All out-of-pocket expenses and personal payment amount

Recently, some friends asked Xiaoxin: What are the out-of-pocket expenses, out-of-pocket expenses, and deductibles on the medical claim form? Why are there so many out-of-pocket expenses? What exactly are the deductions? Asked a lot of people around, they are all confused, can only come to the rescue!

With the improvement of the health insurance system, now hospitalization is very convenient, now many places have realized the health insurance settlement, for many people is very convenient and fast. The hospital will issue a statement for the patient, which records how much money was spent on hospitalization, how much money was reimbursed by the medical insurance and so on.

Most people who don't know much about health insurance don't understand this statement, because it contains a lot of terms and the amount of money behind it.

Today, Xiaoxin for the statement of the terms, for everyone to do a unified introduction, such as: the starting standard, out-of-pocket expenses for drugs, the cost of basic medical care, etc., so that we can quickly read the understanding of the health insurance claims, and then reimbursement, you will be able to understand in the end to reimburse what? This is the first time that you will be able to get the best out of the world.

Individual cash payment amount

:The amount that the patient needs to bear by himself;

Medical insurance fund payment amount

:The total amount of expenses paid by the medical insurance fund, including: outpatient large amount of payment, retirement supplemental insurance payment and other payment methods;

Starting line

:Starting standard following the cost, the medical insurance bureau according to the different categories of insured persons and hospitals to set up the level of the category of the corresponding starting standard;

Starting line

:Starting standard below the costs, the medical insurance bureau according to the different categories of insured persons and hospitals to set up the category of the appropriate Medical Insurance Coverage Amount

:The amount of medical expenses that are covered by medical insurance;

Accumulated Medical Insurance Coverage Amount

:The total amount of medical expenses covered by medical insurance in the current year up to the time of settlement of the current expenses;

Accumulated Payment from Annual Outpatient Fund

:The total payment made for outpatient services for the participant in the current year up to the time of settlement of the current expenses;

Accumulated Payment from Annual Outpatient Fund

:The total payment made for outpatient services for the participant in the current year up to the time of settlement of the current expenses. The total amount of accumulated outpatient payments for the insured;

Annual Outpatient Large Balance

:The amount of money that can be paid by the health insurance for the insured in the current year up to the time of settlement of expenses;

Individual Payment, Out-of-Pocket Payment

:The amount of money that the patient is required to pay for, which consists of Out-of-Pocket Payment, Out-of-Pocket Payment, and Out-of-Pocket Payment.

Out-of-pocket expenses

:The amount of medical expenses that can be included in the scope of reimbursement for the patient to pay, including the starting amount and the amount of money that exceeds the starting amount of the patient's out-of-pocket expenses;

Out-of-pocket expenses

:The amount of money that the patient needs to pay for the medicines and tests that are labeled as "partially out-of-pocket expenses". Assuming that a bottle of drugs priced at 100 yuan belongs to a self-pay drugs, if the percentage of self-pay is 10%, then to pay 10 yuan, which is a self-pay two;

Self-pay:

indicator note for "full self-pay" drugs, the total cost of the examination, the patient has to pay for themselves.

Isn't it, read the above explanation we can understand it. In order to let you visualize the part of the reimbursement, you can look at the following chart:

From the chart, you can see that the medical insurance reimbursement rate, outpatient and hospitalization reimbursement rate have a certain threshold, reimbursement rate and limit. The maximum hospitalization reimbursement is 100,000 yuan, and once it exceeds 100,000 yuan, it is classified as a major medical reimbursement, with a maximum limit of 300,000 yuan.

There is a threshold for reimbursement, and you are responsible for the portion of the reimbursement that is below the threshold. This represents the minimum amount of money you have to pay out of your own pocket, and is usually set at 300-1800 RMB, depending on the region and the level of the hospital, the threshold is also different.

The out-of-pocket items are as follows:

(1) Out-of-pocket medicines: These include 15% of Class B medicines, Class C medicines, imported medicines, and specialty medicines, etc. The following medicines are not covered by the basic medical insurance. There are also the following drugs are not in the basic health insurance reimbursement: (1) the main role of nutritional tonic drugs; (2) part of the animal and animal organs can be used in medicine, dried (water) fruit; (3) with Chinese herbs and Chinese medicine tablets of all kinds of wine preparations; (4) all kinds of drugs in the fruit-flavored preparations, oral effervescent; (5) blood products, protein products (except for special indications and first aid, rescue); (6) the social insurance administrative department stipulates that the social insurance administration to provide the following medicines: (1) the basic health insurance reimbursement: (1) out-of-pocket drugs: including 15% of Class B drugs, Class C drugs, imported drugs, special drugs, and so on. ) social insurance administrative department stipulates that the basic medical insurance fund does not pay for other drugs.

(2) out-of-pocket medical expenses: the use of the basic medical insurance treatment program does not pay part of the medical costs of treatment items: services: (01) registration fees, out-of-hospital consultation fees, medical records, such as fees; (02) clinic fees, examination and treatment of expedited fees, surcharges on the name of the surgery, high quality premiums, special nurses, such as the special needs of the medical services; non-disease treatment items: (01) a variety of beauty, fitness programs and non-functional. Beauty, fitness programs and non-functional cosmetic, orthopedic surgery, etc.; (02) a variety of weight loss, weight gain, height projects; (03) a variety of health check-ups; (04) a variety of preventive, health care diagnostic and therapeutic programs; (05) a variety of medical consultation, medical appraisal. Diagnostic equipment and medical materials: (01) the application of positron emission tomography device (PET), electron beam cT, ophthalmic excimer laser therapy instrument and other large medical equipment for the examination, treatment programs; (02) glasses, dentures, prosthetic eyes, prosthetic limbs, hearing aids and other rehabilitative devices; (03) a variety of health care for their own use, massage, inspection and treatment equipment; (04) the provincial pricing department regulations Can not be charged separately for disposable medical; treatment items: (01) all kinds of organ or tissue transplantation of organ or tissue source; (02) in addition to kidney, heart valves, cornea skin, blood vessels, bone, bone marrow transplantation of other organs or tissue transplantation; (03) myopic orthopaedics; (04) qigong therapy, music therapy, health care of nutritional therapy, magnetic therapy and other complementary therapeutic items; other: ((01) all kinds of infertility, massage, examination and treatment instruments; (04) provincial pricing department regulations. 01) a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program; (02) a variety of scientific research, clinical verification of the diagnosis and treatment program.

(3) out-of-pocket services: more than the basic medical insurance medical services and facilities to pay the standard part of the medical costs and the provisions of the medical services and facilities are not paid for the costs incurred, as well as the following services are not paid for by the basic medical insurance fund of the cost of living services and services and facilities, including: (1) consultation (transfer) transportation costs, emergency vehicle fees; (2) air-conditioning fees, television fees, telephone fees, baby Thermal insulation box fee, food insulation box fee; (3) escort fee, nurse fee, cleaning fee, outpatient medicine fee; (4) meals; (5) recreational activities and other special needs living costs.

After deducting the out-of-pocket expenses, the remaining portion of the reimbursable medical expenses multiplied by the reimbursement rate is the out-of-pocket portion, which we are responsible for.

At this point, you understand the scope of reimbursement and the terminology.

Today, there are a few things that I would like to tell you:

There are a lot of questions about health insurance, especially critical illness insurance, in the process of purchasing it.

For example, is this product good? Can I buy it? The first thing you need to do is to get a good deal on a new product.

There are also a lot of questions about death benefits, especially life insurance.