Expenditure method of medical insurance expenses (1) Reimbursement of medical expenses.
After the insured suffers from illness and medical expenses, the expenses paid by the medical insurance institution for economic compensation are called medical expense reimbursement. It only covers the direct costs of medical services in medical insurance coverage, and the indirect costs related to medical services (such as the loss of income during the illness of patients, transportation fees and accommodation fees paid for going to the hospital, etc.). ) Not included. Under normal circumstances, medical compensation costs account for 80%~90% of the medical insurance fund. In the basic medical insurance system for urban workers in China, the basic medical insurance fund is based on the principle of fixed income, balanced income and expenditure, and a slight balance.
(2) management fees.
Management fee refers to various expenses related to medical insurance services required by medical insurance institutions to maintain normal operation. Mainly includes:
1. Salary: the salary of full-time and part-time medical insurance managers;
2. Official and labor expenses: business trip, publicity, training, inspection, data report, supervision, etc.
3. Water, electricity, coal, gas and rent;
4. Asset depreciation and equipment maintenance;
5. Others: bonuses, etc.
In some countries, the management fees are relatively high, including the salaries, bonuses and benefits of the staff of medical insurance institutions or the salaries of doctors who directly provide medical insurance coverage services, as well as the new equipment, facilities and operating expenses of insurance institutions. The United States has the highest management fee, reaching 25%; Canada is even lower, only 7%. It is generally considered that the management fee should be controlled within 10%. In China, this part of the cost is not allowed to be drawn from the medical insurance fund, but is solved by financial allocation.
(3) Risk reserve.
Risk reserve refers to a special reserve fund drawn from the medical insurance premium according to a certain proportion in accordance with relevant regulations in order to cope with extraordinary medical risks. It is mainly used to protect the basic rights and interests of the insured in the event of extraordinary risks (such as the epidemic of a certain disease). According to some foreign literatures, the extraction ratio of risk reserve usually accounts for 4%~8% of insurance premium.
Payment method of basic medical insurance premium First of all, all co-ordination areas should determine an individual basic medical insurance payment rate suitable for the burden level of local employees, which is generally 2% of wage income. Conditional areas can also appropriately increase the proportion of individual contributions.
Secondly, individuals pay basic medical care according to their own wage income and the local individual contribution rate. In the personal payment base, it should be pointed out that it is not based on my basic salary or standard salary, but on the statistical caliber of wage income stipulated by the National Bureau of Statistics, that is, all wage income, including all kinds of bonuses, labor income and income in kind, is the basic medical insurance premium that I should pay.
Third, individual contributions generally do not require individuals to pay to social insurance agencies, but are paid by the unit from wage income.
First of all, the insured should seek medical treatment and purchase medicines at the designated medical institutions of basic medical insurance, or hang prescriptions to purchase medicines at designated retail pharmacies. Medical expenses incurred in seeking medical treatment in non-designated medical institutions and purchasing medicines in non-designated pharmacies shall not be paid by the basic medical insurance fund, except in accordance with the prescribed conditions such as referral.
Secondly, the medical expenses incurred must conform to the basic medical insurance drug list, diagnosis and treatment items, standard scope of medical service facilities and payment standards, so that medical expenses can be paid by the basic medical insurance according to regulations. Beyond the part, the basic medical insurance is not paid according to the regulations.
Third, for medical expenses that meet the basic medical insurance payment scope, it is necessary to distinguish whether they belong to the overall fund payment scope or the personal account payment scope. Medical expenses that fall within the scope of payment by the overall fund, that is, the expenses above the Qifubiaozhun of the overall fund, shall be paid by the overall fund in proportion, with the highest payment to the top. Individuals also have to bear part of the medical expenses, and all the expenses above the cap amount are paid by individuals or solved by participating in supplementary medical insurance and commercial medical insurance. Medical expenses below Qifubiaozhun shall be settled in individual accounts. If there is a balance in individual accounts, part of the medical expenses that should be paid by individuals within the scope of payment from the overall fund can also be paid.
Suppose: an employee goes to a designated medical institution for outpatient service within one year, resulting in medical expenses 200 yuan; The medical expenses incurred in the two hospitalizations were 20,000 yuan and 1 10,000 yuan respectively, of which the expenses incurred in the two hospitalizations were 2,000 yuan and 1 10,000 yuan respectively; The payment scope of local overall account is divided into outpatient service and hospitalization. Qifubiaozhun for hospitalization: 800 yuan for the first time and 500 yuan for the second time. The overall payment scope is 90%, and the maximum payment limit is 20,000 yuan. So, how should these medical expenses be paid?
1. Outpatient medical expenses are paid directly from personal account. If the employee's personal account has 500 yuan, it will be paid to 200 yuan, and 300 yuan will have the balance.
2. The first hospitalization expense is 20,000 yuan, which needs to be deducted from the medical expenses beyond the scope of the basic medical insurance payment of 2,000 yuan, and then deducted from the minimum payment standard of 800 yuan. The remaining medical expenses 17200 yuan shall be paid by the overall fund 15480 yuan.
3. The second hospitalization expenses 10000 yuan, medical expenses beyond the scope of basic medical insurance payment 1000 yuan need to be deducted, and then the minimum payment standard 500 yuan is deducted. The remaining 8,500 yuan of medical expenses can be paid by the overall planning fund of 7,650 yuan, but since the first hospitalization has been paid by the overall planning fund of15,480 yuan, the maximum payment limit is 200 yuan. Judging from the annual medical expenses burden of the employee, the total expenses are 30,200 yuan, the overall fund is 20,000 yuan, and the personal account can pay 500 yuan, so the individual needs to bear 9,700 yuan.
Medical insurance reimbursement related knowledge 1, emergency medical expenses: the part of the employee's medical expenses exceeding 2,000 yuan in a year (11February 31February).
2. Settlement ratio: 50% of the part of the dispatched personnel above 2,000 yuan will be reimbursed during the contract period, and 50% will be paid by the individual; Within one year, the maximum amount of accumulated reimbursement for outpatient and emergency services of dispatched personnel is 20,000 yuan.
3. The insured shall properly keep the medical documents (including receipts and prescriptions for large amounts) in the outpatient department of the designated hospital. ), as a medical expense reimbursement certificate.
4. Outpatient medical treatment for three special diseases: When the insured person takes anti-rejection drugs due to malignant tumor radiotherapy and chemotherapy, renal dialysis, renal transplantation, etc., the second-and third-level designated hospitals where the insured person sees a doctor should issue a certificate? Disease diagnosis certificate? , and fill in the "medical insurance special disease declaration and approval form", submitted to the district medical insurance center for approval. Outpatient treatment and drug collection for these three special diseases are limited to designated hospitals that have approved treatment, and cannot be purchased in designated retail pharmacies. The medical expenses incurred meet the prescribed scope of outpatient special diseases, with reference to hospitalization settlement.
5. Hospitalization.
How is the medical insurance fee paid?