Large medical expenses subsidy, also known as large medical expenses, mainly refers to the hospitalization expenses incurred by people participating in medical insurance for urban workers in hospitals, which exceed the maximum payment limit paid by the basic medical insurance fund for urban workers. In an insured year, this part of the expenses does not include the expenses below the deductible line and the expenses paid by individuals at their own expense, and the excess part is subsidized by the large medical mutual insurance fund according to a certain proportion.

There is a certain difference between large medical expenses and medical insurance for urban and rural residents, mainly in these two aspects.

First, the payment methods are different. The large medical mutual fund for employees requires the insured units and employees to pay large medical insurance premiums separately on the basis of paying basic medical insurance. Taking Chongqing as an example, the individual payment standard is 5 yuan 60 yuan per person per month, and retirees are deducted from the personal account returned by medical insurance; People with medical insurance for urban and rural residents do not need to pay a large amount of medical insurance fees, and the required expenses are paid by the medical insurance fund, which belongs to the nature of secondary reimbursement.

Second, the reimbursement methods are different. Large medical mutual insurance for employees takes the form of mutual assistance, which mainly solves the subsidy problem of large medical expenses for employees participating in basic medical insurance for employees. Large medical expenses include hospitalization expenses and special outpatient expenses. And the scope of subsidies exceeds the maximum payment limit of the basic medical insurance fund. The maximum payment limit of employee medical insurance is 4 times of the average salary of employees in the previous year. For the part above the maximum payment limit, the expenses below the minimum payment standard and the expenses paid by individuals are also deducted.

The reimbursement scope of residents' serious illness insurance is that if the out-of-pocket expenses paid by the residents' medical insurance fund in accordance with the prescribed proportion exceed a certain amount, that is, the medical expenses are compensated by the serious illness insurance fund in accordance with the regulations, and the assessment standard is mainly the out-of-pocket expenses after the individual's self-funded medical expenses exceed the out-of-pocket expenses.

Conceptually, the large medical insurance for employees is mutual aid and belongs to a subsidy nature; Residents' serious illness insurance also has subsidies, but many people also call it secondary reimbursement. The self-funded part of residents' medical insurance is relatively easy to reach the threshold of reimbursement for serious illness medical insurance.

Whether it is large-scale mutual medical insurance for urban workers or serious illness insurance for urban and rural residents, the reimbursement standard is annual settlement, that is, every year from 65438+ 10/to 65438+February 3 1 is a settlement cycle. After employees have been hospitalized for many times using large mutual medical insurance, if the total expenses paid by the basic medical insurance fund exceed the maximum payment limit, they can apply for large mutual medical insurance subsidies, and the payment channels are the same as the basic medical insurance.

Qifubiaozhun for reimbursement of medical insurance for serious illness of residents is determined according to the per capita disposable income of urban and rural residents in the previous year. For expenses exceeding the threshold stipulated in medical insurance for serious illness, progressive reimbursement shall be implemented according to the amount of expenses paid by individuals. If the progressive expenses reach 654.38+million, they will be reimbursed by 40%; if the progressive expenses exceed 654.38+million to 200,000, they will be reimbursed by 50%; if the progressive expenses exceed 200,000, they will be reimbursed by 60%.

Because China's medical insurance is based on the municipal administrative unit as the overall planning area, large mutual medical insurance and residents' serious illness medical insurance are implemented in accordance with the provisions of the overall planning area. For example, in Kaifeng City, Henan Province, in a statistical year, the insured pays 90% to 1.2 million yuan for medical expenses exceeding the maximum payment limit of the basic medical insurance pooling fund, and the insured bears 10%.

To sum up, the large medical expenses subsidy is mainly aimed at those who pay the large mutual medical insurance for urban workers on the basis of paying the basic medical insurance for urban workers, and the hospitalization or special outpatient expenses exceed the maximum payment limit of the basic medical insurance fund, which belongs to the nature of supplementary medical insurance; If the medical insurance for urban and rural residents is paid, the residents' medical insurance for serious illness shall be paid in a unified way through the basic medical insurance fund, and the medical expenses incurred in hospitalization within one insured year shall be reimbursed for the second time if the self-funded part exceeds the expenses above the deductible standard for reimbursement of serious illness medical insurance.

legal ground

Social Insurance Law of People's Republic of China (PRC) (amended on 20 18).

Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units.

The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.