The payment limit of medical insurance, that is, the maximum payment limit of medical insurance, refers to the maximum amount of medical expenses paid by the basic medical insurance fund to the insured in a medical year. At present, the annual maximum payment for urban workers and flexible employees is 654.38+10,000 yuan, the annual maximum payment for basic medical insurance for adults and elderly residents is 80,000 yuan, and the annual maximum payment for basic medical insurance for students and minors is1250,000 yuan. The maximum payment limit of medical insurance fund refers to the upper limit of medical expenses that can be paid by the overall fund, which exceeds the maximum payment limit. Basic medical insurance will not be paid, the scope of serious diseases, uremia dialysis treatment, anti-rejection drug treatment after tissue and organ transplantation, and the maximum payment limit of the overall fund. The maximum payment limit of medical insurance fund is the so-called "capping line", which refers to the upper limit of medical expenses that can be paid by the overall fund. Medical expenses exceeding the maximum payment limit shall not be paid by the basic medical insurance.

Medical insurance reimbursement conditions:

1, the insured person must go to the designated medical institution of basic medical insurance or the designated retail pharmacy determined by the social insurance institution with the medical prescription issued by the doctor in the designated hospital;

2. The medical expenses incurred by the insured in the process of medical treatment must conform to the scope and payment standards of the basic medical insurance drug list, medical treatment items and medical service facilities standards, and can be paid by the basic medical insurance fund according to regulations;

3. The medical expenses incurred by the insured that meet the payment scope of basic medical insurance shall be paid by the social medical pooling fund in a unified proportion, with the expenses above the Qifubiaozhun and below the maximum payment limit.

To sum up, the maximum payment limit refers to the maximum amount of medical expenses paid by the basic medical insurance fund to the insured in a medical year. At present, the standard is about four times the average wage of employees in this city last year. If the average salary of employees was 10000 yuan last year, the maximum payment limit was about 40000 yuan.

Legal basis:

Article 17 of the Social Insurance Law of People's Republic of China (PRC)

If an individual who participates in the basic old-age insurance dies due to illness or non-work, his survivors can receive funeral grants and pensions; Persons who have completely lost their ability to work due to illness or non-work-related disability before reaching the statutory retirement age can receive disability allowance. The required funds are paid from the basic old-age insurance fund.

Article 18

The state establishes a normal adjustment mechanism for basic pensions. According to the average wage increase and price increase of employees, the basic old-age insurance treatment level will be improved in a timely manner.

Article 19

If an individual is employed across the overall planning area, his basic old-age insurance relationship will be transferred with him, and the payment period will be calculated cumulatively. When an individual reaches the statutory retirement age, the basic pension is calculated in stages and distributed uniformly. Specific measures shall be formulated by the State Council.

Article 20

The state establishes and improves the new rural social endowment insurance system.

Article 28

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

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.