Part of the answer is also my interpretation of the latter policy (I haven't found out about the new regulations on real-time reimbursement, and I don't know)
1. The deductible line for the annual cumulative expenses of outpatient and emergency departments is 2 (Article 4-1), and if your expenses of outpatient and emergency departments are X, then the amount of medical insurance reimbursement for you is .5*(x-2). The condition is 2 <: x< 42。 That is, the upper limit is 42 thousand yuan.
2. The "supplementary medical insurance" mentioned in "Beijing Basic Medical Insurance Regulations" and the "supplementary medical insurance" mentioned in reality (that is, what your company gave you) are not the same concept at all.
The former should actually be called "mutual fund for large medical expenses", which is a part of medical insurance. The mutual fund is responsible for the reimbursement of two parts, one is the part of outpatient and emergency departments from 2 to 42 mentioned in Article 1, and the other is the part of hospitalization expenses after medical insurance reimbursement exceeds 178,86 yuan (according to Article 32, the average salary in Beijing in 29 was 44,715 yuan), and this part is reimbursed by 7%.
The latter is commercial insurance, which was bought by companies like Ping An Insurance Company, in order to supplement the non-reimbursement part stipulated in Beijing Basic Medical Insurance Regulations. Namely x < 2 or x> This part of 42. According to the different regulations given by insurance companies, some commercial insurances are still in charge of 2 <: x< This part of 42 (because this part of the medical insurance only reported 5%) and the part where the medical insurance reimbursement amount exceeded the maximum limit of 278,86 yuan. The details still depend on the details of the commercial insurance selected by your company.
generally speaking, because social security is limited by the deductible line, reimbursement ratio and upper limit, by designated hospitals, by self-funded drugs and treatment fees, and by exemption (such as crimes, self-mutilation, traffic accidents, etc.), commercial supplementary medical insurance is needed, and the state has preferential policies for enterprises to supplement medical insurance, so it is not a great burden for enterprises to supplement medical insurance for employees.
Beijing Basic Medical Insurance Regulations
(Promulgated by Order No.68 of Beijing Municipal People's Government on February 2th, 21
First revised according to Order No.141 of Beijing Municipal People's Government on December 1st, 23
Second revised according to Order No.158 of Beijing Municipal People's Government on June 6th, 25)
Contents
Chapter I General Provisions < p
Chapter IV Basic Medical Insurance Benefits
Chapter V Supplementary Medical Insurance
Chapter VI Medical Management
Chapter VII Organization, Management and Supervision
Chapter VIII Legal Liability
Chapter IX Supplementary Provisions
Chapter I General Provisions
Article 1 In order to ensure that employees and retirees get basic medical treatment and enjoy medical insurance benefits when they are sick, in accordance with relevant state regulations, combined with
article 2 these provisions shall apply to all employers in cities and towns within the administrative area of this municipality, including enterprises, organs, institutions, social organizations, private non-enterprise units (hereinafter referred to as employers), their employees and retirees.
the specific time for the employer, its employees and retirees to participate in the basic medical insurance shall be stipulated by the municipal labor and social security administrative department (hereinafter referred to as the municipal labor and social security administrative department).
article 3 the municipal labor security administrative department is in charge of the medical insurance work in the whole city, organizes the implementation of the medical insurance system, and is responsible for the management, supervision and inspection of the medical insurance work.
the district and county labor and social security administrative departments are responsible for the management, supervision and inspection of medical insurance within their respective administrative areas.
social insurance agencies set up by the municipal, district and county labor and social security administrative departments specifically handle medical insurance.
article 4 the basic medical insurance premium shall be borne by both the employer and the individual employees, and shall be paid by both parties, and the whole city shall make overall plans. The basic medical insurance fund implements the principle of combining social pooling with individual accounts. The level of basic medical insurance should be compatible with the development level of social productive forces in this Municipality and the affordability of finance, employers and individuals.
article 5 on the basis of basic medical insurance, this municipality has established a system of mutual assistance for large medical expenses, and implemented the national medical subsidy scheme for civil servants. enterprises and institutions can establish supplementary medical insurance and encourage employers and individuals to participate in commercial medical insurance.
article 6 in combination with the establishment of the basic medical insurance system, actively promote the reform of the medical and health system in cities and towns, and provide relatively high-quality medical services for employees and retirees at relatively low costs to meet the needs of the broad masses of people for basic medical services.
chapter ii basic medical insurance fund
article 7 the basic medical insurance fund shall be based on income and expenditure, so as to balance revenue and expenditure.
