The total amount of medical insurance contribution is the amount calculated in proportion after paying medical insurance every month. The total expenses are the sum of self-funded expenses and overall expenses. Out-of-pocket expenses cannot be reimbursed and paid in medical insurance, and they need to be fully borne by themselves. Overall planning fee is the base of medical insurance verification. The expenses that inpatients need to pay by themselves are self-funded expenses.

Personal account transfer amount consists of basic medical insurance premiums paid by individuals and basic medical insurance premiums paid by units. All the basic medical insurance premiums paid by individuals are included in personal accounts. The basic medical insurance premium paid by the unit is based on the individual's monthly salary or basic pension, and is included in the individual account according to different proportions. According to different types of medical insurance, the scope and amount of reimbursement are different. The discharge form often defines the reimbursement ratio according to the type of medical insurance insured.

Out-of-pocket expenses accounting includes: threshold fees, out-of-pocket medical treatment items and drug expenses, and the amount to be paid for medical insurance reimbursement drugs (Class B).

If the out-of-pocket expenses have been included in the discharge list, it is the final result after each accounting.

Settlement procedure

1, settlement procedure for inpatient and outpatient treatment of special diseases

Designated medical institutions shall submit the expense list, hospitalization list and related materials of patients discharged from hospital last month to the medical insurance agency before 10 every month, which will be used as the basis for monthly pre-allocation and year-end final accounts after examination. The medical insurance agency pre-allocated the hospitalization and outpatient expenses for special diseases last month.

2. Emergency settlement procedures

The medical expenses incurred by the insured due to emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall handle the reimbursement procedures according to the provisions with the emergency hospitalization medical records, inspection, laboratory test sheets, invoices and detailed list of medical expenses.

Time for transferring medical insurance personal account to account:

The distribution of medical insurance personal accounts is mainly divided into two categories: one is on-the-job personnel and the other is retirees.

Retirees: transfer twice a year, the first time is 1 month, and the second time is in July, both of which are transferred to accounts between 1~5.

On-the-job personnel: After the payment is received, it will be transferred to the account within 1-2 working days.

Proportion of individual account allocation for medical insurance:

Retirees: general retirees are paid at the rate of 5% of the medical insurance base every month; Retired old workers who participated in revolutionary work before the founding of the People's Republic of China were distributed according to the proportion of 6%.

On-the-job personnel: In the first file, the on-the-job personnel under 35 years old are distributed according to the proportion of 2.9% of the individual contribution base; In the second file, employees aged 36-45 are allocated according to the proportion of 3.4% of the individual contribution base; In the third file, employees aged 46 to retirement are allocated according to the proportion of 4.2% of the individual contribution base.

Legal basis:

The "Regulations" of People's Republic of China (PRC) on the basic medical insurance for urban workers twenty-ninth major illness hospitalization expenses paid in the following ways:

First, Qifubiaozhun is controlled in principle at 9%- 1 1% of the average social wage of employees in cities, counties and autonomous counties in the previous year.

Second, the maximum payment limit is controlled in principle at 3-5 times of the average social wage of employees in cities, counties and autonomous counties in the previous year.

Third, the medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid by the overall fund, and the personal burden is certain. Give appropriate care to the proportion of retirees who bear medical expenses.

The scope of serious diseases, the specific standards of Qifubiaozhun and the maximum payment limit, and the proportion of sharing medical expenses above Qifubiaozhun and below the maximum payment limit shall be determined by the provincial people's government.

Thirtieth medical expenses below Qifubiaozhun and above the maximum payment limit shall not be paid by the overall fund.