First, the basic concept of pooling funds
The overall fund refers to the medical insurance fund formed by all the insured within a certain range, which is mainly used to pay the medical expenses of the insured. It embodies the principle of mutual aid in social insurance, that is, to disperse and bear risks through collective financing.
The second is to co-ordinate the scope of fund payment.
The expenses paid by the overall fund are very wide, covering most of the medical expenses of the insured in the medical insurance system. Specifically, it mainly includes the following categories:
1. Hospitalization expenses: including bed expenses, nursing expenses, treatment expenses, operation expenses and other expenses directly related to hospitalization.
2. Drug expenses: the drug expenses in the basic medical insurance drug list purchased by the insured in medical institutions, including western medicine, Chinese patent medicine, Chinese herbal pieces, etc.
3. Examination expenses: expenses for various examinations required by the insured due to illness, such as X-ray, B-ultrasound, CT, MRI, etc.
4. Other medical expenses: such as outpatient treatment expenses, special disease treatment expenses, rehabilitation expenses, etc.
It should be noted that the scope of expenses paid by the overall fund is not unlimited, but limited by the provisions of the medical insurance system. For example, some high-end drugs, imported drugs and medical services with non-basic medical needs may not be covered by the overall fund.
Third, the payment methods and standards of the overall fund.
The payment methods of pooling funds mainly include proportional payment, fixed payment and limited payment. The specific payment standard is formulated by local governments according to the actual situation, which is usually related to the level of medical institutions, the age of insured persons, diseases and other factors. Generally speaking, the higher the proportion of overall fund payment, the less the medical expenses borne by individuals.
To sum up:
The overall fund is mainly used to pay the medical expenses of the insured in medical insurance coverage, including hospitalization expenses, medicine expenses, inspection fees, etc. Through collective fund-raising, risk dispersion and burden can be realized, and a certain degree of medical expenses compensation can be provided for the insured. In practice, the payment scope, payment method and payment standard of the overall fund are clearly stipulated and restricted by the medical insurance system.
Legal basis:
People's Republic of China (PRC) social insurance law
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 29 provides that:
The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.