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].

Group 1 - The core concept of the medical insurance wallet is that it allows insured individuals to transfer funds from their personal medical accounts to their close relatives' medical wallets for medical expenses and medication purchases [2][3] - The medical insurance wallet enables cross-province family mutual aid, allowing insured individuals to transfer funds to family members even if they are in different provinces, provided the family members are enrolled in basic medical insurance [3] - The process to open a medical insurance wallet involves logging into the National Medical Insurance Service Platform and confirming the use of the wallet [4][7] Group 2 - The transfer application process requires the sender to fill in the recipient's basic information, including their relationship and the transfer amount, with a minimum transfer amount of 0.01 yuan and a daily limit of three transfers not exceeding 2000 yuan each [18][28] - If the recipient's medical wallet is not opened or the transfer is not accepted in time, the transferred amount will be returned to the sender's account by 6:00 the next day [28] - The medical insurance reimbursement system operates under a directory management system, where only expenses listed in the directory are eligible for reimbursement, and the directory is subject to annual adjustments [31][32]

Group 1 - The core concept of the medical insurance wallet is that it allows insured individuals to transfer funds from their personal medical insurance accounts to the wallets of close relatives for medical expenses, enabling cross-province usage of personal account funds [1] - Previously, personal medical insurance accounts only allowed for intra-province sharing, but now, if the insured has surplus funds, they can transfer money to family members in different provinces as long as those family members are enrolled in basic medical insurance [1] - The medical insurance wallet is linked to the individual's medical insurance code and can be accessed through the National Medical Insurance Service Platform [2][3] Group 2 - The process to open a medical insurance wallet involves logging into the National Medical Insurance Service Platform, confirming the use of the wallet, and completing the registration [5][6] - Once the wallet is successfully opened, users can apply for fund transfers by providing the recipient's basic information and submitting the request [16][22] - There are limits on the number of transfers and the amount that can be transferred daily, with a maximum of three transfers per day and each transfer not exceeding 2000 yuan [28]

Core Points - The article discusses situations where medical insurance (医保) does not provide reimbursement for medical expenses, highlighting six specific scenarios [2][4][5][7]. Group 1: Situations Where Medical Insurance Does Not Cover Expenses - Work-related injuries are covered by work injury insurance, not medical insurance [2]. - Medical expenses from accidents caused by third parties, such as traffic accidents or fights, are not covered unless the responsible party is identified [2]. - Public health services funded by the government, such as free vaccinations and disease prevention, are not reimbursed by medical insurance [2][4]. - Medical expenses incurred while receiving treatment abroad are not covered by medical insurance [4]. - Preventive health measures, such as routine check-ups and wellness treatments, are not included in the coverage [4]. - Only expenses listed in the three major directories (medical insurance drug directory, medical treatment project directory, and medical service facility directory) are eligible for reimbursement [5][7]. Group 2: The Three Major Directories of Medical Insurance - The drug directory includes: - Class A drugs, which are fully reimbursed [8]. - Class B drugs, which require a personal contribution of 10% or 14% [8]. - Non-reimbursable drugs, often expensive or for rare diseases, are excluded from coverage [8]. - The medical treatment project directory includes necessary and effective clinical treatment projects, but excludes cosmetic procedures and certain fees [9]. - The medical service facility directory covers essential services provided by designated medical institutions, but excludes non-essential services like entertainment fees [9].