Article 8 The basic medical insurance fund consists of the following items:
(1) the basic medical insurance premium paid by the employer;
(2) the basic medical insurance premium paid by individual employees;
(3) interest on the basic medical insurance premium;
(4) late fees for basic medical insurance;
(5) other funds incorporated into the basic medical insurance fund according to law.
article 9 the basic medical insurance premium shall be paid by both the employer and individual employees. Employers and employees shall pay the basic medical insurance premium in full and on time. If it is not paid in full and on time, regardless of individual account, the basic medical insurance fund will not pay its medical expenses.
article 1 employees shall pay the basic medical insurance premium at 2% of their average salary in the previous year.
if the average monthly salary of employees in the previous year is lower than 6% of the average monthly salary of employees in this city in the previous year, 6% of the average monthly salary of employees in this city in the previous year will be the base of payment salary, and the basic medical insurance premium will be paid.
the part where the average monthly salary of employees in the previous year was more than 3% higher than the average monthly salary of employees in this city in the previous year will not be used as the base for payment of wages, and the basic medical insurance premium will not be paid.
if it is impossible to determine the average monthly salary of employees in the previous year, the average monthly salary of employees in this city in the previous year shall be the base of payment salary, and the basic medical insurance premium shall be paid.
article 11 the retired personnel before the implementation of these provisions do not pay the basic medical insurance premium.
after the implementation of these regulations, those who have joined the work and paid the basic medical insurance premiums for 25 years for men and 2 years for women have gone through the retirement procedures in accordance with state regulations, and those who receive the basic pension or retirement fees on a monthly basis will enjoy the basic medical insurance benefits for retirees and will not pay the basic medical insurance premiums.
if you retire after taking part in the work before the implementation of these provisions and pay the basic medical insurance premium for less than the period specified in the preceding paragraph, you will enjoy the basic medical insurance benefits for retirees after you make up the basic medical insurance premium that should be paid by the employer and individual in one lump sum, and you will not pay the basic medical insurance premium. As determined by the administrative department of labor and social security, if the continuous length of service or working years of employees meet the requirements of the state, it shall be regarded as the payment period of basic medical insurance.
Article 12 The employing unit shall pay the basic medical insurance premium at 9% of the sum of the salary bases paid by all employees.
thirteenth basic medical insurance premium payment ratio needs to be adjusted, by the municipal labor and social security administrative department in conjunction with the municipal finance department, submitted to the Municipal People's government for approval.
Article 14 The employing unit shall truthfully declare the average salary of employees in the previous year to the social insurance agency on time, and the social insurance agency shall verify the basic medical insurance payment salary base according to the regulations.
article 15 the basic medical insurance premium payable by the employer shall be withheld by the social insurance agency on a monthly basis by entrusting the employer's bank to collect the money (without payment period).
the basic medical insurance premium that employees should pay is withheld and remitted from their wages by the employer on a monthly basis.
article 16 the basic medical insurance fund shall be managed in a city-wide overall way and at different levels, all of which shall be included in the financial special account of the social security fund, and shall be managed by two lines of revenue and expenditure.
the basic medical insurance fund shall be used for special purposes, and shall not be misappropriated or used to balance fiscal revenue and expenditure.
Article 17 The part raised by the basic medical insurance fund in the current year shall bear interest according to the bank deposit interest rate; The fund principal and interest carried forward from the previous year shall bear interest at the bank deposit rate of lump-sum deposit for 3 months; The deposit fund deposited in the financial special account of the social security fund shall bear interest according to the three-year zero deposit and lump-sum savings deposit interest rate, which is not lower than the interest rate of this grade.
Article 18 The basic medical insurance fund shall implement a unified social insurance budget and final accounts system, financial accounting system and internal audit system.
chapter iii individual accounts for basic medical insurance
article 19 social insurance agencies shall establish individual accounts for basic medical insurance for employees and retirees (hereinafter referred to as individual accounts).
Article 2 An individual account consists of the following items:
(1) Basic medical insurance premiums paid by individual employees;
(2) the basic medical insurance premium paid by the employer who transferred it to the personal account according to the regulations;
(3) interest on the amount stored in the personal account;
(4) other funds incorporated into personal accounts according to law.
Article 21 Part of the basic medical insurance premium paid by the employer shall be credited to the personal account according to the following criteria:
(1) Employees under the age of 35 shall be credited to the personal account according to .8% of their monthly salary base;
(2) Employees over 35 years old but under 45 years old are transferred to individual accounts according to 1% of their monthly salary base;
(3) Employees over the age of 45 are transferred to individual accounts at 2% of their monthly salary base;
(4) Retirees under the age of 7 shall be transferred into individual accounts according to 4.3% of the average monthly salary of employees in this Municipality in the previous year;
(5) Retirees over the age of 7 shall be credited to individual accounts at 4.8% of the average monthly salary of employees in this Municipality in the previous year.
when the standards listed in the preceding paragraph need to be adjusted according to social and economic development and fund revenue and expenditure, the municipal labor and social security administrative department shall, jointly with the municipal finance department, propose an adjustment plan, which shall be promulgated and implemented after being approved by the municipal people's government.
Article 22 The amount stored in an individual account shall be calculated with reference to deposit interest rate, a resident of the bank during the same period.
Article 23 The principal and interest of an individual account are owned by the individual and can only be used for basic medical insurance, but can be carried forward and inherited.
When employees and retirees die, the amount stored in their personal accounts will be transferred to the personal accounts of their heirs; If the heir does not participate in the basic medical insurance, the amount stored in the personal account can be paid to the heir in one lump sum; If there is no heir, the amount of personal account storage will be included in the basic medical insurance pooling fund.
