65,438+0. Qifubiaozhun: within a medical insurance year, the Qifubiaozhun for the first hospitalization is 1.300 yuan (1.800 yuan for employees, 1.300 yuan for retirees), and 650 yuan for the second time and later.
2. Reimbursement proportion: the payment proportion is calculated according to the hospital level by subsection calculation and cumulative payment.
3. Payment limit: the cumulative maximum payment limit of the basic medical insurance co-ordination fund within one year is 654.38+10,000 yuan, and the cumulative maximum payment limit of the large mutual fund is 200,000 yuan and 300,000 yuan.
Hospitalization medical expenses: the part of the medical expenses below the hospitalization threshold of retirees with personal burden higher than 5% and employees with personal burden higher than 10% shall be paid by the unit's supplementary medical insurance. For medical expenses above Qifubiaozhun, the part of retirees whose personal burden is higher than 3% shall be paid by the unit's supplementary medical insurance. The basic medical insurance reimbursement part of the personal burden is less than 3%, according to the basic medical insurance policy.
All medical expenses incurred by Beijing medical insurance participants can be reimbursed accordingly, but not all medical expenses are within the scope of medical insurance reimbursement. Participating in different types of medical insurance and choosing different medical institutions will have an impact on the amount of medical insurance reimbursement. Payment scope of individual medical insurance account of Beijing Medical Insurance:
1, outpatient and emergency medical expenses.
2, to the designated retail pharmacies to buy drugs.
3, the basic medical insurance fund Qifubiaozhun the following medical expenses.
4, more than the basic medical insurance fund Qifubiaozhun part, according to the proportion that should be borne by the individual medical expenses. The insufficient part of personal account shall be paid by myself.
What is the proportion of medical insurance reimbursement in Beijing?
Generally speaking, the economic development in different regions is different, so the reimbursement ratio is different. The following is an explanation of the proportion of employees' medical insurance in Beijing.
After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, 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 this 500 yuan can be reimbursed 50%, that is, 250 yuan.
In case of hospitalization expenses, employees and retirees should pay the minimum amount 1300 yuan when using the basic medical insurance for the first time in a year. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. 1 year The maximum payment limit of the basic medical insurance pooling fund (hospitalization expenses) is 70,000 yuan.
To sum up, in the process of seeing a doctor, if Beijing residents have employee medical insurance, it is best to go to a designated hospital for treatment, so that some expenses can be reimbursed. Reimbursement items are generally divided into outpatient reimbursement and hospitalization reimbursement, and each category has a minimum payment standard. Expenses exceeding this standard will be reimbursed in proportion. At present, the reimbursement rate for outpatient service is 50%, and the maximum amount is 20,000 yuan.
Legal basis:
People's Republic of China (PRC) social insurance law
Twenty-sixth 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.
Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; 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.
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.
Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:
(a) shall 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.