最近不少人在讨论医保的事，我一个同事就跟我提起，说自己最近去医院配了点保健品，想用医保卡付钱，结果被告知不能报销。这件事儿让她有点困惑， 觉得既然参加了医保，所有的医疗相关支出都应该报销才对。 其实这是很多人的理解误区。医保虽然叫"医疗保险"，但它的保障范围并不是无限制的。最近我专门了解了一下2025年的医保政策，发现有6类费用早就被 明确踢出了医保报销的范围。这个事情说大不大，说小不小，关系到咱们每个参保人的钱袋子，很有必要聊清楚。 先说医保的基本规则是什么。医保报销遵循的是目录管理制度，俗称"医保三大目录"，就是药品目录、诊疗项目目录和医用耗材目录。在这三个目录范围内 的费用，医保基金才会按比例报销。但这还不是全部，即使在目录内的费用，也必须满足一定的条件才行。 第一类踢出的费用是工伤相关的。如果你在工作中发生了事故，被认定为工伤，那产生的医疗费用应该由工伤保险来报销，而不是基本医保。这是两个不同 的保险制度，不能重复报销。有人可能会想，那我能不能两个都报啊？答案是不行的。国家规定得很清楚，应当从工伤保险基金中支付的，医保就不报。 第五类是养生保健、体育健身和健康体检这一类费用。这也是最容易被人搞混的一类 ...

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].