Subjectivity of law:

Medical insurance is an insurance to compensate the medical expenses caused by diseases. Social insurance in which employees are provided with necessary medical services or material assistance by society or enterprises due to illness, injury or childbirth. Such as free medical care and labor insurance medical care in China. The medical expenses of employees in China are shared by the state, units and individuals, so as to reduce the burden on enterprises and avoid waste. What is the reimbursement scope of Shanghai medical insurance? Medical insurance mainly includes employee medical insurance and urban residents' medical insurance. What is the scope of their respective reimbursement? How is the standard formulated? 1. The scope of reimbursement of medical insurance for urban residents in Shanghai In 212, the medical insurance benefits for urban residents mainly adjusted the hospitalization reimbursement method according to the national requirements, specifically: the insured residents added the minimum threshold for each hospitalization, and the community health service center (or the first-class medical institution) 5 yuan, the second-class medical institution 1 yuan and the third-class medical institution 3 yuan. For the medical expenses that exceed the minimum threshold, the proportion paid by the urban residents' medical insurance fund is adjusted as follows, and the rest of the medical expenses are borne by the insured: 1. For those over 7 years old, the proportion paid by the fund is adjusted from 7% to 85% for those who seek medical treatment in community health service centers (or first-class medical institutions); 75% for medical treatment in secondary medical institutions; For medical treatment in tertiary medical institutions, 65% will be paid. 2. For people over 6 years old and under 7 years old, the proportion of fund payment is adjusted from 6% to 85% for those who seek medical treatment in community health service centers (or first-class medical institutions); 75% for medical treatment in secondary medical institutions; For medical treatment in tertiary medical institutions, 65% will be paid. 3. For people over the age of 18 and under the age of 6, as well as primary and secondary school students and infants, the proportion of fund payment is adjusted from 5% to 75% for those who seek medical treatment in community health service centers (or first-class medical institutions); 65% for medical treatment in secondary medical institutions; 55% for medical treatment in tertiary medical institutions. Through the above adjustments, the overall reimbursement rate of hospitalization medical expenses for urban residents' medical insurance in this city has increased from about 61% to about 7%. In 212, the outpatient and emergency payment policy of urban residents' medical insurance remained unchanged in 211. 2. Reimbursement scope of employees' medical insurance 1. On-the-job employees' emergency medical expenses 1. On-the-job employees who joined the work before December 31, 2: First, they will be paid from their personal medical account funds, and after the account funds are used up, they will be paid by individuals in cash. In a medical insurance year, after the individual is responsible for 1% of the average annual salary of employees in this city in the previous year, the excess will be shared by individuals and additional funds in a certain proportion. The payment proportion of additional funds varies according to the age of employees: (1) For those who were born before December 31, 1955 and joined the work before December 31, 2, the standard for outpatient and emergency departments at their own expense is 1,5 yuan, 7% of the excess medical expenses will be paid by the additional funds, and the rest will be borne by the on-the-job employees. (two) born from January 1, 1956 to December 31, 1965, and joined the work before December 31, 2, the standard for self-financing of outpatient and emergency departments is 1,5 yuan, and 6% of the medical expenses in excess shall be paid by the additional fund, and the rest shall be borne by the employees. (three) born after January 1, 1966, before December 31, 2 to participate in the work, the standard for outpatient and emergency departments is 15 yuan, more than 5% of the medical expenses will be paid by the additional fund, and the rest will be borne by the employees. (four) after January 1, 21, the new job, the standard for outpatient and emergency departments is 15 yuan, more than 5% of the medical expenses will be paid by the additional fund, and the rest will be borne by the employees. The medical expenses incurred by employees in outpatient serious illness medical treatment, and the on-the-job employees are paid 85% by the overall fund; Retirees are paid 92% by the overall fund. After the payment of the overall fund, the remaining part is paid by the balance funds of individual medical accounts over the years, and the insufficient part is paid by individual cash. In the overall fund to pay the medical expenses above the maximum amount, 8% will be paid by the additional fund, and 2% will be borne by the employees. 2. Outpatient emergency medical expenses for retirees The expenses incurred by retirees for outpatient emergency medical treatment or dispensing medicines at designated retail pharmacies within one year shall be paid by their personal medical account funds. The insufficient part shall be paid by the individual to the self-financing standard of outpatient and emergency departments, and the excess part shall be paid according to the following provisions (excluding the expenses incurred in dispensing medicines at designated retail pharmacies): (1) For those who have gone through retirement procedures before December 31, 2, the self-financing standard of outpatient and emergency departments shall be 3 yuan, and for those in outpatient and emergency departments of first-class medical institutions, 9% of the medical expenses for the excess part shall be paid by additional funds; In the outpatient emergency of secondary medical institutions, more than 85% of the medical expenses are paid by the additional fund; In the outpatient emergency of tertiary medical institutions, more than 8% of the medical expenses are paid by the additional fund; The rest is borne by retirees. (two) born before December 31, 1955, joined the work before December 31, 2, and retired after January 1, 21. The standard for outpatient and emergency departments is 7 yuan. For outpatient and emergency departments in first-class medical institutions, 85% of the excess medical expenses are paid by the additional fund; In the outpatient emergency of secondary medical institutions, more than 8% of the medical expenses are paid by the additional fund; In the outpatient emergency of tertiary medical institutions, more than 75% of the medical expenses are paid by the additional fund; The rest is borne by retirees. (3) Those who were born from January 1, 1956 to December 31, 1965, joined the work before December 31, 2, and went through retirement formalities after January 1, 21, the standard for outpatient and emergency departments is 7 yuan, and those who are in outpatient and emergency departments of first-class medical institutions, 7% of the excess medical expenses will be paid by the additional fund; In the outpatient emergency of secondary medical institutions, more than 65% of the medical expenses are paid by the additional fund; In the outpatient emergency of tertiary medical institutions, more than 6% of the medical expenses are paid by the additional fund; The rest is borne by retirees. (4) Those who were born after January 1, 1966, joined the work before December 31, 2 and went through retirement formalities after January 1, 21, the self-supporting standard for outpatient and emergency departments is 7 yuan, and those who are in outpatient and emergency departments of first-class medical institutions, 55% of the excess medical expenses will be paid by the additional fund; In the outpatient emergency of secondary medical institutions, more than 5% of the medical expenses are paid by the additional fund; In the outpatient emergency of tertiary medical institutions, more than 45% of the medical expenses are paid by the additional fund; The rest is borne by retirees. (five) after January 1, 21 to participate in the work and then go through the retirement procedures, the standard for outpatient and emergency services is 7 yuan, and for outpatient and emergency services in a first-class medical institution, 55% of the medical expenses will be paid by the additional fund; In the outpatient emergency of secondary medical institutions, more than 5% of the medical expenses are paid by the additional fund; In the outpatient emergency of tertiary medical institutions, more than 45% of the medical expenses are paid by the additional fund; The rest is borne by retirees. 92% of the outpatient serious illness expenses of retirees are paid by the overall fund. The rest shall be paid by the surplus funds of individual medical accounts over the years, and the insufficient part shall be borne by the employees. Legal objectivity:

Notice on Adjusting Some Policies of Residents' Basic Medical Insurance (J.H.F. [22] No.17) Article 1 The financing standard of residents' medical insurance in our city in 221. In 221, the individual payment standard for adult residents is 34 yuan, the individual payment standard for children is 24 yuan, and the financial subsidy standard is 58 yuan.