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 toward medical insurance. If we don't know how to reasonably use medical insurance for reimbursement, isn't that money wasted?

Understanding this issue is akin to 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 what to do 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 the content... This video ends here; you won't be able to claim reimbursement.

If you haven't made a mistake, then now you can go to the hospital with your medical insurance card, 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 may require you to pay by other means.

Why is this?

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

If you have a job that pays into the five insurances and one fund, then your medical insurance is the "Basic Medical Insurance for Urban Employees," abbreviated as "Employee Medical Insurance." If you are a student, a farmer, or a wealthy second-generation who has never worked, then your medical insurance is the "Basic Medical Insurance for Urban and Rural Residents," abbreviated as "Resident Medical 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 medical insurance is: "Resident Medical Insurance" has lower contributions and provides less coverage, and it is paid annually. In contrast, "Employee Medical Insurance" has higher contributions and provides more coverage, and after retirement, you can still have medical insurance without paying.

Moreover, the accounts for Employee Medical 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 personal account of "Employee Medical Insurance."

If you have Employee Medical Insurance and there is money in your personal account, you can pay directly after registration. If the money in your personal account is exhausted, you will need to pay by other means. If you have Resident Medical Insurance, you can only pay by other means.

But don't worry, no matter what payment method you use for registration, 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, that's great, I've 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 in cash, it does not mean "medical insurance reimbursement."

As mentioned earlier, the accounts for Employee Medical 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 Medical Insurance does not count as "public funds"; that is your own hard-earned money!

Take a look at your pay stub; it will show "Medical Insurance - Company 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 a special fund 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 Medical Insurance does not have a personal account. The medical insurance contributions from everyone, combined with government subsidies, create a single large account.

But regardless of which type of medical insurance you have, you can only claim "medical insurance reimbursement" if you use the money from this "large account." 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 to claim reimbursement with your medical insurance card?

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 means you can only claim reimbursement after reaching this deductible; any expenses below this threshold must be paid out of pocket.

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

Therefore, the portion between the deductible and the ceiling is the reimbursable portion. The specific values of these two lines vary by region. The exact reimbursement ratio also differs from place to place.

However, the same principle applies: Resident Medical Insurance has a lower deductible but also a lower reimbursement ratio; Employee Medical Insurance has a higher deductible, but once you exceed that deductible, the reimbursement ratio is also higher.

For outpatient visits, the deductible in most cities is accumulated annually. For example, if the outpatient deductible is 100 yuan, it means that regardless of how many times you visit the hospital, you will start getting reimbursed from the 101st yuan you spend this year.

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

It's worth mentioning 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 if you're interested.

But honestly, you don't have to look... Because when you go to the hospital, 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, so you don't need to worry about which medications are reimbursable or how the specific reimbursement ratio is calculated.

So what should you pay attention to that you can decide? It's which hospitals you go to for treatment, as that can affect how much you can get reimbursed.

Taking Beijing as an example, look at these two images showing the reimbursement ratios for Resident Medical Insurance and Employee Medical 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 assess 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 coverage for everyone present.

To accommodate so many people, the medical insurance system naturally tends to encourage everyone to go to small hospitals for minor ailments; if small hospitals cannot resolve the issue, then go to large hospitals. If everyone rushes to the top-tier hospitals for every little headache or fever, wouldn't that overwhelm them?

Additionally, it's worth noting 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 differ, 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 another level of hospital.

But please note, the deductible, reimbursement, large hospitals, small hospitals, etc., are all based on one fundamental premise: 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 a contract with them as your exclusive designated medical institutions. If you go to the designated hospital you selected, 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 also have hospitals that do not require separate contracts and will allow you to claim 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 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 towards the deductible, so I will have to start accumulating the deductible from scratch when I go to the designated hospital later. However, this does not apply to emergencies.

Some friends might be thinking, oh, 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 directly visit 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 take effect 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 claim reimbursement.

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 you do, the reimbursement ratio is higher. In some cities, ordinary outpatient services can only be reimbursed at small hospitals.

Additionally, if you need to be hospitalized, the reimbursement differences among hospitals of different levels 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 remind students specifically.

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

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

Are there any middle or primary school students among the viewers? If so, give a thumbs up; if you're pretending to be young, give a zero. The customization for middle and primary school students' medical insurance is that the premium differs from adults, as it is effectively paid when tuition is paid. 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 chosen designated medical insurance hospital or another hospital that allows reimbursement without selection, and register with your medical insurance card;

If the amount you spent has not reached the deductible, you will need to pay with cash or the money in your personal account from Employee Medical 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 final amount you pay, whether by swiping your medical insurance card or cash, will already reflect 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, cross-regional referrals, and major illness insurance.

First, if you are a college student and need to be referred from the school infirmary to see a doctor outside, you will not be able to directly calculate reimbursement 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 infirmary;

For cross-regional medical treatment, remember to submit an application for cross-regional medical treatment on WeChat or Alipay, and you can claim reimbursement when you see a doctor in another city. However, sometimes it cannot be reimbursed directly, so you will need to keep your medical records and invoices, pay upfront, and then seek reimbursement from the medical insurance bureau later.

