医保报销有了“新变化”？这“6项”费用或将踢出报销名单，事关参保人的利益

Core Viewpoint - The article discusses the limitations of medical insurance (医保) coverage, highlighting six categories of expenses that are explicitly excluded from reimbursement under the 2025 medical insurance policy. It emphasizes the importance of understanding these exclusions to manage personal healthcare expenses effectively [1][9]. Summary by Categories Excluded Expenses - The first category of excluded expenses is those related to work injuries, which should be covered by work injury insurance rather than basic medical insurance [3]. - The second category includes expenses for which a third party is responsible, such as medical costs resulting from an assault or car accident, which should be covered by the responsible party's insurance [3]. - The third category encompasses public health expenses, including vaccinations and disease prevention measures, which are funded by the government and not reimbursed by medical insurance [4]. - The fourth category consists of expenses incurred from medical treatment abroad, including in Hong Kong, Macau, and Taiwan, which are not reimbursed under any circumstances [4]. - The fifth category includes wellness, fitness, and health check-up expenses, which are considered preventive rather than treatment-related and thus not covered by medical insurance [4]. - The sixth category is a broad clause allowing for the exclusion of other expenses deemed non-reimbursable by the national medical insurance authority [6]. Changes in Policy - Starting in 2025, a new incentive mechanism called "zero reimbursement incentive" will be introduced, rewarding individuals who do not use their medical insurance for a year with an increase in the maximum payment limit for major illness insurance, with a minimum increase of 1,000 yuan per year [6]. - Continuous enrollment incentives will also be implemented, allowing individuals who maintain continuous enrollment for four years to increase their major illness insurance limit for each subsequent year of continuous enrollment [6]. - A waiting period for reinstating medical insurance benefits has been established, requiring individuals who have been uninsured for over four years to wait a total of six months before their benefits are restored [7]. - The scope of personal medical insurance accounts will be expanded in 2025, allowing funds to be used for family members' medical expenses, enhancing the efficiency of insurance fund usage [7]. - New reimbursement policies for specific chronic and special diseases have been introduced, with some diseases having reimbursement rates as high as 95% and the removal of threshold fees for certain childbirth-related expenses [7]. Overall Implications - The 2025 medical insurance reform aims to balance basic coverage with waste prevention while expanding and optimizing coverage in certain areas [9]. - It is crucial for individuals to understand the boundaries of medical insurance coverage, as it does not cover all medical-related expenses, particularly preventive and wellness costs [9]. - For comprehensive protection, combining medical insurance with commercial health insurance is recommended to cover gaps in the medical insurance system [9].