In a natural year, the deductible standard and payment ratio of general outpatient expenses incurred by employees within the scope of overall regional policies shall be implemented according to the following provisions: the deductible standard is 800 yuan; 60% of first-class designated medical institutions, 55% of second-class designated medical institutions and 50% of third-class designated medical institutions; The contribution rate of retired employees is 5 percentage points higher than that of on-the-job employees. In a natural year, the payment limit of the general outpatient expenses of employees is 2000 yuan. The payment limit is not carried forward or accumulated to the next year.

What is the starting point and cumulative calculation method of general outpatient co-ordination?

Within a natural year, the qifubiaozhun for designated medical institutions at level 1 and below is 500 yuan, and the qifubiaozhun for designated medical institutions at level 2 and above is 800 yuan.

The insured person was treated in a first-class hospital, and the general outpatient medical expenses that met the medical insurance policy in that year were included in the settlement after the accumulated expenses reached the Qifubiaozhun of the first-class hospital in 500 yuan; When visiting a secondary or tertiary hospital, the general outpatient expenses that meet the requirements of the medical insurance policy are accumulated to the Qifubiaozhun 800 yuan of the secondary or tertiary hospital, and the general outpatient medical expenses that meet the requirements of the medical insurance are included in the settlement. If the insured changes the designated medical institution during the year, the cumulative Qifubiaozhun shall not exceed 800 yuan.

Example: On July 6th, Xiao Wang, an on-the-job employee, went to the general outpatient department of a 3A hospital to spend 650 yuan, of which 600 yuan was the expenses within the overall planning scope, (600-500)*70%=70 yuan, excluding the threshold of 500 yuan. On July 20th, Xiao Wang went to the general outpatient department of the tertiary hospital again, spending 962 yuan, and the expenses within the overall scope were 850 yuan. Because the threshold of tertiary hospitals is 800 yuan, this year, Xiao Wang's threshold of primary hospitals has accumulated to 500 yuan. After tertiary hospitals accumulate 300 yuan, they need to settle accounts according to 50% of the proportion paid by tertiary hospitals, and the employee pooling fund will pay (850-300) * 50% =.

To sum up, in an insured year, the minimum payment standard of the pooling fund is that the medical expenses incurred by the insured in the designated medical institutions in medical insurance coverage reach 600 yuan, and the general outpatient co-ordination limit is paid, with employees 1.200/ person-year and retirees 1.800/ person-year.

Legal basis:

People's Republic of China (PRC) social insurance law

Article 28

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Article 29

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, 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.