First, the payment methods are different. The large medical mutual fund for employees must be paid by the units and employees of the insured under the premise of paying social medical insurance. Taking Chongqing as an example, the individual payment standard is 5 yuan 60 yuan per person per month, and retired employees are deducted from their personal accounts returned by medical insurance; Insurers of urban and rural residents' medical care do not need to pay a lot of medical insurance expenses, and the required expenses are paid by the medical insurance fund, which is a feature of secondary reimbursement.
Second, expense reimbursement is different. Extra-large mutual aid and mutual aid medical insurance for employees includes mutual aid and mutual aid, which is the key to deal with the problem of large medical expenses subsidies for employees participating in basic medical insurance. Large medical expenses include hospitalization expenses and special outpatient expenses, and the scope of subsidies exceeds the maximum payment limit of social medical insurance medical insurance fund. The maximum payment limit of medical insurance for employees is 4 times of the average social wage in the previous year. For the part exceeding the maximum payment limit, the following expenses need to be deducted, such as my own expenses.
The category of medical insurance reimbursement of residents' serious illness insurance refers to that the out-of-pocket expenses of residents' medical insurance fund exceed a certain credit limit after being paid according to the regulations, which actually reaches the deductible line of medical insurance reimbursement for serious illness, and then the medical expenses are compensated by the critical illness insurance assets according to the regulations. The key to the assessment index is the out-of-pocket medical expenses outside the deductible line.
From the definition, large medical insurance for employees is mutual assistance and belongs to the characteristics of a subsidy; Residents' serious illness insurance also has the characteristics of subsidies, but many people also call it secondary reimbursement. It is very high to meet the subsidy standard of employees' super-large mutual medical insurance. It is relatively easy for residents to pay part of their own medical insurance to reach the deductible line for reimbursement of serious illness medical insurance.
Whether it is urban and rural residents' super-large mutual medical insurance or urban residents' serious illness insurance, the reimbursement standard is based on this year's settlement, that is, the annual settlement period is from 65438+ 10 to 65438+February 3 1. After many hospitalizations, the medical insurance fund of social medical insurance has paid more than the maximum payment limit, which can be subsidized by large medical insurance, and the payment channel is the same as that of social medical insurance.
The deductible line for reimbursement of medical insurance for seriously ill families is determined according to the per capita disposable income of urban residents this year. For expenses exceeding the deductible line stipulated in the medical insurance for serious illness, the method of progressive reimbursement shall be implemented according to the amount of expenses paid by the enterprise. For example, when the progressive expenditure exceeds 654.38 million, it will be reimbursed according to 40% of the expenses; When the progressive expenditure exceeds 654.38+10,000 to 200,000, it will be reimbursed according to 50% of the expenses; When the progressive expenditure exceeds 200,000, it will be reimbursed at 60% of the expenses.
Because our country's medical insurance is based on municipal government agencies and institutions as the overall planning area, the super-large mutual medical insurance and residents' serious illness medical insurance are implemented in accordance with the provisions of the overall planning area. For example, Kaifeng City, Henan Province requires a large amount of medical insurance. In a statistical analysis year, the medical expenses that the insured exceeds the maximum payment limit of the social medical insurance pooling fund to less than1.2000 yuan shall be paid by the serious illness medical assistance commercial insurance, and the personal burden of the insured shall be1.2000 yuan.
Generally speaking, the large medical expense subsidy is usually a supplementary medical treatment for those who pay large sums of money to help each other in urban workers' medical insurance under the premise of paying social medical insurance, and the hospitalization or unique outpatient expenses exceed the maximum payment limit of the basic medical insurance fund. Insured workers who pay medical insurance for urban and rural residents shall pay medical insurance for seriously ill families according to the basic medical insurance fund, and the hospitalization expenses shall be part of the medical expenses incurred during the year of paying social security, and the expenses above the deductible line for reimbursement of seriously ill medical insurance shall be reimbursed for the second time.