I. Medical insurance for employees

Employees who have been employed, such as government agencies, institutions, state-owned enterprises, private enterprises, organizations, etc., are paid social insurance by employers according to the labor law, that is, five of the five insurances and one fund that we usually talk about the most. It consists of medical insurance, maternity insurance, industrial injury insurance, unemployment insurance and endowment insurance. The insurance paid by these people for employees by the unit is called employee medical insurance.

second, residents' medical insurance

except for those who participate in employee medical insurance, those who take their household registration as the unit pay their own fees to participate in medical insurance. In 217, according to the unified deployment of the State Council, the national medical insurance system for urban and rural residents has been integrated. That is, the original new rural cooperative medical system and urban residents' medical insurance are integrated together, which is called urban and rural residents' medical insurance.

Third, the difference

lies in the following five aspects:

1 Different objects

Residents' medical insurance is mainly aimed at unemployed residents, low-income households, students and children;

medical insurance for employees is aimed at working units or flexible employees, individual industrial and commercial households, etc.

2 Different sources of expenses

Residents' medical insurance is paid by individuals and subsidized by finance; The amount of general financial assistance is much more than that paid by individuals;

employees' medical insurance is paid by both the unit and the individual, generally 8% by the unit and 2% by the individual;

3 Different payment standards

Residents' medical insurance is paid annually, and there is a collection period. Generally, the next year's fee is paid from September to December every year. If the payment is not made within the collection period, there will be a certain waiting period, that is, there will be a period of time when they cannot enjoy the treatment;

employees' medical insurance is paid monthly. Generally speaking, the payment is made before the date of each month. If the payment is overdue, there will be a late payment fee. Moreover, if medical expenses occur during the unpaid period, they will not be reimbursed first, and will not be reimbursed until the payment is made.

4 Different benefits

Residents' medical insurance contributions are low, so the benefits are low, and the reimbursement ratio is generally about 45% ~ 65%;

Employees pay medical insurance every month, and the treatment is high, and the reimbursement ratio is generally about 7% ~ 9%;

Note:

① Employees will pay a part of their money into their personal accounts (except those who are self-employed and have no accounts), and residents generally do not have personal accounts. Of course, some cities have better conditions and will pay a part of their money into social security cards to buy medicines, but it is generally only tens of dollars.

② Regarding the reimbursement ratio, local policies are different. Please call 12333 to consult the local community department for the specific ratio.

(Example: Taking Beijing as an example, let's take a concrete look at the reimbursement ratio of employee medical insurance and urban and rural residents' medical insurance in 218.

The reimbursement of the insured in Beijing Medical Insurance is very different from the reimbursement of hospitalization. Generally speaking, the "strength" of outpatient reimbursement is smaller, as shown in the following figure, firstly, the deductible is higher, and secondly, the proportion of reimbursement is lower.

the deductible is only when the medical expenses exceed this amount can be reimbursed, and the deductible of outpatient service is cumulative and counted as one year.

For example, employee Xiao Li has been to the hospital twice this year, and the first medical expense is 8 yuan, which cannot be reimbursed. The second medical expenses are 1 yuan, which still cannot be reimbursed. Then in 218, as long as Xiao Li goes to the hospital again, no matter how much he spends, he can be reimbursed in proportion.

in addition, many hospitals in Beijing have regulations that urban and rural residents need to go through the referral procedures in the community (or cooperative medical points) before they can go to the big hospitals for outpatient treatment, otherwise they will not be reimbursed.

Looking at hospitalization reimbursement of medical insurance, the deductible line of employees is lower than that of outpatient reimbursement, but the deductible line of urban and rural residents is higher than that of outpatient reimbursement. However, the reimbursement ratio of employees and urban and rural residents is almost higher than that of outpatient reimbursement. The details are as follows:

The deductible for hospitalization is not cumulative, and the medical expenses for the next hospitalization cannot be reimbursed if it is lower than the deductible.

However, according to Beijing's regulations, except for students and children, if other people are hospitalized for the second time (and later) in the same year, the deductible standard will be halved, the deductible for employees and retirees will be reduced to 65 yuan, and the deductible for urban and rural residents will also be halved.

