Social insurance we all know that it contains five insurance, but in our lives, the most used should be the five insurance in the medical insurance, medical insurance, usually in the hospital treatment and drugstore to sell drugs can be reimbursed, but the specific details of the insurance we do not have a clear understanding.
Recently, the circle of friends are forwarded to the medical insurance reimbursement V map, many people do not quite understand, so the multi-policy fish decided to explain to everyone!
First of all, we need to know the reimbursement rate of social security medical insurance:
Take Beijing medical insurance card as an example
Simply put, the outpatient reimbursement rate of social security medical insurance has a certain starting line and reimbursement rate, with the maximum limit of 20,000; and there is also a certain starting line and reimbursement rate of the inpatient reimbursement rate of social security medical insurance, with the maximum limit of 100,000, and once it exceeds 100,000, it is reimbursed up to 300,000 for serious illnesses.
The V-chart of Medicare reimbursement mentioned by the user is for the breakdown of medical expenses and to analyze the reimbursement of social security Medicare.
So I did the following breakdown, which is as follows:
Medical Expenses
The area of the V-chart represents all of our medical expenses, are they all reimbursable?
Suppose Sister Ma spent $400,000 on her hospitalization, and then this red section represents the $400,000 that Sister spent on medical expenses.
Excluding the starting line
Medicare reimbursement is the starting line, and you are responsible for all costs below the starting line. The starting line is different for outpatient and hospitalization, and it varies from region to region, and from hospital level to hospital level, with the general starting line set at 300-1800 RMB.
The Beijing social security health insurance, for example, Ma should be medical expenses in the 400,000 to be separated from outpatient and inpatient costs, and reimbursement of outpatient costs deducted from the starting line, the rest of the reimbursement can be reimbursed for the same reason, hospitalization costs.
Maximum
Starting lineAre the above expenses fully reimbursable? No. Social Security Medicare reimbursement has a limit, a ceiling line, and the portion that exceeds the maximum limit is also its own responsibility.
Social security health insurance sets different limits in different regions. The ceilings vary by social security category. Hospitalization reimbursement of the general most 30 high limit of 0,000, outpatient reimbursement is generally 20,000.
Ma big sister in the disease hospitalization more than 300,000, so the need for excess, Ma big sister to bear the burden of their own.
Out-of-pocket
Below the cap line, after deducting the starting line reimbursement. The answer is definitely no. As MultiCare Fish said at the top, Social Security Medicare reimbursement is a reimbursement rate, i.e., a percentage of the reimbursement amount that you have to cover, i.e., your out-of-pocket expenses.
Different regions, different types of social security, hospitals have different levels, while the percentage of out-of-pocket expenses is different, usually set at about 10%. Ma's reimbursement: outpatient reimbursement = (outpatient medical expenses - starting line) x (100 percent - out-of-pocket percentage); inpatient reimbursement = (cap line - starting line) x (100 percent - out-of-pocket percentage).
Out-of-pocket elements
Do you think that after some deductions, you should be reimbursed for the rest? Social security health insurance has strict rules on medicines and treatment programs. This means that some imported drugs, special medicines, medical equipment, and medical services are used for the treatment process. The cost is high not to mention the fact that social security health insurance does not reimburse at all, called out-of-pocket items, so the most intermediate part is part of the actual reimbursement.
Madam: Hospital reimbursement = (cap line? -? Starting line? - out-of-pocket content) x (100 percent - out-of-pocket percentage).
After such heavy calculations and deductions, it is still possible to get reimbursed for a minor illness because it is difficult to use some of the out-of-pocket items. Once it is a serious illness, the self-funded component will be a large percentage. In fact, after reimbursement, the patient still need to bear a lot of medical expenses, what to do?
Commercial insurance
Today, the role of commercial insurance can no longer be ignored. If you are not reimbursed by the social insurance, you can be reimbursed and compensated by the commercial insurance.
Starting line: Many health insurances now include outpatient reimbursement, accidental outpatient reimbursement and sickness outpatient reimbursement so that you can be reimbursed for the starting line and reduce costs.
Out-of-pocket: Most inpatient health insurance policies include an inpatient hospital allowance, which pays the patient a certain amount per day to compensate.
Out-of-pocket financial elements and beyond the cap line (maximum limit): Since both are involved, usually major or serious illnesses, you can take out health insurance and critical illness insurance. Payment is made as soon as a diagnosis is made. For example: million health insurance (1 year) can be reimbursed for the treatment of disease; critical illness insurance has a long and short, once diagnosed, in line with the insurance contract, according to the agreed amount of insurance to carry out the payment, to help the treatment, the later recovery and make up for the loss.
Multiple insurance fish reminder: social insurance health insurance reimbursement after the event, that is, after spending a lot of money after the reimbursement, commercial insurance first pay out after treatment.
So, in the social security want to reimburse most of the medical expenses is not very realistic, especially after suffering from serious illness or serious illness, high medical costs need to pay out of pocket to be a lot, but the increase in commercial insurance, you can resist serious illness medical costs high insurance can not be the shortcomings of the people need to pay attention to it.
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