First, the concept and characteristics of medical insurance fund payment
Medical insurance fund payment refers to paying the medical expenses of the insured through the medical insurance fund. This payment method mainly depends on the medical insurance expenses paid by individuals and units, forming a certain fund pool to compensate the economic losses of the insured in the medical process. The characteristics of medical insurance fund payment are that the funds come from the contributions of the insured, which has clear personal rights and interests, and the scope of payment usually covers the expenses in the basic medical insurance catalogue.
Second, the concept and characteristics of overall payment
Overall payment is a way to pay medical expenses through overall regional funds in the medical insurance system. The funds for overall payment come from government subsidies, social donations, fund appreciation and other channels, which have strong social and economic characteristics. The characteristic of overall payment is that its payment scope is wider, which may cover some expenses outside the basic medical insurance catalogue, and at the same time reduce the economic burden of the insured through the risk sharing mechanism.
Third, the difference between medical insurance fund payment and overall payment.
1. Different sources of funds: medical insurance fund payment mainly depends on the insured, while overall payment includes government subsidies, social donations and other sources of funds.
2. Different scope of payment: The medical insurance fund usually covers the expenses in the basic medical insurance catalogue, while the overall payment may cover a wider range of medical expenses, including some expenses outside the catalogue.
3. The risk sharing mechanism is different: the overall payment can reduce the economic burden of the insured to a certain extent through the risk-taking mechanism, while the medical insurance fund payment depends more on the individual contribution level.
To sum up:
Medical insurance fund payment and overall payment have their own characteristics and functions in the medical insurance system. Medical insurance fund payment mainly depends on individual contributions, and the scope of payment is relatively clear; Overall payment has stronger social economy, can cover a wider range of medical expenses, and reduce the economic burden of the insured through the risk-taking mechanism. The two payment methods complement each other, and isomorphism has become the cornerstone of China's medical insurance system.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 23 provides that:
Employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations.
Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.
Article 28 provides that:
Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
People's Republic of China (PRC) social insurance law
Article 30 provides that:
The following medical expenses are not included in the payment scope of the basic medical insurance fund:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Go abroad for medical treatment.
Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.