The medical insurance reimbursement ratio formula for tertiary hospitals: medical insurance reimbursement calculation formula = total cost - deductible - self-paid portion of drugs and examinations * reimbursement ratio.

The medical insurance reimbursement ratio standards for tertiary hospitals are as follows: 1. The outpatient medical expenses that meet the regulations for patients with Class A chronic diseases will be paid by the overall fund at 85%.

The cost of outpatient hemodialysis, peritoneal dialysis and cyclosporine A after organ transplantation for patients in the renal failure stage of chronic renal failure will be increased by another ten percentage points on the above basis; 2. Deductible standard for Class B chronic diseases: 300 yuan

.

For outpatient medical expenses incurred by patients with Category B chronic diseases that meet the regulations, 80% of the portion above the deductible standard shall be paid, and the maximum payment limit for chronic diseases cannot be exceeded within a medical year or validity period; 3. Insured persons can be recognized as two Category B patients at the same time

Chronic diseases are managed according to the first recognized dual disease type, and the deductible is calculated separately for each disease type.

The identification and management of chronic diseases and the maximum payment limit will be adjusted in a timely manner by the human resources and social security department based on the overall fund revenue and expenditure.

The standards, detailed rules and procedures for chronic disease identification shall be formulated separately by the municipal human resources and social security administrative department.

Medical insurance reimbursement process: 1. Confirm the scope of reimbursement: During the treatment process, you need to confirm whether your treatment items are within the scope of medical insurance reimbursement; 2. Collect reimbursement materials: collect relevant treatment records, drug receipts, medical expense lists, etc.

Materials; 3. Go to the social security department for reimbursement: submit relevant materials to the local social security department and go through the medical insurance reimbursement procedures; 4. Wait for review: the social security department will conduct relevant reviews and comparisons to confirm the reimbursement ratio and amount; receive the reimbursement money

: After passing the review, you can receive medical insurance reimbursement at the designated bank.

What items can be reimbursed by medical insurance: 1. Inpatient treatment: Medical insurance can reimburse for hospitalization due to illness or accident, including medical service fees, medicine fees, material fees, examination fees, etc.; 2. Outpatient treatment: Medical insurance can reimburse for outpatient treatment

Medical expenses, including registration fees, diagnosis fees, examination fees, drug fees, etc.; 3. Physical examination: Medical insurance can reimburse individuals for self-paid physical examination expenses.

It should be noted that regulations in different regions and policies may differ, and the specific scope and standards of reimbursement are subject to local policies.

To sum up, the reimbursement ratio of major and chronic disease medical insurance is determined based on local policies and regulations, and the reimbursement ratio may differ in different regions.

Generally speaking, the reimbursement ratio of chronic disease medical insurance includes two aspects: basic medical insurance payment ratio: the basic medical insurance payment ratio refers to the proportion paid by the medical insurance fund, generally ranging from 70% to 80%; personal self-payment ratio: personal self-payment ratio

The payment ratio refers to the proportion of medical expenses that an individual needs to bear, generally ranging from 20% to 30%.

Legal basis: Article 28 of the "Social Insurance Law of the People's Republic of China" that meets the basic medical insurance drug catalog, diagnosis and treatment items, medical service facility standards, and emergency and rescue medical expenses shall be deducted from the basic medical insurance fund in accordance with national regulations.

Pay.

Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance agency and the medical institution and pharmaceutical business unit.

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