(2) in Qianqian unit
Example 2, a working employee in this year due to illness in a local hospital for the first time, hospitalization medical expenses 30,000 yuan, of which: the use of Class B drugs catalog costs for 12,000 yuan; the use of large-scale medical equipment inspection costs for 1,200 yuan, the calculation is:
1, the basic health insurance reimbursement:
(1) Calculate the total amount of the individual's upfront burden: 2,640 yuan. Among them:
Personal burden of Class B drugs: 12,000 × 20% = 2,400 yuan, personal burden of special inspection and treatment costs: 1,200 × 20% = 240 yuan, excluding the first part of the burden, into the sub-section of the shared medical costs of 27,360 yuan.
(2) Segmental sharing:
The total personal burden is 3588 yuan. Among them:
Starting line: 900 yuan (tertiary hospital)
First segment: ?5000-900 × 20% = 820 yuan
Second segment: ?10000-5000 × 15% = 750 yuan
Third segment: ?15000 10,000 × 10% = 500 yuan
The fourth segment: ?27,360-15,000 × 5% = 618 yuan
The total amount paid out by the co-ordination fund is 23,772 yuan, of which:
The first segment: ?5,000-900 × 80 percent = 3,280 yuan
Second paragraph: ?10,000-5,000 × 85 percent = 4,250 yuan
Third paragraph: ?15,000-10,000 × 90 percent = 4,500 yuan
Fourth paragraph: ?27360- 15000×95% = 11742 yuan
Total of the above items: personal burden: 6228 yuan, accounting for 20.76% of the total expenditure? Reimbursement from the Pooled Fund: 23,772 yuan, accounting for 79.24 percent of the total expenditure.
2. Supplementary medical insurance reimbursement:
Reimbursement amount = (27360-900-23772) × 70% = 1881.6 yuan
3. Basic + supplementary total reimbursement:
23772 + 1881.6 = 25653.6 yuan.
Individuals need to pay: 30000-25653.6 = 4346.4 yuan.
(If you do not participate in the supplemental medical insurance individual out-of-pocket payment of 6228 yuan)
(C) in Yu unit:
Example 3: the on-the-job workers Li (has participated in the supplemental medical insurance), 53 years old, hospitalized in the former Neijiang Railway Hospital, incurred medical expenses *** 1680 yuan. The hospital's threshold fee was 560 yuan (640 yuan for local hospitals of the same level), the fee for the use of self-financed drugs and self-financed diagnostic and therapeutic items was 110 yuan, and the fee for the use of Class B drugs and diagnostic and therapeutic items for which part of the fee was paid was 420 yuan.
The medical expenses eligible for basic medical insurance are:
1680-110-420×20%=1486 yuan
1, basic medical insurance reimbursement:
(1486-560)×75%= 694.50 yuan
2. Supplementary medical insurance reimbursement: divided into two parts:
(1) Threshold fee reimbursement:
(1) 560 × 30% = 168 yuan
(2) Threshold fee reimbursement above the threshold, below the cap line:
(1486-560-694.50) × 70% = 162 yuan ) × 70% = 162.50 yuan
(3) Total: 330.05 yuan
3. Basic + supplemental total reimbursement:
694.5 + 330.05 = 1024.55 yuan
Individuals' out-of-pocket expenses are:
1680-694.50 -330.05 = 624.55 yuan. 330.05 = 655.45 yuan
(If the specific provisions are not in line with the relevant policies of the co-ordination area, the provisions of the co-ordination area shall prevail)
Three, what are the provisions of the basic medical insurance reimbursement?
1. General principle: The basic medical insurance and supplementary medical insurance will not reimburse the costs of items other than the out-of-pocket part, 20% of the cost of Class B drugs and items for which part of the cost is paid, and other restricted reimbursement rates.
2. Threshold fee for basic medical insurance (reimbursement will only be given for expenses exceeding this standard):
(1) For units in Sichuan: 400 yuan for first-level hospitals, 650 yuan for second-level hospitals, and 970 yuan for third-level hospitals. The starting standard is calculated on a per visit basis, and for two or more (including two) stays in a second- or third-level hospital within a natural year, the starting standard will be reduced by RMB 80 yuan per visit. Expenses below the starting standard will be paid from personal accounts or in cash.
(2) In Qianqian: 900 yuan for third-level hospitals and corresponding medical institutions, 700 yuan for second-level hospitals and corresponding medical institutions, and 500 yuan for other medical institutions. Multiple hospitalizations within a natural year will be reduced by 200 RMB respectively according to the above standards in turn. The minimum threshold fee is 300 yuan for tertiary hospitals; 200 yuan for secondary hospitals; and 100 yuan for other medical institutions.
The threshold fee for retirees shall be reduced by 200 yuan respectively according to the above standards, but shall not be lower than the minimum threshold fee.
(3) In Yu units: 400 yuan for first-level hospitals, 640 yuan for second-level hospitals, and 880 yuan for third-level hospitals.
The threshold fee will be reduced by 1 percentage point each time on the basis of the above standard for hospitalization in the original Yu Railway Hospital within one year.
3. Capping line of basic medical insurance co-ordination fund (maximum reimbursement amount within one year, including outpatient special disease expenses):
(1) Units in Sichuan: the current implementation standard is 35,000 RMB/year.
(2) Units in Qianqian: The current implementation standard is 39,000 RMB/year.
(3) Chongqing units: the current implementation of the standard 32,000 yuan / year.
What are the reimbursement standards for hospitalization medical expenses?
1. Basic medical insurance reimbursement:
Only the part above the threshold fee and below the ceiling of the integrated fund is reimbursed.
(1) In Sichuan units:
Reimbursement amount = (total cost - threshold fee - out-of-pocket expenses - cost of Class B drugs and items paying part of the cost x 20%) x (75% + age x 0.2%).
(2) In Qianqian Unit:
The part above the threshold fee up to 5000 yuan (including 5000 yuan, the same hereinafter) is 20% of the individual's burden; the part from 5000 yuan to 10000 yuan is 15% of the individual's burden; the part from 10000 yuan to 15000 yuan is 10% of the individual's burden; and the part from 15000 yuan to the cap line is 5% of the individual's burden. The remaining part is paid by the integrated fund.
Extended reading: insurance how to buy, which is good, hand to teach you to avoid the insurance of these "pits"