First, the scope of medical insurance reimbursement
Not all expenses can be reimbursed by medical insurance. To understand the proportion of medical insurance reimbursement, we must first understand the scope of medical insurance reimbursement.
1. deductible line and capping line
Deductible: Outpatient or hospitalization expenses must reach a certain amount before they can be reimbursed by medical insurance.
The threshold of outpatient and inpatient expenses is different, so is each region, and even different hospitals in the same region.
Cap line: the upper limit of reimbursement for outpatient or inpatient expenses is the cap line.
There are also differences in hospitals of different levels in different regions of the capping line.
2. Self-funded and self-funded
Self-funded part: the part that cannot be reimbursed in the medical insurance catalogue.
At one's own expense: all expenses outside the medical insurance catalogue, such as imported drugs and targeted drugs, are also included in the deductible line.
3. Medical insurance reimbursement part
Medical insurance can only reimburse outpatient and inpatient medical expenses in the medical insurance catalogue.
There are three medical insurance catalogues, namely, the catalogue of medicines, the catalogue of diagnosis and treatment items and the catalogue of medical service facilities.
Last year, the state revised the drug list and expanded the scope of reimbursement. The reimbursement ratio of outpatient expenses and hospitalization expenses is different.
Take Beijing as an example:
1. Outpatient expenses
The following is the reimbursement ratio of outpatient expenses in Beijing, including hospital type, deductible line and reimbursement ratio.
Note: In Beijing, the outpatient service of on-the-job workers needs more than 1.800 yuan to be reimbursed. The community hospital in this city is the first choice for medical treatment, and the reimbursement rate is higher than that of non-community hospitals, rather than deliberately going to large hospitals.
For example:
Zhang San had already arrived at the deductible line before, and the outpatient fee was 3,000 yuan, of which the self-funded part was 800 yuan, and the self-funded part was 1 1,000 yuan. So the amount that can be reimbursed by medical insurance is:
(3000-800-1000) × 90% =1080 yuan
Zhang San needs to pay 1920 yuan.
Zhang San was hospitalized (in a tertiary hospital), and the a * * * cost was 20,000 yuan, including 8,000 yuan at his own expense and 5,000 yuan at his own expense. The amount that can be reimbursed by medical insurance is:
(20000-1300-8000-5000) × 85% = 5700 yuan.
Zhang San still needs to pay 14300 yuan.
The above data are for reference only, and the specific reimbursement amount should be calculated according to the actual situation.
After the basic medical insurance is reported, those who meet the reimbursement conditions of serious illness insurance can enjoy the reimbursement policy of serious illness insurance and re-reimburse.
Since 2016 65438+1kloc-0/2 the State Council issued the Opinions on Integrating the Medical Insurance System for Urban and Rural Residents, various localities have merged the medical insurance for urban residents and the new rural cooperative medical system into the medical insurance for urban and rural residents.
Urban and rural residents only need to pay a few hundred dollars of medical insurance every year, which is much cheaper than employee medical insurance, so the treatment standard is generally lower than employee medical insurance.
There are many designated hospitals for employees' medical insurance, and the reimbursement ratio is relatively high, generally 70%-90%, and the upper limit of reimbursement is about 200,000-500,000.
However, the proportion of medical insurance reimbursement for urban and rural residents is low, mostly 40%-70%, and the upper limit of reimbursement is about10-200,000.