1, students and children. In a settlement year, medical expenses below RMB 6,543,800+0,800 yuan that meet the scope of reimbursement occurred. The threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 55%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no qifubiaozhun for first-class hospitals, and the reimbursement rate is 65%;
They are old people in their seventies. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no qifubiaozhun for first-class hospitals, and the reimbursement rate is 65%;
3. Other urban residents. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%.
Reimbursement scope:
1, medical expenses insurance liability in medical insurance coverage.
Part of the expenses still borne by individuals after reimbursement of basic medical insurance, serious illness insurance and medical assistance in the medical insurance catalogue. , shall bear the liability for compensation within the agreed scope of insurance liability. 1 10,000 insured amount,10.5 million free of compensation, the reimbursement rate is 80%, and the reimbursement rate for continuous participation is increased to 85%;
2, medical insurance liability outside the scope of hospitalization expenses.
The expenses outside the medical insurance catalogue are still borne by individuals after being reimbursed by basic medical insurance, serious illness insurance and medical assistance. , shall bear the liability for compensation within the agreed scope of insurance liability. 1 10,000 insured amount,1.8,000 free of compensation, the reimbursement rate is 60%, and the reimbursement rate for continuous participation is increased to 65%;
3, outpatient specific high drug cost insurance liability
The part of the drug expenses paid in designated hospitals and pharmacies, which is borne by individuals, shall be liable for compensation within the agreed scope of insurance liability. 700,000 insured amount, 26 kinds of drugs, and the insurance liability of the outpatient drugs/inpatient medical insurance expenses for rare diseases is * * * 20,000 yuan, and the compensation ratio is 80%;
4. Clearly stipulate the insurance liability of outpatient drugs/hospitalization medical insurance expenses for rare diseases.
The part of the drug expenses paid in designated hospitals and pharmacies, which is borne by individuals, shall be liable for compensation within the agreed scope of insurance liability. The insured amount is 300,000 yuan, 12 kinds of drugs, and the insurance liability of outpatient specific high drug expenses is 20,000 yuan, and the reimbursement ratio is 70%.
To sum up, basic medical insurance (including basic medical insurance for urban workers and basic medical insurance for urban and rural residents) is closely related to inclusive prices. Focus on ensuring the high medical expenses caused by major diseases and accidental injuries, and provide more adequate protection for major diseases. Compared with general commercial insurance, there are no restrictions on the age and occupation of the insured, and the health conditions are more tolerant. At the same time, the product also expanded the treatment cost of 20 kinds of high-priced specific drugs and 10 kinds of designated rare disease drugs outside the medical insurance catalogue.
Legal basis:
Article 2 of People's Republic of China (PRC) Insurance Law
The term "insurance" as mentioned in this Law refers to the commercial insurance behavior in which the applicant pays the insurance premium to the insurer according to the contract, and when the insured dies, suffers from disability, illness or reaches the age and time limit agreed in the contract, the insurer shall be liable for the property losses caused by the possible accidents agreed in the contract.
essay
This Law is applicable to insurance activities in People's Republic of China (PRC).
Article 5
The parties to insurance activities shall exercise their rights and perform their obligations in accordance with the principle of good faith.