However, when medical insurance is reimbursed, not all medical expenses during hospitalization can be reimbursed, but there are many restrictions: catalog restrictions, deductible lines, capping lines, and reimbursement ratio restrictions.
It can be said that although medical insurance is a medical benefit provided by the state to each of us, it is not a panacea.
There is a "one point three catalogue" restriction on medical insurance reimbursement, and only those within the prescribed scope can be reimbursed.
Some points are that designated hospitals and retail pharmacies will be reimbursed for medical treatment, while social security such as private clinics and overseas medical treatment does not support reimbursement.
Three. Catalogue, that is, the reimbursement scope of drugs, diagnosis and treatment items and medical service facilities of basic medical insurance. Only qualified personnel can be reported:
The expenses incurred by the insured in the use of drugs, medical treatment projects or medical service facilities belong to the "three-category catalogue" and can be reimbursed according to regulations;
Do not belong to the "three directories", medical insurance will not be reimbursed.
As for plastic surgery, weight loss, myopia and so on. These items beyond the scope of social security cannot be reimbursed.
Generally speaking, the reimbursement of medical insurance expenses follows these rules, and all medical expenses within these rules can be reimbursed:
1. Normal treatment period (medical insurance has not been paid off);
2. Seek medical treatment in designated medical institutions;
3. Conforming to the scope of "three catalogues";
4. Above the deductible line and within the capping line.
On the other hand, expenses beyond the prescribed limits cannot be reimbursed.
Although the proportion of medical insurance reimbursement is not low, there is a deductible line, a reimbursement limit and a reimbursement scope.
At the bottom is the "deductible line", just like the "deductible" in commercial insurance. You can't report below the deductible;
The top "top line" is the maximum reimbursement amount of the medical insurance fund, that is, the maximum reimbursement amount that the insured can get from the medical insurance fund within one year, and the excess must be paid by himself.
Then, after cutting the head and tail, can you report everything in the middle?
Not exactly.
Don't forget, there are other expenses that are not in the medical insurance catalogue, such as the cost of imported drugs and plastic surgery, which belong to self-funded medical care, and the rest cannot be reimbursed at their own expense.
How much can medical insurance be reimbursed?
The first formula:
Reimbursement amount = (total cost of treatment-deductible line-self-paid part) Reimbursement proportion Maximum reimbursement amount
Let's talk about how much medical insurance can reimburse under different circumstances.
(1) How much can the outpatient department reimburse?
Many of the diseases seen in the outpatient clinic are minor illnesses, and the money in the personal account of the general medical insurance card can be directly used as cash.
All expenses will not be too much, so outpatient clinics generally have to accumulate to the deductible line of one-year limit, and those exceeding the minimum deductible line will be reimbursed in proportion.
For example, in Beijing, the minimum deductible line for outpatient reimbursement is 1800 yuan, after which reimbursement can only be made.
Suppose the Lao Wang clinic next door costs 6000 yuan a year, of which 1000 yuan is not covered by social security reimbursement.
Then, the reimbursement amount of old Wang Neng = (outpatient fee-deductible line-self-funded medicine) 70% = (6000-1800-1000) 70% = 2240 yuan, and the self-funded medicine is 3760 yuan.
(2) How much can be reimbursed for hospitalization?
At present, hospitalization medical insurance reimbursement is very convenient. The hospital is automatically connected to the medical insurance system, and the medical insurance directly reimburses the hospitalization expenses when leaving the hospital.
Take Lao Wang next door to Zhengzhou as an example.
Suppose Lao Wang next door is hospitalized in a 3A hospital, and the cost is13,000 yuan, of which 2,000 yuan is social security medicine for external use.
Then Lao Wang's reimbursable amount = (8000-2000) 55% (13000-8000-2000) 65% = 5250 yuan.
* * * Medical expenses 13000 yuan, medical insurance reimbursement of 5250 yuan, and self-expense of 7750 yuan.
(3) How much can a serious illness be reimbursed?
Medical insurance for major diseases can be reimbursed.
Take Lao Wang next door to Zhengzhou as an example.
For example, Lao Wang got lung cancer and spent 400,000 yuan in a 3A hospital, of which 60,000 yuan was for social security.
Then the first reimbursement for medical expenses by old RoyceWong is: (8000-2000) 55% (15000-8000) 65% = 95600 yuan, and his own expenses are 244400 yuan.
According to Zhengzhou's second reimbursement policy for housing insurance, after one reimbursement, if the hospitalization expenses borne by individuals exceed 1. 1 10,000, they can enjoy the second reimbursement for serious illness.
Then the second reimbursement expense for Lao Wang's serious illness is: (10-1000) 60% (244,400-65,438+ten thousand) 70% =154,680 yuan.
In this way, the total expenses of the two medical insurance reimbursement =95600 154680=250280 yuan, and the self-funded part is only 149720 yuan.
And now the second reimbursement in many places is a "one-stop settlement". As long as it meets the bottom line standard of second reimbursement, it is particularly convenient to settle accounts directly once and twice after discharge.
