Serious illness insurance guarantees the compliance medical expenses that need to be borne by individuals after urban residents' medical insurance and new rural cooperative medical compensation. The actual payment ratio is not less than 50%, and the actual reimbursement ratio can be as high as 95%, but the policies vary from place to place. The settlement is automatically audited by the medical insurance department through the data system. After the maximum reimbursement of the medical insurance pooling fund, the excess will be reimbursed. The maximum reimbursement limit of medical insurance pooling funds in most areas is 80,000 yuan, and the part exceeding 80,000 yuan is reimbursed by stages according to a certain proportion. The maximum limit is 6.5438+0.8 million.
Social security and medical insurance have no classification of diseases, and are only reimbursed according to medical expenses. Whether it is the reimbursement of the medical insurance pooling fund or the reimbursement of the serious illness medical assistance fund, it is only for the reasonable part, and the self-funded drugs are not reimbursed. In other words, the expenses for reimbursement are deducted from the self-funded part and reimbursed in proportion. Social insurance premium collection agencies shall collect social insurance premiums in full and on time according to law, and regularly inform employers and individuals of the payment.
If the social insurance premium collection agency arbitrarily changes the base and rate of social insurance premium payment, resulting in underpayment or overpayment of social insurance premium, the relevant administrative department shall order it to recover the social insurance premium that should be paid or refund the social insurance premium that should not be paid; The directly responsible person in charge and other directly responsible personnel shall be punished according to law. Those who conceal, transfer, occupy or misappropriate social insurance funds or illegally invest and operate shall be ordered to recover by the administrative department of social insurance, the financial department and the auditing organ; Illegal income, confiscate the illegal income; The directly responsible person in charge and other directly responsible personnel shall be punished according to law.
legal ground
People's Republic of China (PRC) social insurance law
Twenty-third 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.