Article 24 If the unemployed do not pay the basic medical insurance premium, their personal accounts will stop being included, and the balance can continue to be used. During the period of receiving unemployment insurance benefits, the unemployed enjoy Medicaid treatment in accordance with the provisions of unemployment insurance.
Article 25 When people who participate in the basic medical insurance move around the insured districts and counties, they only transfer the basic medical insurance relationship, and do not transfer the personal account amount; Cross-regional, county or cross-regional flow, the transfer of basic medical insurance relations, while transferring personal account storage.
chapter iv basic medical insurance benefits
article 26 the basic medical insurance pooling fund and individual account shall delimit their respective payment ranges and be accounted for separately, and shall not occupy each other. In accordance with the basic medical insurance fund to pay the scope of medical expenses, paid by the basic medical insurance fund and individual accounts.
article 27 the medical expenses paid by the basic medical insurance fund to employees and retirees shall conform to the list of basic medical insurance drugs, the list of diagnosis and treatment items, the scope of service facilities and the payment standards stipulated by this municipality.
the list of basic medical insurance drugs, the list of diagnosis and treatment items, the scope of medical service facilities and the specific measures for payment standards shall be formulated separately by the municipal labor and social security administrative department in conjunction with relevant departments.
Article 28 Personal accounts shall pay the following medical expenses:
(1) Medical expenses for outpatient and emergency treatment;
(2) the cost of purchasing medicines at designated retail pharmacies;
(3) medical expenses below the minimum threshold of the basic medical insurance pooling fund;
(4) medical expenses that exceed the threshold of the basic medical insurance pooling fund and should be borne by individuals in proportion.
I will pay for the insufficient payment in my personal account.
Article 29 The basic medical insurance pooling fund pays the following medical expenses:
(1) Medical expenses for hospitalization;
(2) medical expenses within 7 days before the emergency rescue observation and hospitalization;
(3) outpatient medical expenses of radiotherapy and chemotherapy for malignant tumor, renal dialysis and taking anti-rejection drugs after renal transplantation.
Article 3 The basic medical insurance fund shall not pay the following medical expenses:
(1) seeing a doctor in a medical institution other than the designated one, except for emergency;
(2) purchasing drugs in non-designated retail pharmacies;
(3) Injuries caused by traffic accidents, medical accidents or other accidents;
(4) Injuries are caused by taking drugs, fighting or other illegal acts;
(5) being treated for suicide, self-mutilation, alcoholism and other reasons;
(6) being treated abroad or in Hongkong, Macao Special Administrative Region and Taiwan Province;
(seven) according to the provisions of the state and the city should be paid by the individual.
article 31 medical expenses incurred by employees of an enterprise due to work-related injuries and occupational diseases shall be implemented in accordance with the relevant provisions of industrial injury insurance. The medical expenses for the birth of female employees shall be implemented in accordance with the relevant provisions of the state and this Municipality.
article 32 the qifubiaozhun for payment from the basic medical insurance pooling fund is determined at about 1% of the average salary of employees in this municipality in the previous year. The qifubiaozhun for the medical expenses incurred by an individual in hospitalization for the second time and later in a year is determined by about 5% of the average wage of employees in this city in the previous year.
article 33 the accumulative maximum payment limit of medical expenses paid by the basic medical insurance pooling fund to employees and retirees in one year is determined by about 4 times of the average salary of employees in this city in the previous year.
article 34 when the qifubiaozhun and the maximum payment limit paid by the basic medical insurance pooling fund need to be adjusted, the municipal labor and social security administrative department shall, jointly with the municipal finance department, propose it and report it to the municipal people's government for approval, and the municipal labor and social security administrative department shall issue it.
article 35 the basic medical insurance pooling fund shall set a settlement period for the payment of medical expenses.
the settlement period is set according to the time of hospitalization of employees and retirees, radiotherapy and chemotherapy for malignant tumors, renal dialysis and outpatient treatment with anti-rejection drugs after renal transplantation.
Article 36 Medical expenses incurred by employees and retirees in a settlement period shall be calculated by stages and paid cumulatively according to the level of the hospital and the amount of expenses, and shall be shared by the basic medical insurance pooling fund and individuals according to the following proportions:
(1) Medical expenses incurred in tertiary hospitals:
1. For the part with the minimum threshold of 3, yuan, the pooling fund will pay 85% and the employees will pay 15%;
2. For the part exceeding 3, yuan to 4, yuan, 9% shall be paid by the overall fund and 1% by the employees;
3. for the part exceeding 4, yuan, the overall fund will pay 95% and the employees will pay 5%.
(2) Medical expenses incurred in secondary hospitals:
1. For the part with the minimum threshold of 3, yuan, the overall fund will pay 87% and the employees will pay 13%;
2. For the part exceeding 3, yuan to 4, yuan, 92% shall be paid by the overall fund and 8% by the employees;
3. For the part exceeding 4, yuan, 97% will be paid by the overall fund and 3% by the employees.