The amount that the employee medical insurance pooling fund can use within one year includes the maximum payment limit of the basic medical insurance pooling fund and the payment limit of the social insurance department. The maximum payment limit of the basic medical insurance pooling fund is 654.38+10,000 yuan; Medical expenses exceeding this limit shall be reimbursed by the social insurance department in different proportions according to the scope of expenses, specifically, 85% for the part below RMB 0-40,000, 90% for the part below RMB 40,000-80,000 and 95% for the part above RMB 80,000. In each medical year, the maximum payment limit of social insurance department is 6.5438+0.5 million yuan. Therefore, the maximum reimbursement amount of employee medical insurance in a medical year is 250,000 yuan.
The scope and limit of medical insurance reimbursement for employees:
1, coverage of basic medical insurance policy: covering outpatient treatment, hospitalization treatment, outpatient treatment for special diseases, etc. ;
2. Reimbursement ratio: According to different regions and policies, the reimbursement ratio is usually between 50% and 90%, and the specific ratio needs to refer to local regulations;
3. The annual maximum payment limit: each region is set according to the level of economic development and medical expenses, and the excess is borne by individuals;
4. deductible standard: refers to a certain amount that individuals need to pay before medical insurance reimbursement, and the part that exceeds the deductible can be reimbursed;
5. scope of drugs and services: only drugs and services included in the medical insurance catalogue can be reimbursed, and the expenses of non-medical insurance catalogue need to be paid in full by individuals.
To sum up, the maximum reimbursement amount of employee medical insurance in a medical year is 250,000 yuan, including the maximum payment limit of the basic medical insurance pooling fund and the payment limit of the social insurance department.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 23
Employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees 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.