1, reimbursement ratio of employee medical insurance outpatient service:
After the on-the-job employees see a doctor in the outpatient and emergency department of the hospital, the medical expenses of more than 2,000 yuan can be reimbursed, and the reimbursement ratio is 50%. For retirees under 70 years old, expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 500 yuan can reimburse 50%, that is, 250 yuan.
2, residents' medical insurance outpatient reimbursement ratio:
The medical expenses incurred by the insured patients in the outpatient department of designated medical institutions shall be settled directly by swiping the card at the settlement counter of residents' medical insurance with the medical insurance prescription and social security card. In an insurance year, if the total outpatient expenses are below 50 yuan, the medical insurance fund will pay 40%, and the expenses above 50 yuan will be borne by individuals.
3, rural medical insurance outpatient reimbursement ratio:
(1) village clinics and village center clinics are reimbursed 60%, and the prescription drug fee limit for each visit 10 yuan, and the prescription drug fee limit for temporary rehydration for doctors in health centers is 50 yuan.
(2) Reimbursement for medical treatment in town health centers is 40%. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 100 yuan.
(3) The reimbursement for medical treatment in secondary hospitals is 30%, and the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 200 yuan.
(4) 20% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan.
Outpatient medical insurance reimbursement process:
1. For outpatient and inpatient treatment, the insured person must show his social security card and swipe his card for medical treatment. The outpatient department must inform the hospital of the treatment category (such as chronic disease and outpatient service). If the card card is not produced or the treatment category is not clear, the medical expenses incurred by the insured employees when they seek medical treatment will not be paid by the medical insurance fund;
2, the insured in the designated retail pharmacies to buy drugs, must show my citizen card, inform the treatment category (such as outpatient chronic diseases, special), according to the relevant policies to buy drugs, because of special circumstances by others purchasing drugs, must show the insured and the purchaser's identity card, and registered by the pharmacy;
3, outpatient co-ordinate the implementation of the first diagnosis and referral system based on community health service institutions. Insured persons can be first diagnosed or referred to community-managed medical institutions in designated community health service institutions for urban workers' basic medical insurance; Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral, and emergency rescue is not subject to this restriction. After the outpatient chronic disease subsidy limit is used up, you can directly enjoy the outpatient co-ordination treatment from the next cost, without referring to the original chronic disease. After the subsidy limit for specific outpatient items is used up, the referral procedures must be handled according to the provisions of outpatient co-ordination, and ordinary medical records can be used to enjoy the outpatient co-ordination treatment, but drugs bought in pharmacies do not enjoy the outpatient co-ordination treatment.
To sum up, social medical insurance is a social insurance system established by the state and society according to certain laws and regulations to provide basic medical needs for workers within the scope of protection. It is undertaken by the government and implemented and managed by economic, administrative and legal means.
Legal basis:
Article 28 of People's Republic of China (PRC) Social Insurance Law
Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Article 29
The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.