Legal analysis: Shanghai retirees’ medical insurance benefits are divided into two types: those under 69 years old and those over 70 years old. On April 1 of each year, funds will be injected into personal medical insurance accounts by the Medical Insurance Bureau. In recent years, funds have been injected every year The funds are 1,120 yuan for those under 69 years old and 1,280 yuan for those over 70 years old. Use the funds in the account first, and then enter the self-pay section after using up the amount. The amount is 700 yuan. If the amount exceeds 700 yuan, it enters the ***pay section. It is borne by both medical insurance and personal insurance. The specific proportions are listed below. One year is from April 1st of each year to March 31st of the next year, and it is settled once a year.

The medical insurance benefits for retirees in Shanghai, for those under 69 years old, are based on the following standards:

Outpatient services: Outpatient and emergency medical treatment by retirees within one year shall comply with the provisions of this city’s urban employee basic medical insurance The expenses will be paid by the funds included in the personal medical account in the current year. The shortfall will be paid by the individual up to the outpatient and emergency level, which is 700 yuan. The excess will be paid by the additional fund according to a certain proportion, that is: first, second and third levels. For outpatient and emergency services at medical institutions, 80%, 75% and 70% will be paid by the supplementary fund respectively.

Outpatient serious illness: 92% of the medical expenses incurred by retirees for severe uremic dialysis, chemotherapy and radiotherapy for malignant tumors will be paid by the overall fund. The remainder will be paid from the balance of their personal medical accounts over the years, and the shortfall will be borne by the individual.

Hospitalization (including hospitalization for observation in the emergency observation room): Expenses incurred by retirees for hospitalization within one year that comply with the provisions of this city’s basic medical insurance for urban employees are subject to a hospitalization deductible (December 31, 2000 700 yuan for those who have retired recently; 1,200 yuan for those who have retired after January 1, 2001). 92% of medical expenses above the hospitalization deductible are paid by the overall fund.

Family hospital beds: 80% of the medical expenses incurred in home hospital beds are paid by the overall fund, and the remainder is paid by the balance of personal medical accounts over the years. The shortfall is borne by the individual.

Maximum payment limit: The maximum payment limit of the overall fund is 280,000 yuan. If retirees are hospitalized or stay in the emergency observation room for observation in a medical insurance year, the medical expenses incurred above the deductible standard, as well as outpatient serious illness or home hospital bed medical expenses, if they are below the maximum payment limit, shall be paid according to the above provisions. For medical expenses above the maximum payment limit of the unified fund, 80% will be paid by the additional fund, and the remainder will be borne by the individual.

Retirees who are over 70 years old are subject to the following standards:

Outpatient services: The expenses incurred by retirees for outpatient and emergency medical treatment within one year that are in compliance with the basic medical insurance regulations for urban employees in this city are covered by His or her personal medical account will be included in the fund payment that year, and the shortfall will be paid by the individual up to the outpatient and emergency level, which is 700 yuan, and the excess will be paid by the supplementary fund in a certain proportion, that is: outpatient and emergency care at first-, second-, and third-level medical institutions. , 85%, 80% and 75% will be paid by the additional fund respectively.

Outpatient serious illness: 92% of the medical expenses incurred by retirees for severe uremic dialysis, chemotherapy and radiotherapy for malignant tumors will be paid by the overall fund. The remainder will be paid from the balance of their personal medical accounts over the years, and the shortfall will be borne by the individual.

Hospitalization (including hospitalization in the emergency observation room): Expenses incurred by retirees for hospitalization within one year that are in compliance with the provisions of this city’s basic medical insurance for urban employees are subject to a hospitalization deductible (December 31, 2000 It is 700 yuan for those who retired recently; 1,200 yuan for those who retired after January 1, 2001). 92% of the medical expenses above the hospitalization deductible are paid by the overall fund.

Family hospital beds: 80% of the medical expenses incurred in home hospital beds are paid by the overall fund, and the remainder is paid by the balance of personal medical accounts over the years. The shortfall is borne by the individual.

Maximum payment limit: The maximum payment limit of the overall fund is 280,000 yuan. If retirees are hospitalized or stay in the emergency observation room for observation in a medical insurance year, the medical expenses incurred above the deductible standard, as well as outpatient serious illness or home hospital bed medical expenses, if they are below the maximum payment limit, shall be paid according to the above provisions. For medical expenses above the maximum payment limit of the unified fund, 80% will be paid by the additional fund, and the remainder will be borne by the individual.

Legal basis: "Social Insurance Law of the People's Republic of China"

Article 12 The employer shall pay basic pension insurance in proportion to the total wages of its employees as prescribed by the state. The fee shall be recorded into the basic pension insurance pooling fund.

Employees shall pay basic pension insurance premiums in accordance with the proportion of their wages stipulated by the state and record them into their personal accounts.

Individual industrial and commercial households without employees, part-time employees who have not participated in basic pension insurance in the employer, and other flexible employment personnel who participate in basic pension insurance shall pay basic pension insurance premiums in accordance with national regulations, respectively. Credited to the basic pension insurance pooling fund and personal account.

Article 23 Employees shall participate in the basic medical insurance for employees, and the employer and employees shall jointly pay the basic medical insurance premiums in accordance with national regulations.

Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees in the employer, and other flexible employment personnel can participate in the basic medical insurance for employees, and individuals must pay for the basic medical insurance in accordance with national regulations. fee.

Article 35 The employer shall pay work-related injury insurance premiums based on the total wages of its employees and the rate determined by the social insurance agency.

Article 44 Employees shall participate in unemployment insurance, and the employer and employees shall jointly pay unemployment insurance premiums in accordance with national regulations.

Article 53 Employees shall participate in maternity insurance, and the employer shall pay maternity insurance premiums in accordance with national regulations. Employees shall not pay maternity insurance premiums.