When reimbursing, if you find that the medical insurance card cannot be swiped, it is either because there is no money left in the card or you went to the wrong hospital.

Medical insurance cards are essential for everyone, as important as ID cards!

Many people have only a vague understanding of how to use medical insurance cards! For example, what is a designated hospital, how to register for medical treatment in another place, how to apply for secondary reimbursement, etc.!

Based on everyone's inquiries, we have summarized six major tips for saving money on medical insurance reimbursement to help you save a significant amount! Let's take a look one by one!

Choose the right designated hospital

When reimbursing, if you find that the medical insurance card cannot be swiped, it is either because there is no money left in the card or you went to the wrong hospital.

Key point:

Medical insurance reimbursement must be at designated hospitals or pharmacies!

Going to the wrong hospital will not be reimbursed!

If you are unsure whether the nearby hospital is a designated hospital, here’s a quick way to check:

Log into the National Medical Insurance Service Platform APP, click on "Designated Medical Institutions" in the "Query Service" section on the "Home" page, and you can check with one click~

Prioritize using medications within the directory

What can be reimbursed by medical insurance and what cannot be reimbursed is hidden in three major directories:

Drug Directory

Category A Drugs: Essential for clinical treatment, widely used, effective, and among similar drugs, those with lower prices. Medical insurance reimburses 100%, and you don't have to spend your own money!

Category B Drugs: Available for clinical treatment choices, effective, and among similar drugs, those with slightly higher prices than Category A drugs. Individuals need to pay a certain percentage (varies by region), and the remaining amount is reimbursed by medical insurance, with reimbursement ratios generally between 60%-90%.

Based on the existing classification of Category A and B drugs, the National Medical Insurance Bureau will research and formulate a Category C Drug Directory, with plans to release the first version within the year.

Diagnosis and Treatment Directory

Includes treatment fees, examination fees, surgical fees, etc. Some can be reimbursed by medical insurance, some require partial out-of-pocket payment, and some must be fully paid out of pocket.

Service Facility Directory

Mainly includes bed fees; ordinary wards can be reimbursed, while VIP wards must be paid out of pocket. Additionally, ambulance fees and caregiver fees cannot be reimbursed.

Key point:

When seeking treatment at a hospital, it might be helpful to remind the doctor to prioritize medications within the medical insurance coverage when the efficacy is similar, so that medical insurance can reimburse you! The same applies to the diagnosis and treatment directory and service facilities!

Don't go to large hospitals for minor ailments

The principle of medical insurance reimbursement is: the higher the hospital level, the lower the reimbursement ratio, meaning you pay less!

Hospital Level Classification:

Tertiary hospitals, such as top-tier hospitals
Secondary hospitals, such as second-tier hospitals
Primary hospitals, such as community hospitals

Taking Shanghai as an example, the reimbursement benefits for employees for outpatient and emergency visits are as follows:

Key point:

For minor ailments, if a community hospital can treat you well, it is better not to go to a top-tier hospital, as you will often have to wait in long lines, and the reimbursement ratio for medical insurance will decrease.

Never let medical insurance lapse

Resident insurance is paid annually, while Employee Insurance must be paid for 20-25 years to enjoy lifelong medical insurance benefits.

In most regions, if medical insurance lapses for two months, you will not be able to enjoy medical insurance benefits. If you make up the payment within three months, you can use it normally the following month, and it will be considered continuous coverage.

If you make up the payment after more than three months, there will be a waiting period of three to six months during which you cannot reimburse medical insurance, and it will be considered as re-enrollment, resetting the continuous coverage years.

Key point:

Make sure not to let your medical insurance lapse. If it accidentally lapses, it is best to make up the payment within three months.

Medical insurance can be reimbursed twice

Secondary reimbursement refers to the major illness medical policy of medical insurance. In most cities, you do not need to pay extra; as long as you participate in Employee Insurance or Resident Insurance and pay on time, you can automatically enjoy it.

After the first reimbursement, if the out-of-pocket expenses exceed a certain amount (varies by region), you can apply for secondary reimbursement through major illness insurance.

Do you need to apply for secondary reimbursement?

No application is needed! As long as the out-of-pocket expenses exceed the secondary reimbursement deductible, the secondary reimbursement will automatically activate, and the amount will be settled together with the first medical insurance payment upon discharge, reflected in the discharge settlement statement! Very user-friendly.

Register for medical treatment in another place in advance

After registering for medical treatment in another place, you can settle directly with your medical insurance card upon discharge, just like normal treatment!

The registration process is very simple and can be done online:

Search for "National Medical Treatment in Another Place Registration" mini-program on WeChat, click on "Application for Medical Treatment in Another Place," and follow the prompts step by step.

If your local area does not support online registration, you need to consult the local medical insurance center to see if you can register by phone or in person.

Groups suitable for medical treatment in another place:

Long-term expatriates: employees sent abroad for a long time or elderly people helping their children take care of grandchildren
Referrals to other places: if local treatment is ineffective, you need to go to a large city for treatment
Temporary emergencies: sudden illnesses during travel or business trips

Key point:

The settlement for medical treatment in another place follows the principle: directory for the place of treatment, policy of the insured location.

What can be reimbursed and what cannot be reimbursed is based on the three major directories of the place of treatment.

How much can be reimbursed, what the deductible is, what the reimbursement ratio is, and what the maximum reimbursement amount is... all these follow the policies of the insured location.

Original title: Six simple tips for saving money with medical insurance, essential for seeing a doctor.