Legal basis: Article 30 of the Social Insurance Law of People's Republic of China (PRC), the following medical expenses are not included in the scope of payment of the basic medical insurance fund: (1) those that should be paid by the industrial injury insurance fund; (2) It shall be borne by a third party; (three) shall be borne by public health; (4) Go abroad for medical treatment. Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.
Extended data:
(A), outpatient reimbursement ratio
After getting the basic medical insurance for urban workers, if they are on-the-job workers, they can only be reimbursed for medical expenses of more than 2,000 yuan in the outpatient and emergency departments of hospitals, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan.
For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 500 yuan can reimburse 50%, that is, 250 yuan.
(2) Proportion of hospitalization reimbursement
At present, when the basic medical insurance is first used within one year, the minimum payment for employees and retirees is 1300 yuan. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. The maximum annual payment limit (hospitalization expenses) of the basic medical insurance pooling fund is currently 70,000 yuan.
(3), hospitalization Qifubiaozhun
Three-level hospitals and above: The deductible lines for multiple hospitalizations in 700 yuan within one year are 500 yuan, 400 yuan and 300 yuan, and the reimbursement rate of medical insurance for employees is 20 16.
Secondary hospitals include secondary specialized hospitals: 600 yuan was hospitalized several times in one year, followed by 400 yuan, 300 yuan and 200 yuan.
The first level includes the following hospitals: hospitalization in 500 yuan for many times within one year, and minimum compensation for 300 yuan and 200 yuan, 100 yuan.
Above the deductible and below the maximum payment limit, 85% of class A and general medical expenses are paid by on-the-job employees.
Retiree payment: 90%. Class B drugs pay 75% and cutting-edge drugs pay 70%. Medical insurance for employees with chronic diseases, special diseases and major diseases, the annual Qifubiaozhun is 700 yuan. Class A and general diagnosis and treatment 80%, class B 75%, high accuracy 70%.
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