In daily life, people sometimes get sick. If it is a minor illness or pain, the average family can still bear it. But if there are some serious diseases, the pressure on the family will not be small. If you have medical insurance, you can reimburse part of it to alleviate certain economic pressure.
First, the calculation of medical insurance reimbursement ratio
1, hospitalization reimbursement
(1) on-the-job employees
If the medical expenses are between 1.300 yuan and 30,000 yuan (including 30,000 yuan), the reimbursement ratio is 85%;
For medical expenses ranging from 30,000 yuan to 40,000 yuan (including 40,000 yuan), the reimbursement ratio is 90%;
If the medical expenses are between 40,000 yuan and 654.38+10,000 yuan (including 654.38+10,000 yuan), the reimbursement rate is 95%;
If the medical expenses are between 654.38 million yuan and 300,000 yuan (including 300,000 yuan), the reimbursement rate is 85%, and the deductible line for hospitalization reimbursement is 654.38+0.300 yuan.
(2) Retirees
If the medical expenses are between 1.300 yuan and 30,000 yuan (including 30,000 yuan), the reimbursement ratio is 91%;
For medical expenses ranging from 30,000 yuan to 40,000 yuan (including 40,000 yuan), the reimbursement rate is 94%;
If the medical expenses are between 40,000 yuan and 654.38+10,000 yuan (including 654.38+10,000 yuan), the reimbursement rate is 97%;
If the medical expenses are between 654.38 million yuan and 300,000 yuan (including 300,000 yuan), the reimbursement rate is 90%, and the deductible line for hospitalization reimbursement is 654.38+0.300 yuan.
2, outpatient reimbursement
(1) On-the-job employees: 90% are reimbursed for medical treatment in community clinics, and 70% are reimbursed for medical treatment in non-community clinics. Outpatient reimbursement deductible line 1800 yuan, with a maximum reimbursement amount of 20,000 yuan.
(2) For retirees under the age of 70, the reimbursement rate for community outpatient service is 90%, and that for non-community outpatient service is 85%; For the elderly over 70 years old, the reimbursement rate of community outpatient service is 90%, and that of non-community outpatient service is 90%. The reimbursement deductible line is 1.300 yuan, and the reimbursement limit is 20,000 yuan.
Second, the medical insurance reimbursement conditions
1, the newly insured and re-insured employees who have stopped paying 1 year or more shall participate in the basic medical insurance according to law and pay for 6 consecutive months (excluding the overdue period), and enjoy the basic medical insurance benefits according to regulations; 2, continuous payment of less than 6 months, do not enjoy the basic medical insurance benefits; 3. If the payment is interrupted for less than one year, you will enjoy the treatment according to the regulations after re-insurance payment; 4, the interruption of payment personnel do not enjoy the basic medical insurance benefits during the interruption of payment.
Three, the six rules of medical insurance reimbursement
Article 1: Pay attention to seeking medical treatment and buying medicines in designated institutions.
There are designated institutions for medical insurance. Be sure to remember where your designated hospital is when you join the insurance. Only when you go to a designated hospital for medical treatment and hospitalization can you be reimbursed. If you go to a non-designated medical institution, there is no way to reimburse the treatment expenses, and you can only bear it yourself.
The same is true for buying medicine. Only designated pharmacies with medical insurance can swipe their medical insurance cards to buy medicines. Not designated pharmacies can only pay for themselves.
Article 2: Don't transfer to another hospital without permission.
Some diseases can't be seen in designated medical institutions. If you want to go to a better hospital for treatment, you must first apply for referral, and the referral with complete procedures can be reimbursed; If you don't apply for referral, it is still equivalent to going to a designated medical institution that you have no choice, and you still can't reimburse. There is often a gap in the reimbursement ratio. Generally speaking, the higher the level of hospital treatment, the lower the reimbursement rate.
Article 3: medical insurance can only be reported if the deductible line crosses the line.
Moreover, medical insurance has a deductible, and you can only reimburse it after you pay that amount in advance. For example, in a certain place, the outpatient deductible line is 1.800 yuan. If the total amount of outpatient medical treatment in one year is less than 1.800 yuan, the money must be paid by itself; Once it exceeds 1800 yuan, it can be reimbursed.
At the same time, medical insurance also has a cap line, which means that medical insurance can give you the most money, and the excess money cannot be reimbursed.
Article 4: Some drugs cannot be reimbursed.
Drugs that can be reimbursed by medical insurance are specific. Only drugs in the medical insurance catalogue can be reimbursed, but drugs outside the medical insurance catalogue cannot be reimbursed, such as many imported drugs, targeted drugs and patented drugs. So communicate with the doctor before taking medicine. If you want to save money, use the medicine in the catalogue.
Article 5: Some special surcharges cannot be reimbursed.
The most common thing is to be hospitalized in your own private room, or ask for special services, such as specialized doctors and nurses. These are not reimbursable. If you really have special needs, pay for it yourself.
Article 6: Be careful not to exceed the reimbursement period.
Social security card must be used to settle all kinds of expenses when leaving the hospital. Special circumstances can not be settled immediately, you can later take documents and vouchers to the medical insurance department for manual reimbursement of medical expenses. But we should hurry up at this time, because there is often a time limit.
Some local medical insurance departments will conduct liquidation before the end of the year, and will not reimburse after the deadline. Don't forget to reimburse the medical expenses because of carelessness. You can only bear these expenses yourself after the deadline. I hope it will be helpful to the calculation of the proportion of medical insurance reimbursement, the conditions of medical insurance reimbursement and the contents of the six rules of medical insurance reimbursement.
Legal objectivity:
Article 28 of the Social Insurance Law conforms to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue medical expenses, and shall be paid by the basic medical insurance fund in accordance with state regulations. Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, 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.