The total payment limit is as follows:
The maximum payment limit of the overall fund, also known as the cap line, refers to the maximum amount of medical expenses paid by the overall fund in a year (65438+ 10/to 65438+February 3 1).
The maximum annual payment limit of the urban workers and flexible employees pooling fund is 654.38+10,000 yuan; The annual maximum payment limit of the basic medical insurance fund for adults and elderly residents is 80 thousand yuan; The maximum annual payment limit of the basic medical insurance pooling fund for students and minor residents is 1.25 million yuan.
The payment standard of medical insurance card as a whole is: the payment proportion and maximum payment limit of outpatient co-ordination fund for on-the-job employees are 200 yuan, the payment proportion level is 50% for on-the-job employees and 60% for retirees, and the maximum payment limit is 800 yuan.
Overall payment means that the related medical expenses of the insured person are paid by the funds in the overall account. In addition, the overall management of medical insurance includes personal accounts and overall accounts. Among them, the personal account fund is the part that the insured needs to pay for medicine purchase, hospital outpatient expenses and hospitalization expenses in some designated pharmacies, and it is the balance returned to the medical insurance card after paying medical insurance every month.
To sum up, the Qifubiaozhun of the overall fund is based on the average salary of employees in the city in the previous year, which is included in each hospitalization. Qifubiaozhun is mainly set to avoid unnecessary hospitalization or outpatient expenses occupying resources and ensure that the overall fund has enough funds to treat serious diseases.
Legal basis:
People's Republic of China (PRC) social insurance law
Article 29
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.
Article 26
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.