It doesn't matter. Today, we will take the general hospitalization as an example, introduce the calculation formula of 1 medical insurance benefits, sort out 8 key words, and help you understand this hospitalization statement in 2 minutes, so that you can change from a zero-based "medical insurance white" to an "expert" who clearly grasps the medical insurance reimbursement benefits.
First of all, I'd like to give you a grand introduction
Calculation formula of total reimbursement of medical insurance
Total fund payment (that is, the total medical insurance reimbursement we often say) = (total medical expenses-all self-paid-out-of-pocket expenses-proportional out-of-pocket expenses-actual out-of-pocket expenses) × reimbursement proportion+supplementary insurance payment for serious illness medical assistance.
As you can see, this formula involves eight key words: total medical insurance reimbursement, total medical expenses, all out-of-pocket expenses, out-of-pocket expenses, proportional out-of-pocket expenses, actual deductible, reimbursement ratio, and supplementary insurance payment for serious illness medical assistance. These eight keywords ultimately determine how much your medical insurance can reimburse.
Next, we take the statement of medical treatment in different places in Sichuan Province as an example.
Unveiling the Mystery of Medical Insurance Statement in General Hospital
See what it looks like.
Inter-provincial medical insurance statements are different.
But the core content is unified.
Let's start with
As long as you understand the following statement.
Nature is also a one-stop shop.
Please pay attention to the above statement. We marked 12 the main factors that affect the reimbursement amount of general hospitalization medical insurance. This 12 factor also corresponds to and determines eight key words in the formula for calculating medical insurance benefits.
Look here
Smart friends have started asking questions.
How to determine the reimbursement ratio in the formula?
The amount in line with the policy scope and the amount paid by the fund
How did you get it?
What does each keyword mean?
Let's see how the reimbursement ratio is determined ↓
Taking the above statement as an example, the age of the insured, the type of insurance and the hospital level of medical treatment determine the reimbursement ratio.
According to Chengdu's medical insurance policy, the medical insurance reimbursement rate of urban workers' basic medical insurance participants in tertiary hospitals is 85%. If the insured is over 50 and under 60, and the reimbursement rate increases by 2%, then his reimbursement rate is 87%.
We continue to look at the amount that meets the policy scope and the amount paid by the fund ↓
Amount in compliance with the policy = total medical expenses-all out-of-pocket expenses-out-of-pocket expenses-proportional out-of-pocket expenses. I believe that smart people have discovered that the amount in line with the policy scope in the statement is 5=4-6-7-8.
Fund payment amount = (the amount within the scope of the policy-the actual out-of-pocket amount) × reimbursement ratio, that is,1= (5-10 )× reimbursement ratio in the statement.
Here we should focus on the issue of reimbursement ratio. We often receive inquiries from the insured-what is my reimbursement rate? You may have thought about it before. For example, if you spend 10000 yuan in hospital, and your reimbursement rate is 85%, then you think medical insurance should be reimbursed 8500 yuan. Now, through our explanation, do you also understand that the original amount of medical insurance reimbursement is not simply the total medical expenses × reimbursement ratio, but refers to (the amount in line with the policy-the actual deductible) × reimbursement ratio.
So, what exactly do these keywords mean? Here is a brief explanation for you ↓
Needless to say, the total medical expenses are a total cost incurred by your hospitalization;
The total amount of self-funded expenses can be simply understood as the expenses that are not reimbursed by medical insurance. For example, some drugs and medical consumables are not reimbursed by medical insurance;
Out-of-pocket expenses refer to some medicines, medical consumables and bed fees. The medical insurance fund is paid at a price limit, and all the parts above the price limit are paid by individuals. For example, the price of a medical consumables is 1000 yuan, and the maximum payment limit of medical insurance fund is 800 yuan, so the remaining 200 yuan is called out-of-pocket expenses;
Proportional out-of-pocket payment mainly refers to class B drugs, some medical treatment items included in medical insurance reimbursement and medical consumables that need to be borne by individuals first. For example, the price of Class B drugs is 500 yuan, and individuals need to pay 10% first, then this 500× 10% = 50 yuan is the proportional deductible;
The actual deductible amount is what we usually call the threshold fee. For example, the insured workers in this town seek medical treatment in tertiary hospitals, and the threshold fee is 800 yuan.
If you want to know what expenses you pay for an ordinary hospitalization, which are out-of-pocket expenses and which are proportional expenses, you can take a closer look at the detailed list of hospitalization expenses, which is also clear at a glance.
After sorting out these problems
Sharp-eyed, you must have another problem.
Why can't the payment amount of mutual medical assistance supplementary insurance for critical illness in the formula be seen in the statement?
This is because the policies and names of mutual medical assistance and supplementary insurance for serious illness in various co-ordination areas are inconsistent, but in order to keep consistent with the fund code value issued by the National Medical Insurance Bureau, the Sichuan medical insurance settlement table is uniformly named as "Large Medical Expenses Subsidy Fund". In fact, you just need to remember that the "large medical expenses subsidy fund" in the statement refers to what we call supplementary medical insurance for serious illness.
Then we will put the insured person in the hospitalization statement.
All data are calculated once in combination with the formula.
See if our formula is correct.
Total medical insurance reimbursement = (the part where the total self-funded medical expenses exceed the self-funded price limit: 2 136- the proportion of out-of-pocket payment: 800)× reimbursement proportion: 87%+ the payment amount of supplementary medical insurance for serious illness. Let's take a look at the figures separately. Then there is the total amount of medical insurance reimbursement =(×87%+ if we use a calculator to verify, we will find that the total amount of medical insurance reimbursement calculated by us is completely consistent with the total amount of fund payment on the statement.
Now, we use eight keywords.
Unveiled the mystery of the hospitalization statement for medical treatment in different places
Do you also calculate the total medical insurance reimbursement?
Very clear ~
If so, quickly forward it to a circle of friends.
So your friends can, too
Read the statement of hospitalization in different places in 2 minutes!
Source | Chengdu Medical Insurance
Editor | Jin Longteng Liu Xinyu
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