Related questions and answers: medical insurance reimbursement scope 1. Reimbursement scope of residents' medical insurance
1, hospitalization expenses;
2. Medical expenses within 7 days before emergency observation and hospitalization;
3, in line with the provisions of the urban residents special disease outpatient medical expenses;
4. Other expenses that meet the requirements.
Second, the reimbursement standard
1. Hospitalization: The reimbursement rate of hospitalization medical expenses between the Qifubiaozhun and the highest payment limit in line with the policy is 85% in the first-class hospitals (community health service centers and town health centers) that implement the basic drug system, and the reimbursement rate is increased by 2 percentage points if the village clinics of outpatient contracted medical institutions are transferred to the town health centers of medical institutions for hospitalization. The reimbursement rate of other first-level hospitals (County Second Hospital and County Maternal and Child Health Hospital) is 75%, the reimbursement rate of second-level hospitals (County People's Hospital and County Chinese Medicine Hospital) is 70%, and the reimbursement rate of third-level hospitals (Binhai Affiliated Hospital, Binzhou People's Hospital, Central Hospital and Third Hospital) is 75%. ) It is 55%.
After the medical insurance payment standard of 2065438+2006 is unified into a standard in 220 yuan, any insured resident who goes to a provincial networked hospital (such as a provincial hospital) can issue a referral certificate in our local county-level hospital and go to the county medical insurance office for the record. The medical insurance office can directly transmit the patient's hospitalization information to the patient's reimbursement system in the provincial networked hospital on the provincial platform, so that patients can enjoy the reimbursement treatment directly when they leave the hospital, and enjoy the reimbursement ratio higher than the local 25%. This fully reflects the convenience and benefits that 220 yuan, a unified payment standard of 20 16, has brought to our urban and rural residents.
2. General outpatient medical treatment: within one year, the minimum payment standard of outpatient medical expenses is 50 yuan, and the maximum payment limit of the insured person's outpatient pooling fund this year is 900 yuan. The reimbursement rate of general outpatient co-ordination medical expenses between Qifubiaozhun and the maximum payment limit is directly 50%; The trouble of canceling the secondary compensation system.
3. Outpatient chronic disease treatment: In 20 16 years, outpatient chronic diseases include malignant tumor (including leukemia), uremia, organ transplantation, diabetes (complicated with infection or one of the complications of heart, kidney, eye and nerve), hypertension phase III (one of the complications of heart, brain and kidney), rheumatoid disease (active phase) and pulmonary heart disease (right heart failure). Coronary heart disease (left ventricular failure), obstructive emphysema, tuberculosis, aplastic anemia, severe psychosis, epilepsy, hemophilia, phenylketonuria, etc. The basic medical insurance for urban and rural residents gives appropriate subsidies to the outpatient medical expenses of the above-mentioned chronic diseases. Within a year, the qifubiaozhun for outpatient chronic diseases is 500 yuan, which is calculated separately from the qifubiaozhun for hospitalization, and the highest subsidy ratio for outpatient chronic medical expenses within the policy scope between qifubiaozhun and the highest payment limit is no more than 50%.
4. Treatment of urban and rural residents' serious illness insurance: within one year, the inpatient medical expenses incurred by insured residents and the outpatient chronic disease expenses included in the overall fund payment scope will be compensated by residents' serious illness insurance after the compensation of urban and rural residents' basic medical insurance. The deductible line of serious illness insurance for urban and rural residents is 6.5438+0.2 million yuan, and the compliance medical expenses borne by individuals below 6.5438+0.2 million yuan will not be compensated. If the compliance medical expenses borne by individuals exceed1.2000 yuan (including1.2000 yuan) but are less than1.2000 yuan, 50% compensation will be given; More than 6,543,800 yuan (including 6,543,800 yuan) and less than 200,000 yuan shall be compensated by 60%; More than 200,000 yuan (including 200,000 yuan) will be compensated by 65%, with a maximum compensation of 300,000 yuan per person.
There was once a patient with lung cancer in the county people's hospital, and the total cost was 6 1 620.48 yuan. After the medical insurance reimbursement at the time of discharge settlement, I didn't expect to get a serious illness insurance subsidy of 7370.04 yuan at the same time. As long as inpatients in networked hospitals meet the conditions of serious illness insurance, they will receive serious illness insurance subsidies immediately at the time of discharge settlement.
5, students and children due to accidental injuries in accordance with the provisions of the policy of outpatient medical expenses, in accordance with the provisions of the outpatient co-ordination, the maximum payment limit is 5000 yuan.
6 insured residents due to acute, dangerous and serious illness after emergency treatment without hospitalization, the emergency medical expenses shall not be reimbursed; If the patient is hospitalized after emergency, the emergency medical expenses that meet the requirements can be merged into the hospitalization expenses for reimbursement; In accordance with the provisions of the emergency medical expenses, after the door (emergency) diagnosis invalid death, according to the reimbursement rate of 50%.
7. The medical expenses incurred by insured residents in hospital due to trauma and childbirth that meet the requirements of the policy shall be reimbursed according to the prescribed proportion, and there is no limit.