Whether it's employee health insurance or resident health insurance, there is a starting line and a ceiling, but the reimbursement limit is different depending on the region and is not uniform across the country. In general, the reimbursement limit is closely related to the economic level of the city, some regions have a reimbursement limit of 150,000 yuan, and some regions have a reimbursement limit of only 300,000 yuan. So this depends on the economic level of the region has a relationship.
No matter how much you spend on medical treatment, you should first calculate the amount you can be reimbursed according to the starting line and reimbursement rate of the medical insurance, and remove the out-of-pocket expenses. Assuming that the reimbursable portion exceeds the reimbursement threshold, you won't be reimbursed for the excess.
General outpatient reimbursement is capped at about 20,000 yuan
Inpatient reimbursement is capped at about 300,000 yuan
Some major illnesses have no cap
Medicare reimbursement limits:
Rural:
Outpatient reimbursement is capped at 60% of the total amount paid for outpatient services in the village health center and the village center, with a limit of 10 yuan for prescriptions and 10 yuan for medicines per visit. Limit of 50 yuan per visit, limit of 200 yuan for prescription drugs; Chinese medicine invoice attached to the prescription limit of 1 yuan per sticker; township-level cooperative medical outpatient reimbursement annual limit of 5,000 yuan.
Hospitalization
Reimbursement scope: medicine: auxiliary examination: EKG, X-ray fluoroscopy, filming, laboratory tests, physical therapy, acupuncture, CT, nuclear magnetic **** vibration and other examination fees limit of 200 yuan; surgical fees (with reference to the national standard, more than 1,000 yuan reimbursement of 1,000 yuan). 60 years of age or older hospitalized in a health center, the treatment and nursing care costs are reimbursed 10 yuan per day, limit of 200 yuan. yuan, with a limit of 200 yuan.
Reimbursement rates: township health centers reimburse 60%; secondary hospitals reimburse 40%; tertiary hospitals reimburse 30%.
Major illnesses
Any hospitalized patient who participates in the cooperative medical care will be reimbursed for the one-time or yearly accumulative reportable medical expenses of more than 5,000 yuan, i.e., 5,001-10,000 yuan will be reimbursed at 65%, and 10,001-18,000 yuan will be reimbursed at 70%. The annual limit of compensation for inpatient hospitalization and outpatient blood dialysis for uremia, outpatient radiotherapy and chemotherapy for tumors is 11,000 yuan at the township level cooperative medical treatment.
Self-medical treatment (without designated hospitals for medical treatment or without a referral order), self-purchased medicines, medicines that cannot be reimbursed under the public medical care regulations and medical expenses not in line with family planning; outpatient treatment fees, consultation fees, hospitalization fees, meals, companion fees, nutritional fees, blood transfusion fees (except for those who have a family blood bank, which is reimbursed according to the relevant regulations), heating and cooling, ambulance fees, special care and other expenses; car accidents medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; orthopedics, plastic surgery, dentures, prosthetics, organ transplants, named surgery fees, consultation fees, etc.; reimbursement within the scope of reimbursement, but outside the limit.
Towns:
Town residents who are hospitalized for more than two times in one billing year will no longer be charged the starting standard fee from the second hospitalization. If they are transferred to another hospital or hospitalized for more than two times, the difference will be made up in accordance with the stipulated starting standard of the hospital to which they are transferred or re-admitted.
Students and children
In a billing year, for medical expenses under 180,000 RMB incurred that are eligible for reimbursement, the starting standard for a tertiary hospital is 650 RMB, with a reimbursement rate of 50% and an upper limit of 2,000 RMB; the starting standard for a secondary hospital is 300 RMB, with a reimbursement rate of 60%; and a primary hospital does not set a starting standard, with a reimbursement rate of 65%.
Age 70 and above
In a billing year, for medical expenses of less than 100,000 yuan that are eligible for reimbursement, the starting standard for Level III hospitals is 650 yuan, with a reimbursement rate of 50% and a ceiling of 2,000 yuan; the starting standard for Level II hospitals is 300 yuan, with a reimbursement rate of 60%; and Level I hospitals do not have a starting standard, with a reimbursement rate of 65%.
Other urban residents
In a billing year, for medical expenses of less than 100,000 yuan that are eligible for reimbursement, the starting standard for third-level hospitals is 659 yuan, and the reimbursement rate is 50% with an upper limit of 2,000 yuan; the starting standard for second-level hospitals' hospitalization is 300 yuan, and the reimbursement rate is 55%; and the reimbursement rate for first-level hospitals does not have a starting standard, and the reimbursement rate is 60%.
Employees:
Generally speaking, the economic development of different regions varies, so the reimbursement rate also varies, the following on the situation of the proportion of Beijing employees' health insurance coverage.
After getting medical insurance, if you are an active employee, you can only be reimbursed for medical expenses over 1,800 yuan after visiting the outpatient or emergency clinic of a hospital, and the reimbursement rate is 50%. If you are a retiree under the age of 70, you can be reimbursed for expenses over $1,300, and the reimbursement rate is 70%. If the retiree is over 70 years old, the reimbursement rate is 80 percent for expenses over $1,300.
And regardless of the type of person, the maximum limit for expenses paid for outpatient and emergency major medical expenses is 20,000 yuan. For example, if you are an active employee and you spend $2,500 on an outpatient visit, you can be reimbursed 50 percent of the $500 portion, which is $250.
In the case of hospitalization expenses, the starting amount is $1,300 for the first time you use basic medical insurance to pay in a 2009 year, whether you are an active employee or a retiree. And for the second and subsequent hospitalization medical expenses, the starting amount is determined at 50%, which is 650 yuan. And the maximum amount of payment from the basic medical insurance fund (hospitalization expenses) is 70,000 yuan in 1 year.
The standard of hospitalization reimbursement is related to the level of the hospital where the insured person stays, such as staying in a tertiary hospital, from the starting standard to 30,000 yuan, the employee pays 15%, or 85% reimbursement; 30,000 yuan to 40,000 yuan, the employee pays 10%, 90% reimbursement; over 40,000 yuan to the maximum payment limit part of the cost, then 95% can be reimbursed, the employee only needs to pay 5%. And while retirees pay 60 percent of what active (that is, the aforementioned) employees pay individually, anything below the threshold is paid by the individual.
Legal basis:
Article 28 of the Social Insurance Law of the People's Republic of China*** and the State of China, in line with the basic medical insurance drug directory, diagnostic and treatment items, standards of medical services and facilities, as well as emergency and rescue medical expenses, in accordance with state regulations from the basic medical insurance fund.