Taking Zhengzhou as an example, according to Article 25 of the Measures for Basic Medical Insurance for Urban Residents in Zhengzhou (Trial), the expenses below the minimum threshold shall be paid by the individual first; The expenses above Qifubiaozhun and below the maximum payment limit shall be borne by the overall fund and individual insured residents in proportion.
According to different types of designated medical institutions, the threshold of resident medical insurance hospitalization pooling fund is divided into: 300 yuan, a first-class designated medical institution; 600 yuan, a secondary designated medical institution; 900 yuan, a tertiary designated medical institution. The medical expenses incurred by the insured residents in different types of designated medical institutions that meet the requirements above the Qifubiaozhun and below the maximum payment limit shall be borne in the following proportion:
A class of designated medical institutions (including community health service institutions), the overall fund to pay 60%, individuals bear 40%;
Two types of designated medical institutions, the overall fund to pay 55%, individuals bear 45%;
Three types of designated medical institutions, the overall fund to pay 50%, individuals bear 50%;
The insurance year of residents' medical insurance is calculated according to the natural year. In a natural year, the cumulative maximum payment limit of the overall fund is 25,000 yuan (including the prescribed disease expenses for hospitalization and outpatient service).
Extended data:
"Measures for the Basic Medical Insurance for Urban Residents in Zhengzhou (Trial)" Article 31 In any of the following circumstances, the medical expenses incurred by the insured residents for medical treatment shall not be paid:
(a) receiving treatment abroad or in Hong Kong, Macao and Taiwan;
(2) Suicide or self-mutilation (except mental illness);
(three) fighting, alcoholism, drug abuse and other criminal acts that cause injuries or violate the "Public Security Administration Punishment Law";
(four) traffic accidents, accidental injuries, medical accidents and other medical expenses borne by the other party;
(five) belonging to the scope of work-related injury insurance (including occupational diseases) or maternity insurance;
(six) other circumstances that do not pay according to the regulations.
Baidu Encyclopedia-Measures of Zhengzhou Municipality on Basic Medical Insurance for Urban Residents (for Trial Implementation)