1, medical insurance benefits payment refers to the medical insurance agency providing medical services to the sick employees and reimbursing their medical expenses according to the conditions and treatment standards stipulated in advance after the employees who participate in the basic medical insurance get sick;
2. The payment of medical insurance benefits includes the payment of sick leave benefits and medical expenses. The treatment of sick leave will be elaborated in the third section, which focuses on the payment of medical expenses;
3. Employers and their employees pay medical insurance premiums according to regulations, and employees can enjoy basic medical insurance benefits; Workers who have not paid medical insurance premiums cannot enjoy basic medical insurance benefits. Medical insurance fund deductible standard:
(1) According to the regulations, the minimum deductible line is controlled at about 10% of the average annual salary of local employees in principle, and the medical expenses below the minimum deductible line are paid from personal accounts or by individuals themselves;
(2) Among them, 10% is only the general standard stipulated by the state, and all localities can adjust the threshold of pooling funds reasonably according to local conditions on the basis of the national standard, such as Shanghai 20 10 threshold of pooling funds and Beijing 20 10 threshold of pooling funds.
(3) The outpatient medical expenses (examination fees, medicine fees and other related expenses) below the deductible standard shall be paid by the employee's personal medical account fund first. After the employee's personal medical account fund is used up, the employee must pay first, and the overall fund is not used to pay the outpatient medical expenses.
Legal basis: Article 28 of the Social Insurance Law of People's Republic of China (PRC).
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.