calculation formula of medical insurance reimbursement = total cost-deductible line-self-paid part of drugs and inspection * reimbursement ratio. Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for economic losses caused by disease risks. The medical insurance fund is established through the payment of employers and individuals. After the insured person suffers from medical expenses, the medical insurance institution will give him some economic compensation.

The specific provisions of medical insurance reimbursement are as follows:

1. Medical treatment and drug purchase in medical institutions and pharmacies specified by medical insurance can be reimbursed, and emergency expenses incurred by people participating in medical insurance in non-designated medical institutions can also be reimbursed;

2. Only drugs purchased in the Basic Medical Insurance Catalogue can be reimbursed. All Class A drugs are reimbursed, while Class B drugs are partially reimbursed, but Class C drugs cannot be reimbursed.

3. Only those who meet the scope of basic medical insurance diagnosis and treatment items can be fully reimbursed or partially reimbursed. ;

4. The service facilities can only be reimbursed if they meet the standard scope of medical service facilities of basic medical insurance. It mainly includes hospital bed fees and emergency and outpatient observation bed fees, such as nursing fees and meals, which cannot be reimbursed.

The calculation method of medical insurance reimbursement ratio is as follows:

1. The reimbursement ratio within the scope of medical insurance policy is equal to the medical insurance reimbursement expenses divided by the reportable expenses. When the reportable expenses are certain, the value of medical insurance reimbursement expenses needs to be larger if the reimbursement ratio is high, and the medical insurance reimbursement expenses are equal to the reportable expenses-part of the policy pays-deductible line multiplied by the overall fund payment ratio. It can be seen that the medical insurance department can increase the reimbursement expenses of medical insurance by reducing part of the policy self-payment, lowering the deductible line and increasing the proportion of overall fund payment, thus increasing the reimbursement proportion within the medical insurance policy;

2. The actual reimbursement ratio is equal to the medical insurance reimbursement expenses divided by the reportable expenses plus the non-reportable expenses. When the non-reportable expenses are small, the larger the medical insurance reimbursement expenses, the higher the actual reimbursement ratio can be. However, if the value of non-reportable expenses accounts for a large part, even if the medical insurance pooling fund pays 1% of the reportable expenses, the actual reimbursement ratio is very low. For example, in this example, the expense of 11323 cannot be reported. 2 yuan is too large, even if the medical insurance reimbursement expense = reportable expense =7755. 21, the actual reimbursement ratio is only 4. 65%。

I hope the above contents can help you. If you have any questions, please consult a professional lawyer.

Legal basis:

Article 28 of the Social Insurance Law of the People's Republic of China

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

article 29

the part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be directly settled by the social insurance agency, medical institutions and pharmaceutical trading units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places, so as to facilitate the insured to enjoy the basic medical insurance benefits.

article 23

employees shall participate in the basic medical insurance for employees, and the employer and employees shall pay the basic medical insurance premiums in accordance with the state regulations. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees in the employer and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.