The calculation of payment ratio of medical insurance pooling fund involves many factors, including medical insurance policy, identity of the insured, location of medical treatment, type of medical expenses, etc.

First, understand the medical insurance policy

The calculation of the payment ratio of medical insurance pooling fund needs to know the local medical insurance policy first. There may be differences in medical insurance policies in different regions, including the provisions of deductible, reimbursement ratio and maximum payment limit. Therefore, when calculating the payment ratio of medical insurance pooling fund, we must first understand and abide by the local medical insurance policy.

Secondly, determine the identity of the insured.

The identity of the insured is also an important factor affecting the payment ratio of the medical insurance pooling fund. For example, there may be differences in the reimbursement ratio between employee medical insurance and resident medical insurance, and insured persons with different ages, occupations and income levels may also enjoy different reimbursement ratios.

Third, distinguish the location of medical treatment

Medical treatment in different places will also affect the payment ratio of the medical insurance pooling fund. Generally speaking, the reimbursement rate of the insured in primary medical institutions will be higher than that in advanced medical institutions. This is to encourage the insured to make rational use of medical resources and reduce the burden of high-level medical institutions.

Four, calculate the type of medical expenses

The calculation of the payment ratio of the medical insurance pooling fund also needs to be differentiated according to the types of medical expenses. Generally speaking, the expenses that can be reimbursed by medical insurance include medicine, examination, treatment and operation. , but the reimbursement ratio of different projects may be different. At the same time, we also need to pay attention to the self-funded items stipulated in the medical insurance policy, which are not covered by the medical insurance pooling fund.

When calculating the payment ratio of the medical insurance pooling fund, the above factors should be comprehensively considered and calculated according to the formula stipulated in the medical insurance policy. Generally speaking, the payment ratio of medical insurance pooling fund = (reimbursable medical expenses-deductible line) × reimbursement ratio. In the specific calculation process, we also need to pay attention to the accumulation and classification of various expenses to ensure the accuracy of the calculation.

To sum up:

The calculation of payment ratio of medical insurance pooling fund involves many factors, including medical insurance policy, identity of the insured, location of medical treatment, type of medical expenses, etc. In the calculation process, it is necessary to understand and abide by the local medical insurance policy, comprehensively consider various factors, and calculate according to the prescribed formula. By reasonably calculating the payment ratio of the medical insurance pooling fund, the medical security rights and interests of the insured can be better guaranteed and the rational use of medical resources can be realized.

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.

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.

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