Although there are so many differences between medical insurance for employees and medical insurance for urban and rural residents, in fact, what needs to be done in the whole process of medical treatment and reimbursement is similar. The deductible line and reimbursement ratio will be automatically calculated by hospitals and medical insurance centers, so we can learn more about medical insurance knowledge if we have the will. If we don't understand it, it won't have much impact. )

5 Different payment requirements

Residents' medical insurance must be paid annually, and they can't enjoy treatment if they don't pay. There is no retirement, and some cities also require residents to pay fees continuously, otherwise they cannot enjoy the treatment. If it is interrupted, it may be necessary to pay back the expenses of previous years (I always think this is not appropriate, only a few cities have this requirement)

What is the difference between the reimbursement ratio of residents' medical insurance and employees' medical insurance?

1. What is the minimum threshold for hospitalization within the local hospitalization year?

Qifubiaozhun refers to the "threshold" that can be paid by the basic medical pooling fund according to regulations. That is to say, before the pooling fund pays the hospitalization expenses, the individual employee must bear a certain amount of medical expenses before the pooling fund starts to pay. According to the regulations of our city, the qifubiaozhun for the first time in a medical year is 3 yuan, 5 yuan and 7 yuan. Qifubiaozhun for the second hospitalization will be halved, and Qifubiaozhun will no longer be set for the third hospitalization.

2. how is the settlement of medical expenses for local in-service staff calculated?

the maximum payment limit of the basic medical co-ordination fund is 2, yuan. After deducting out-of-range medical expenses (at one's own expense, partly at one's own expense), above the Qifubiaozhun, the expenses shall be reimbursed in a progressive manner. Within 1, yuan (including 1, yuan), the personal burden is 9%, 13% and 15% in the first, second and third level hospitals respectively; From 1, yuan to 2, yuan (including 2, yuan), the personal burden is 7%, 9% and 11% in the first, second and third level hospitals respectively; From 2, yuan to 3, yuan (including 3, yuan), the personal burden is 7%; 3, yuan to the maximum payment limit, the personal burden is 5%.

3. How is the settlement of medical expenses for local retirees calculated?

The personal burden of retirees is half of that of on-the-job employees, and that of old workers before the founding of the People's Republic of China is half of that of retirees. The minimum threshold and maximum payment limit are the same as those of on-the-job employees.

medical insurance for residents

are all medical expenses included in the reimbursement scope during hospitalization? What is the minimum payment standard?

a: not all medical expenses during hospitalization are included in the scope of reimbursement, only medical items that meet the requirements of residents' medical insurance policies are included in the scope of reimbursement, specifically, those in the basic medical insurance drug list, diagnosis and treatment items list and medical service facilities list are reimbursed.

hospitalization qifubiaozhun is divided into the following situations:

1. local hospitalization qifubiaozhun. Qifubiaozhun for the first hospitalization in the year are: 2 yuan, a first-class medical institution (including community health service center), 5 yuan, a second-class medical institution, and 7 yuan, a third-class medical institution; The Qifubiaozhun for the second hospitalization was reduced to 1 yuan; The two qifubiaozhun of township hospitals implementing the national basic drug system are 1 yuan; Private designated medical institutions with undetermined levels shall implement the Qifubiaozhun of secondary medical institutions; For the third hospitalization, no deductible line will be set.

The payment ratio of hospitalization medical expenses within the policy range from Qifubiaozhun to Maximum Payment Limit is 85% and 7% for township health centers and county hospitals that implement the national basic drug system, 75% for other first-class medical institutions, 65% for second-class medical institutions, 6% for third-class medical institutions, and 6% for private medical institutions that have not been graded.

(from Laiwu Human Resources and Social Security Bureau)

I paid 8, employees' old-age insurance, and it took two years to get the money. Now I don't want to enjoy it any more. Can I get the money back?

Reply from the Pension Insurance Department of the Municipal People's Social Security Bureau: Generally speaking, employees' pension insurance benefits cannot be withdrawn. In special circumstances, such as repeated payment, employees' going abroad to settle down or emigrating, or employees' death before retirement, they can go through the formalities of withdrawing their pension insurance with relevant materials.

I am a five-guarantee household with a first-class visual disability. I have bought old-age insurance for residents in the town. Why don't I pay old-age insurance subsidies when I have reached the age?

reply from the people's social security bureau of Nonggao District: According to the ID card information, the information of Chen Yongzeng's old-age insurance in Yangzhuang Town has been registered and entered. However, because the old-age insurance will add new recipients every month, it will be processed in batches, and it will take some time to register personal information and bank accounts, but it will be reissued from the month when the benefits are received. Chen Yongzeng's pension insurance will be issued in the near future.

Further reading: How to buy insurance, which is better, and teach you how to avoid these "pits" of insurance.