The capping line refers to the maximum payment limit of the medical insurance fund, that is, the reimbursement amount that the insured can get from the medical insurance fund within one year. Medical expenses exceeding the cap line can be solved by participating in supplementary medical insurance and commercial medical insurance. The part exceeding the top line of basic medical insurance can be included in the scope of serious illness insurance for urban and rural residents according to the actual burden of medical expenses. Serious illness insurance is the expansion and extension of the basic medical security system, which mainly pays the high medical expenses of seriously ill patients on the basis of basic medical insurance payment. After the insured residents are paid by the basic medical insurance, the expenses beyond the deductible line of serious illness insurance shall be included in the scope of payment of serious illness insurance according to the regulations.
The medical insurance reimbursement process is as follows:
1. If local employees are hospitalized, they should be hospitalized in the designated medical insurance hospital paid by the unit. When you are hospitalized, you should submit medical insurance and medical insurance directly to the medical insurance department of your hospital, and automatically reimburse the basic medical expenses at the time of settlement;
2. Employees hospitalized in other places who are sick due to business trip or long-term work in other places must be in emergency and can be hospitalized in local hospitals, but they must report to the Municipal Supervision Department of the Medical Insurance Bureau within three days;
3. Referral to other places for medical treatment has no effect in the hospital where the unit pays, or the hospital doctor suggests transferring to other places. Must be a designated hospital, central hospital, municipal people's hospital, and send a referral letter and related inspection materials to the supervision department of the medical insurance bureau for review, and can be transferred after approval.
To sum up, 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.
Legal basis:
Article 28 of the Regulations on Medical Insurance
Personal accounts are used to pay medical expenses beyond the scope of the overall fund payment; If the personal account is insufficient to pay, it shall be borne by me.
Article 29
The hospitalization expenses for major diseases are paid in the following ways:
(a) Qifubiaozhun in principle control in the city, county, autonomous county last year, the average social wage of workers 9%-0%;
(two) 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;
(three) medical expenses above the minimum deductible and below the maximum payment limit are mainly paid by the overall fund, and individuals bear a certain proportion. 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.