Legal analysis: the reimbursement ratio of medical insurance for operation expenses

1. The reimbursement ratio of outpatient and emergency expenses

1. On-the-job employees can only be reimbursed for medical expenses of more than 1,8 yuan after seeing a doctor in the outpatient and emergency departments of the hospital, and the reimbursement ratio is 5%.

2. For retirees under the age of 7, the expenses above 1,3 yuan can be reimbursed, and the reimbursement rate is 7%.

3. For retirees over 7 years old, 8% of the expenses above 1,3 yuan can be reimbursed.

Second, the reimbursement ratio of hospitalization expenses

The maximum payment of the basic medical insurance pooling fund (hospitalization expenses) in a year is currently 7, yuan.

1. The standard of hospitalization reimbursement is related to the level of the hospital where the insured person lives. If he lives in a tertiary hospital, the employee will pay 15% from the minimum payment standard to the cost of 3, yuan, that is, 85% will be reimbursed;

the employee will pay 1% and reimburse 9% of the expenses ranging from 2, yuan to 4, yuan;

3. 95% of the expenses exceeding 4, yuan to the maximum payment limit can be reimbursed, and employees only need to pay 5%.

4. The proportion of retirees' personal payment is 6% of the on-the-job (that is, the above-mentioned) employees, but all those below the minimum threshold are paid by individuals.

Legal basis: Social Insurance Law of the People's Republic of China

Article 23 Employees shall participate in the basic medical insurance for employees, and the employer and employees shall pay the basic medical insurance premium in accordance with the national regulations.

individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees in the employing unit and other flexible employees can participate in the basic medical insurance for employees, and individuals will pay the basic medical insurance premium according to state regulations.

article 24 the state establishes and improves the new rural cooperative medical system.

the measures for the administration of the new rural cooperative medical system shall be formulated by the State Council.

article 25 the state establishes and improves the basic medical insurance system for urban residents.

the basic medical insurance for urban residents combines individual contributions with government subsidies.

people who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people over 6 years old and minors from low-income families, etc. will be subsidized by the government.

article 26 the treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Article 27 Individuals who participate in the basic medical insurance for employees will not pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with the provisions of the state, if the accumulated payment reaches the fixed number of years stipulated by the state when they reach the statutory retirement age; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.

article 28 medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards, and emergency and rescue shall be paid from the basic medical insurance fund in accordance with state regulations.

article 29 the part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be directly settled by the social insurance agency, medical institutions and pharmaceutical trading units.

the social insurance administrative department and the health administrative department should establish a settlement system for medical expenses in different places, so as to facilitate the insured to enjoy the basic medical insurance benefits.

Article 3 The following medical expenses are not included in the payment scope of the basic medical insurance fund:

(1) Those that should be paid from the industrial injury insurance fund;

(2) It shall be borne by a third party;

(3) It shall be borne by public health;

(4) seeking medical treatment abroad.

the medical expenses shall be borne by the third party according to law. if the third party fails to pay or cannot determine the third party, the basic medical insurance fund shall pay in advance. After the basic medical insurance fund has paid in advance, it has the right to recover from the third party.

article 31 social insurance agencies may sign service agreements with medical institutions and pharmaceutical trading units to regulate medical service behavior according to the needs of management services.

medical institutions should provide reasonable and necessary medical services for the insured.