Listening to these questions one after another, Brother Bao raised his eyebrows and showed a confident smile. As a "medical insurance expert", it is more than enough to answer these small questions. ...
Knowledge point 1: What is critical illness insurance?
Serious illness insurance is actually the abbreviation of serious illness insurance for urban and rural residents. It is an extension of the basic medical insurance system, which mainly aims at the high medical expenses of seriously ill patients and provides further protection on the basis of paying basic medical reimbursement.
To put it simply, serious illness insurance is an "additional risk" of the basic medical insurance for urban and rural residents, a national policy of benefiting the people and a medical supplement to the basic medical security. Its purpose is to prevent the masses from becoming poor or returning to poverty due to illness.
Knowledge point 2: How does critical illness insurance reimburse?
Want to know how to reimbursement for serious illness, to understand the following four elements:
Protection target: urban and rural residents insured by medical insurance (not covered by employee medical insurance).
Do I need to pay separately? There is no need to pay insurance separately. The basic medical insurance premium for urban and rural residents paid by the insured has included the serious illness insurance premium, and no additional payment is required.
Deductible line and reimbursement ratio: Like basic medical insurance, critical illness insurance also has a deductible line standard, and medical expenses that do not exceed the deductible line are not reimbursed, while those above the deductible line are reimbursed according to the prescribed proportion.
Generally speaking, the deductible line of serious illness insurance is to pay a certain amount of medical expenses after the reimbursement amount of basic medical insurance reaches the maximum limit line. The specific deductible amount and reimbursement ratio will be formulated by the overall planning areas, which will vary from place to place. In addition, the serious illness insurance has increased the inclination to the poor, the deductible line has been reduced by 50%, the reimbursement ratio has been increased by 5%, and the payment ceiling line has also been cancelled.
Reimbursement method: The reimbursement method of major illness insurance is similar to that of basic medical insurance. Medical expenses that meet the scope of medical insurance catalogue after reaching the deductible line of serious illness insurance can be reimbursed according to the prescribed proportion; Similarly, the part beyond the critical illness insurance cap line will not be reimbursed. But this situation is very rare, because the general amount of critical illness insurance is enough for most people.
Let's take the medical reimbursement of Uncle Li, the insured person of XX residents' medical insurance, as an example to talk about how to settle the reimbursement for serious illness.
At present, the deductible standard of serious illness insurance in XX city is 6.5438+0.2 million yuan.
The standard is divided into three grades according to the individual cumulative payment:
65,438+60% for critical illness insurance between 2000 and 30,000 yuan.
Pay 65% between 30,000 yuan and 6,543,800 yuan.
65438+ 75% for more than 10,000 yuan.
Let's assume that Uncle Li spent 65,438+million on his first admission this year, including 65,438+million for all self-funded items and 65,438+million-65,438+million for medical insurance reimbursement = 90,000. According to the medical insurance policy of XX City, the basic medical insurance reimbursement is 90,000 yuan × 50% = 45,000 yuan. Individuals pay 90,000-45,000 yuan = 45,000 yuan.
45,000 yuan exceeds the minimum payment standard of serious illness insurance in XX city10.2 million yuan. Serious illness insurance in accordance with the principle of cumulative reimbursement:
60% of the 65438+2000 yuan and 30000 yuan (inclusive) will be reimbursed, that is, (30000 yuan -65438+2000 yuan) ×60% = 1800 yuan.
More than 30,000 yuan, 6,543,800 yuan and the following part will be reimbursed by 65%, that is, (45,000 yuan-30,000 yuan) × 65% = 0.975 million yuan.
That is to say, Uncle Li Can's final reimbursement for serious illness is10.08 million yuan +0.975 million yuan = 20,550 yuan.
Finally, with the basic medical insurance for urban and rural residents, Uncle Li reimbursed 20,550 yuan (45,000 yuan = 65,550 yuan) and actually paid 34,450 yuan.