Medical insurance means that employers and employees pay the basic medical insurance premium in full and on time according to the principle of compulsory social insurance. It is also the basic guarantee for employees to get sick. So, what are the functions and benefits of employee medical insurance? First, the basic medical insurance system for employees is a social medical insurance system that guarantees the basic medical rights of employees according to law. Enforced by laws and regulations, the basic model of combining social pooling medical funds with individual medical accounts is implemented. Like pension, work injury, unemployment and maternity insurance, it is the basic insurance item of social insurance. Secondly, the standard of basic medical insurance for employees is: the employee basic medical insurance pooling fund and individual account shall be accounted for separately according to their respective payment scope, and shall not be crowded out.
(1) Personal account, which is used to pay out-patient expenses, out-of-pocket expenses of hospitalization and shopping expenses of designated pharmacies.
(2) the overall fund is used to pay for hospitalization and some outpatient serious illness expenses. The overall fund payment has a minimum payment standard and a maximum payment limit. Qifubiaozhun is controlled in principle at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled in principle at about 4 times of the average annual salary of local employees. Medical expenses below Qifubiaozhun shall be paid by personal account or borne by individuals. Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid by the overall fund. Employee medical insurance benefits: the protection provided by enterprise employee medical insurance includes normal outpatient and hospitalization expenses. Serious illness assistance needs to be guaranteed outside the ordinary medical insurance. There is no rate for serious illness, and all of them are borne by individuals.
Legal basis:
"Accounting System of Social Insurance Fund" Article 28 The expenditure of employees' basic medical insurance fund includes the expenditure of employees' basic medical insurance benefits, the transfer expenditure, the expenditure of subsidizing subordinates, the expenditure of solving superiors and other expenditures. Employees' basic medical insurance benefits are included in the employees' basic medical insurance fund benefits and employees' basic medical insurance personal account benefits according to regulations. Employee's basic medical insurance fund treatment expenditure refers to the medical expenses compensation expenditure paid by the co-ordination fund, including hospitalization expenses, outpatient serious illness and outpatient co-ordination expenses, within the scope of co-ordination fund payment according to regulations, above Qifubiaozhun and below the maximum payment limit. In the co-ordination areas where maternity insurance and employee basic medical insurance are merged, the employee basic medical insurance co-ordination fund treatment expenditure includes maternity treatment expenditure. Maternity treatment expenses include maternity medical expenses and maternity allowance expenses. Employee basic medical insurance personal account treatment expenditure refers to the expenditure paid by personal account according to regulations, mainly including outpatient expenses, hospitalization expenses and medical expenses incurred in designated retail pharmacies. Personal account funds shall not be used for non-medical expenses in principle. The basic medical insurance fund for employees shall, according to the specific circumstances, subsidize the lower-level expenditures and the higher-level expenditures respectively in the overall fund and the individual account fund. The transfer expenses of the employee's basic medical insurance fund shall be charged in the individual account fund.