The payment scope of medical insurance pooling fund includes: 1 outpatient expenses that can be reimbursed according to medical insurance regulations; 2. Hospitalization medical expenses; 3. Special outpatient expenses, such as tumor radiotherapy and chemotherapy, renal dialysis and anti-rejection treatment after organ transplantation. ; 4. Patients admitted to hospital after emergency rescue should observe their expenses within 7 days before hospitalization.
2. Payment of supplementary medical insurance: medical expenses that meet the relevant provisions of social insurance and are borne by individuals other than patients' basic medical insurance.
The payment scope of supplementary medical insurance includes: 1 medical expenses when personal account is insufficient; 2. Medical expenses that should be paid by individuals outside the basic medical insurance pooling fund; 3. Medical expenses that should be paid by individuals except for mutual funds that pay large medical expenses.
3. Medical assistance payment: the amount paid by the medical assistance fund according to the regulations in the medical expenses incurred by the patient this time.
4. Personal burden: The expenses borne by the insured who participate in employee medical insurance and urban and rural residents' medical insurance when purchasing medicines in outpatient clinics, hospitals and pharmacies according to relevant regulations can be divided into personal self-payment and personal self-payment.
(1) Individual self-payment: the amount of medical expenses incurred by the patient in this medical treatment that falls within the scope of the basic medical insurance catalogue (individual self-payment = deductible line+advance self-payment+self-payment above the capping line, including the self-payment part in the catalogue and the compensation part of the secondary reimbursement fund during the treatment transition period), and is paid in packages according to the disease type, disease group, bed date and other ways. Is fixed by the patient.
(2) Personal expenses: The medical expenses incurred by the patient in this medical treatment are all paid by the individual, which is not included in the basic medical insurance catalogue according to relevant regulations.
5. Other payments (including funds or single settlement funds only): The medical expenses incurred by patients in this diagnosis and treatment shall be paid by enterprises, commercial insurance and other funds or funds in addition to the basic medical insurance payment.
6. Personal payment: The medical expenses actually paid by the individual for this medical treatment are divided into personal account payment and personal cash payment.
(1) Personal account payment: used to pay out-of-pocket expenses of the insured within the policy scope of designated medical institutions.
The scope of personal account payment includes: medical expenses below the deductible line of basic medical insurance fund incurred by designated medical institutions of basic medical insurance 1; 2 more than the basic medical insurance fund deductible, medical expenses shall be borne by individuals in proportion; 3 medical expenses exceeding the maximum payment limit of the basic medical insurance fund; 4. Medical expenses that should be paid by individuals at their own expense; 5 in the basic medical insurance designated retail pharmacies to buy drugs.
(2) Personal cash payment: the amount paid by individuals through cash, bank cards, WeChat, Alipay and other channels.
The relationship between the above items: total amount = medical insurance pooling fund payment+supplementary medical insurance payment+medical assistance payment+personal burden; Personal burden = other contributions+personal contributions.