Medical insurance cost expenditure method (a) the reimbursement of medical expenses.
After a participant falls ill and incurs medical expenses, the medical insurance organization will make financial compensation for his expenses, known as the reimbursement of medical expenses. It includes only the direct costs of medical services incurred within the scope of medical insurance coverage, while indirect costs related to medical services (such as loss of income during the period of illness, transportation to hospitals, accommodation costs, etc.) are not included. Usually, medical compensation expenses account for 80% to 90% of the medical insurance fund. In China's basic medical insurance system for urban workers, the basic medical insurance fund is based on the principle of income to determine expenditure, balance of income and expenditure, with a slight surplus of medical cost compensation.
(ii) Management fee.
Management fee refers to the various costs and expenses related to the business of medical insurance services required by the medical insurance organization to maintain normal operation. It mainly includes:
1. Salaries: salaries of full-time and part-time health insurance administrators;
2. Expenditures for official business and labor: business trips, publicity, training, research, information reporting and supervision, etc.;
3. Water, electricity, coal, gas and rent;
4. Depreciation of assets and maintenance of equipment;
5. Others: bonuses and so on.
Some countries have higher overhead costs, including salaries, bonuses, and benefits for health insurance organization personnel or salaries for physicians who provide direct Medicare-covered services, as well as new types of equipment, facilities, and operating expenses for insurance organizations. The United States has the highest overhead at 25%; Canada is lower at 7%. It is generally considered desirable to keep overhead costs within 10 percent. In China, this part of the cost is not allowed to withdraw in the medical insurance fund, but by the financial allocation to solve.
(iii) Risk reserve.
Risk reserve refers to the medical insurance organization to cope with the extraordinary medical risks, refers to the medical insurance premiums in accordance with the relevant provisions of a certain percentage of a special reserve. It is mainly used for the occurrence of extraordinary risks (such as the pandemic of a certain disease), there can be enough money to protect the basic rights and interests of the insured. Some foreign literature suggests that the withdrawal ratio of risk reserve usually accounts for 4% to 8% of the insurance premium.
Methods of paying basic medical insurance premiumsFirst of all, each coordinating region should determine an individual basic medical insurance contribution rate suitable for the burden level of local workers, generally 2% of salary income, and the proportion of individual contributions can also be raised appropriately in regions with conditions.
Secondly, by the individual to their salary income as a base, according to the prescribed local individual contribution rate to pay the basic medical. In the individual contribution base, it should be pointed out that not according to my basic salary or standard salary as the base, but according to the National Bureau of Statistics stipulates the statistical caliber of wage income as the base, that is, all wage income, including all kinds of bonuses, labor income and in-kind income and all wage income as the base, multiplied by the stipulated rate of individual contributions, that is, the basic medical insurance premiums payable by me.
Thirdly, individual contributions are generally not required to be paid by the individual to the social insurance agency, but by the unit from the wage income.
Methods of medical care for the insured First of all, the insured should consult and purchase medicines at the designated medical institutions of the basic medical insurance, and they can also purchase medicines outside the designated retail pharmacies with prescriptions. Medical expenses incurred in non-designated medical institutions and non-designated pharmacies, except in accordance with the referral and other prescribed conditions, the basic medical insurance fund will not pay.
Secondly, medical expenses incurred must be in accordance with the scope and payment standards of the basic medical insurance drug catalog, diagnostic and treatment items, and medical service facility standards in order to be paid by the basic medical insurance in accordance with the regulations. The basic medical insurance will not pay for the excess.
Thirdly, for medical expenses that are within the scope of payment of basic medical insurance, it is necessary to distinguish whether they are covered by the centralized fund or the individual account. The medical expenses covered by the integrated fund, i.e. the expenses above the threshold of the integrated fund, will be paid by the integrated fund on a pro rata basis, up to the ceiling amount. Individuals are also responsible for part of the medical expenses, while all expenses above the ceiling are paid by individuals or resolved through participation in supplementary medical insurance or commercial medical insurance. Medical expenses below the threshold are covered by the individual account, and if there is a balance in the individual account, it can also cover part of the medical expenses that should be paid by the individual within the scope of payment by the integrated fund.
Assumptions: a worker in a year to the provisions of the designated medical institutions, a visit to the outpatient clinic, incurred medical costs 200 yuan; two hospitalization medical costs were 20000 yuan and 10000 yuan, of which two hospitalization occurred beyond the basic medical insurance drug directory and diagnostic and therapeutic items, such as the cost of 2000 yuan and 1000 yuan; the local unified account to pay for the scope of outpatient and hospitalization division, hospitalization starting standard, the first payment standard should be part of the individual to pay for. Hospitalization, hospitalization starting standard for the first time for 800 yuan, the second for 500 yuan, the coordinated payment of the scope of the cost of payment ratio of 90%, the maximum payment limit of 20000 yuan. So, how should these medical expenses be paid?
1. Outpatient medical expenses will be paid directly from the personal account, if the employee's personal account has 500 yuan, 200 yuan will be paid, and there is still a balance of 300 yuan.
2. For the 20,000 yuan of the first hospitalization cost, it is necessary to deduct 2,000 yuan of medical expenses beyond the scope of basic medical insurance, and then deduct the starting standard of 800 yuan, and for the remaining part of the medical cost of 17,200 yuan, 15,480 yuan will be paid by the integrated fund.
3. For the 10,000 yuan of the second hospitalization expenses, it is necessary to deduct 1,000 yuan of the medical expenses beyond the scope of payment of basic medical insurance, and then deduct the starting payment standard of 500 yuan, and for the remaining part of the medical expenses of 8,500 yuan, 7,650 yuan will be paid by the co-ordinated fund. However, since the first hospitalization has already been paid for by the co-ordinated fund of 15,480 yuan, and the maximum payment limit is 20,000 yuan, therefore, only 4,520 yuan can be paid from the integrated fund for the second hospitalization. From the employee's annual medical cost burden, the total **** spent 30,200 yuan, the integrated fund paid 20,000 yuan, the individual account can pay 500 yuan, the individual need to bear 9,700 yuan.
Related knowledge of medical insurance reimbursement 1, outpatient and emergency medical expenses: in the year of the active employees (January 1 ~ December 31) in line with the provisions of the basic medical insurance coverage of the accumulated medical expenses exceeding 2,000 yuan or more part.
2. Settlement ratio: 50% reimbursement for the part of over 2,000 yuan for dispatched staff during the contract period, and 50% out-of-pocket payment by individuals; the maximum amount of outpatient and emergency reimbursement paid to dispatched staff is 20,000 yuan cumulatively in a year.
3. The insured personnel should keep the outpatient medical bills (including receipts and prescription bottoms for the parts below the large amount) of the outpatient treatment in the designated hospitals as the vouchers for the reimbursement of medical expenses.
4, three kinds of special disease outpatient medical care: participants suffering from malignant tumors radiation therapy and chemotherapy, kidney dialysis, kidney transplantation to take anti-rejection drugs need to be in the outpatient medical care, by the participants in the second and third level of designated hospitals for medical care to be issued? Disease diagnosis certificate and fill in the "Medical Insurance Special Disease Declaration and Approval Form" and submit it to the District Medical Insurance Center for approval and filing. Outpatient medical treatment and medicine collection for these three special diseases are limited to the approved designated hospitals, and cannot be purchased at designated retail pharmacies. If the medical fees incurred are within the scope of outpatient special diseases, they will be settled with reference to hospitalization.
5. Inpatient medical care.
How medical insurance costs are spent