The starting standard and reimbursement ratio of urban residents' basic medical insurance are determined differently according to the categories of insured persons.
1. Students and children
In a settlement year, for medical expenses under 180,000 RMB incurred within the scope of reimbursement, the starting standard for Level 3 hospitals is 500 RMB and the reimbursement rate is 55%; the starting standard for Level 2 hospitals is 300 RMB and the reimbursement rate is 60%; and Level 1 hospitals do not have a starting standard and the reimbursement rate is 65%.
2. For elderly people aged 70 or above
In a settlement year, if they incur medical expenses of less than 100,000 yuan that are eligible for reimbursement, the starting standard for tertiary hospitals is 500 yuan, and the reimbursement rate is 50%; the starting standard for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; and there is no starting standard for primary hospitals, and the reimbursement rate is 65%.
3. For other urban residents
In a billing year, if they incur medical expenses of less than 100,000 RMB that are eligible for reimbursement, the starting standard for third-level hospitals is 500 RMB, and the reimbursement rate is 50%; for second-level hospitals, the starting standard for hospitalization is 300 RMB, and the reimbursement rate is 55%; and for first-level hospitals, there is no starting standard, and the reimbursement rate is 60%.
Urban residents who are hospitalized for more than two times in one billing year will no longer be charged for the starting standard 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 starting payment standard of the hospital to which they are transferred or re-admitted.
The difference between urban residents' medical insurance and urban workers' medical insurance
In China, all employees working in enterprises must apply for social security, which includes medical insurance. However, the need for medical insurance is not only for employed workers, students and unemployed people need medical insurance when they are sick, which is the significance of the existence of urban residents' medical insurance.
1, the applicable population is different
According to the director of the Municipal Health Insurance Department Sun Zhentian introduction, the applicable population of urban workers' health insurance for all urban employers, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, Hong Kong, Macao and Taiwan business investment enterprises, private enterprises, etc.), organs, institutions, public organizations, social groups, private non-enterprises and other units of the workers.
The urban residents' medical insurance is applicable to urban residents who are not covered by the basic medical insurance for urban workers and the new rural cooperative medical care, including mainly underage residents, meaning primary and secondary school students (including students of vocational high schools, junior colleges, and technical schools), preschoolers, and other underage residents under the age of 18 years old; elderly residents, meaning urban residents aged 60 years old for males and 55 years old for females; and other non-employed urban residents. (c) Urban residents; and other non-working adult urban residents. College students will also be covered by urban residents' medical insurance in the future.
2, the contribution method is different
The urban workers' medical insurance is based on the unit's total wages of the employees according to a certain contribution ratio, paid by the unit;
The unit has to bear the employees' total wages of 7%, and the individual has to bear the 2% of the base of the wages of the individual's own contribution. This year, due to the economic crisis on the operation of enterprises caused by a certain impact, from April to December this year, the time period, the contribution of enterprise units from 7% down to 6%, in order to reduce the burden on enterprises.
Medical insurance for urban residents is paid for by individuals through their neighborhood committees or schools (kindergartens), while the government provides subsidies on top of individual and family contributions. The fund-raising standards for minor residents, adult residents and elderly residents are 100 yuan, 360 yuan and 360 yuan per person per year respectively, of which individual contributions are 40 yuan, 280 yuan and 150 yuan respectively; government subsidies are 60 yuan, 60 yuan and 210 yuan respectively. It can be seen that the standard of urban residents' medical insurance is much lower than that of urban workers' medical insurance, which is about 1/5 of the per capita financing of urban workers' medical insurance fund.
3. Different treatment
Employees taking part in the urban workers' medical insurance can enjoy the reimbursement of hospitalization expenses, reimbursement of outpatient expenses of coordinated medical categories, and the treatment of the individual account for paying the outpatient medical expenses, and the reimbursement ratio is higher than that of urban residents' medical insurance. The reimbursement rate is higher than that of the urban residents' medical insurance. After deducting the out-of-scope expenses, the reimbursement rate for hospitalization expenses is 75% for the part of hospitalization expenses above the minimum threshold up to RMB 5,000; 80% for the part of hospitalization expenses between RMB 5,000 and RMB 10,000; 85% for the part of hospitalization expenses above RMB 10,000, with a corresponding increase of 10% for retired employees; the reimbursement rate for outpatient expenses of the integrated diseases is 80% for active employees and 85% for retired employees.
Residents enrolled in the urban residents' medical insurance are entitled to reimbursement of hospitalization expenses and outpatient expenses for integrated diseases. As the contribution rate is lower, the treatment is also relatively lower. The reimbursement of hospitalization expenses for insured residents is 55% of the amount above the minimum threshold (the same as that of the urban workers' medical insurance) after deduction of out-of-scope expenses, up to a maximum cumulative reimbursement of 30,000 yuan per medical year. The outpatient expenses for the coordinated diseases are reimbursed at 50 percent of the amount above the starting line (300 yuan).
Summary, the above is the urban residents medical insurance reimbursement ratio, in China, working employees have basic medical insurance, and farmers in rural areas also have agricultural insurance, the rest of the people living in towns and cities without working minors, the elderly, the unemployed, and other people for the urban residents medical insurance. It has different reimbursement options depending on the medical situation, up to 65 percent.
Legal basis:
The Social Insurance Law of the People's Republic of China
Article 28
Medical expenses that are in accordance with the basic medical insurance drug catalog, diagnostic and therapeutic items, and medical service facility standards, as well as those for emergencies and rescues, shall be paid out of the basic medical insurance fund in accordance with state regulations.
Article 29
The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.
The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.