If you have a chronic illness, remember to register for "outpatient chronic special disease" to claim more reimbursement during subsequent treatments, which can be treated as outpatient care but settled at the inpatient reimbursement ratio. 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 may be able to claim reimbursement 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 restrict 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 deductible for "major illness insurance," you can apply for secondary reimbursement.

The discussion about using medical insurance for treatment reimbursement is almost complete. However, you see the progress bar still has a bit left, right? Because besides medical treatment, medical insurance has other uses: buying medicine, getting vaccinations, purchasing commercial insurance, and even sharing with family members. These are all practical ways to save money. If you spend less at the hospital, you definitely want to keep reading.

Let's start with 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 be reimbursed just like for outpatient visits.

Even if your city has not started the pilot program yet, as long as you have Employee Medical 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 your personal account is still your own, it cannot be withdrawn, so it feels better than paying cash directly. Currently, most cities only support offline card swiping; however, 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 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 are unaware of is that in some places, medical insurance can also be used to purchase commercial insurance. This is not yet possible in Beijing, but many places support it. For example, if you are in a region with free shipping and feel that you or your family need to buy some commercial insurance in addition to basic medical insurance, and if the balance in your personal account is sufficient, you can use it to pay the premium, which is a practical use of the funds.

Another great feature is that the money in your personal account can also be used by family members. This means that by linking accounts, family members can withdraw money from the main account. This is to avoid situations where some family members have accumulated 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 in 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 Medical Insurance or Resident Medical Insurance, they can pool their resources.

We have discussed so much, such as your own insurance information, personal account balance, and various functions like family pooling, most of which 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: there are some situations where you should not use medical insurance.

For example, if you have a work-related injury, you should use work injury insurance; if you have a liability accident, you should have the responsible party cover the medical expenses. In cases where someone else can pay, if you directly swipe your medical insurance card, that would be a significant loss.

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

Quick Look! Six Tips to Save Money on Medical Insurance - Tencent News Medical insurance cards are essential, as important as ID cards! How to use the medical insurance card is often only partially understood! For example, what is a designated hospital, how to register for cross-regional medical treatment, 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, helping 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 your medical insurance card cannot be swiped, it is either because there is no money left or you went to the wrong hospital.

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

How to use the medical insurance card is often only partially understood! For example, what is a designated hospital, how to register for cross-regional medical treatment, 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, helping you save a significant amount! Let's take a look one by one!

Choose the Right Designated Hospital

When reimbursing, if you find that your medical insurance card cannot be swiped, it is either because there is no money left 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 a nearby hospital is a designated hospital, here’s a quick way to check:

Log in to 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 Medications in the Directory

What can be reimbursed by medical insurance and what cannot be reimbursed is hidden in the 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 need to spend your own money!

Category B Drugs: Available for clinical treatment choices, effective, and among similar drugs, those slightly higher in price than Category A drugs. Individuals need to pay a certain proportion (varies by region), and the remaining amount is reimbursed by medical insurance, generally at a rate of 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 out-of-pocket payments, and some require full out-of-pocket payments.

Service Facility Directory

Mainly includes bed fees; ordinary wards can be reimbursed, while VIP wards require out-of-pocket payments. 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 will 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 outpatient and emergency services for employees are as follows:

Key Point:

For minor ailments, if a community hospital can treat you well, it's 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 be lower.

Never Let Your Medical Insurance Lapse

Resident medical insurance is paid annually, while Employee Medical Insurance requires 20-25 years of contributions to enjoy lifelong medical insurance benefits.

In most regions, if your 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 3-6 months, during which you cannot claim medical insurance reimbursement, and it will be considered a new enrollment, recalculating the continuous coverage period.

Key Point:

You must not let your medical insurance lapse! If it accidentally lapses, it's 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 Medical Insurance or Resident Medical Insurance and pay on time, you can automatically enjoy it.

After the first reimbursement, if the out-of-pocket portion exceeds 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, it will automatically activate, and the amount will be settled together with the first medical insurance payment at discharge, reflected in the discharge settlement statement! Very user-friendly.

Register for Cross-Regional Medical Treatment in Advance

After registering for cross-regional medical treatment, you can settle directly with your medical insurance card when you are discharged, just like normal treatment!

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

Search for the "National Cross-Regional Medical Treatment Registration" mini-program on WeChat, click "Cross-Regional Medical Treatment Registration Application," 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.

Cross-Regional Registration Suitable Groups:

Long-term residents: Employees on long-term assignments or elderly people helping their children take care of grandchildren
Cross-regional referrals: If local treatment is ineffective and you need to go to a large city for treatment
Temporary emergencies: Sudden illnesses during travel or business trips

Key Point:

The principle for settling cross-regional medical treatment is: based on the local directory, following the insurance policy of the insured location.

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

How much is reimbursed, what the deductible is, what the reimbursement ratio is, and what the maximum reimbursement amount is... These are all executed according to the policy of the insured location.

Original Title: Six Simple Tips for Saving Money on Medical Insurance, Essential for Medical Treatment