Take the proportion of medical insurance payment in Beijing as an example: the employer pays 10% of its total payment base every month, and the employee pays 2% of his salary as a whole for serious illness+3 yuan.
Medical insurance reimbursement limit:
Rural areas:
Outpatient service
Reimbursement for medical treatment in village clinics and village center clinics is 60%, and the prescription drug fee limit for each visit is 10 yuan, and the prescription drug fee limit for temporary rehydration for doctors in health centers is 50 yuan;
40% reimbursement for medical treatment in the town health center, with the limit of 50 yuan for each medical examination and operation fee and the limit of prescription fee 100 yuan;
Second-level hospitals will be reimbursed 30% for medical treatment, with each examination fee and operation fee limited to 50 yuan and prescription drug fee limited to 200 yuan;
Third-level hospitals will be reimbursed 20% for medical treatment. The examination fee and operation fee for each visit are limited to 50 yuan, and the prescription drug fee is limited to 200 yuan;
Chinese medicine invoice with prescription, each paste limit 1 yuan; The annual compensation limit for rural cooperative medical clinics is 5000 yuan.
be hospitalized
Reimbursement scope: medical expenses: auxiliary examination: ECG, X-ray fluoroscopy, radiography, laboratory test, physiotherapy, acupuncture, CT, nuclear magnetic resonance and other examination expenses 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan).
The elderly over 60 years old are hospitalized in health centers, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan.
Reimbursement ratio: town health centers reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.
serious illness
All inpatients who participate in cooperative medical care, whose medical expenses exceed 5,000 yuan at one time or for the whole year, should be compensated by stages, that is, 500 1- 10000 yuan is 65%, and1-18000 yuan is 70%. The annual compensation limit of town-level cooperative medical system hospitalization, uremia outpatient hemodialysis and tumor outpatient radiotherapy and chemotherapy is 1. 1 ten thousand yuan.
exonerate
Medical treatment at one's own expense (no designated hospital or referral form), drugs purchased at one's own expense, drugs that cannot be reimbursed according to the provisions of public medical care, and medical expenses that do not conform to family planning; Outpatient treatment fee, visiting fee, hospitalization fee, meals fee, escort fee, nutrition fee, blood transfusion fee (except for family blood storage, which shall be reimbursed according to relevant regulations), cooling and heating fee, ambulance fee, special nursing fee, etc.
Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents; Orthopedics, cosmetic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc. ; Within the scope of reimbursement, beyond the limit.
Towns:
Urban residents hospitalized for more than two times in a settlement year, starting from the second hospitalization, no longer charge Qifubiaozhun fees. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.
Students, children
In a settlement year, medical expenses less than 6,543,800 yuan+0.8 million yuan that meet the scope of reimbursement occurred. The threshold of tertiary hospitals is 650 yuan, with a reimbursement rate of 50% and an upper limit of 2,000 yuan; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%;
There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
At least 70 years old and above.
In a settlement year, medical expenses below 654.38+10,000 yuan that meet the scope of reimbursement occur. The threshold of tertiary hospitals is 650 yuan, with a reimbursement rate of 50% and an upper limit of 2,000 yuan;
The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%;
There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 65%.
Other urban residents
In a settlement year, medical expenses below 654.38+10,000 yuan that meet the scope of reimbursement occur. The threshold for tertiary hospitals is 659 yuan, the reimbursement rate is 50%, and the upper limit is 2,000 yuan.
The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%.
Employees:
Generally speaking, the economic development in different regions is different, so the reimbursement ratio is different. The following is an explanation of the proportion of employees' medical insurance in Beijing.
After receiving medical insurance, if they are on-the-job employees, the medical expenses above 1800 yuan can only be reimbursed, and the reimbursement rate is 50%.
For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed.
No matter what kind of people, the maximum payment limit for outpatient and emergency medical expenses is 20 thousand yuan. For example, if you are an on-the-job employee, and the outpatient medical expenses are 2,500 yuan, then 500 yuan can reimburse 50%, that is, 250 yuan.
If it is hospitalization expenses, the minimum payment for employees and retirees is 1300 yuan when the basic medical insurance is used for the first time within one year in 2009.
And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. 1 year The maximum payment limit of the basic medical insurance pooling fund (hospitalization expenses) is 70,000 yuan.
The reimbursement standard for hospitalization is related to the level of the hospital where the insured person is located. For example, in a tertiary hospital, employees have to pay 15%, that is, 85%, from the threshold to 30,000 yuan.
The expenses of 30,000-40,000 yuan shall be paid by employees themselves 10%, and 90% shall be reimbursed;
If the expenses exceed 40,000 yuan to the maximum payment limit, 95% can be reimbursed, and employees only need to pay 5%. Retirees pay 60% of the on-the-job employees, but all below the minimum threshold are paid by individuals.
Legal basis:
People's Republic of China (PRC) social insurance law
second
The state establishes social insurance systems such as basic old-age insurance, basic medical insurance, industrial injury insurance, unemployment insurance and maternity insurance, so as to guarantee citizens' right to receive material assistance from the state and society in accordance with the law when they are old, sick, injured, unemployed and have children.
Article 23
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 26
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Article 28
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.