Is the 2019 medical insurance reimbursement limit for enterprise employees in Handan City, Hebei Province calculated on a per-time hospitalization basis or on an annual basis?

1. Employee Medical Insurance

For employed persons, such as agencies, institutions, state-owned enterprises, private enterprises, groups, etc., the employer shall pay social insurance for employees in accordance with the labor law, that is, We usually talk about the five insurances and one fund among them the most. It consists of medical insurance, maternity insurance, work-related injury insurance, unemployment insurance, and pension insurance. The insurance for these people paid by the unit for employees is called employee medical insurance.

2. Resident Medical Insurance

Except for employees’ medical insurance, persons who participate in the medical insurance shall pay their own fees based on their place of residence. In 2017, according to the unified deployment of the State Council, the national medical insurance system for urban and rural residents has been integrated. That is, the original new rural cooperative medical care and urban residents' medical insurance are integrated together, called urban and rural residents' medical insurance.

3. The difference

lies in the following five aspects:

1. Different target orientation

Resident medical insurance is mainly for those who are unemployed Residents, subsistence allowance households, students and children, etc.;

Employee medical insurance is aimed at people with workplaces or flexible employment, individual industrial and commercial households, etc.;

2 Cost sources are different

Resident medical insurance is paid by individuals, and the finance provides subsidies; the amount of general financial subsidies is much greater than what individuals pay;

Employee medical insurance is paid by both units and individuals, usually The unit pays 8% and the individual pays 2%;

3 The payment standards are different

Resident medical insurance is paid on an annual basis and has a collection period, usually from September to December each year. If you do not pay the fees for the next year within the collection period, there will be a certain waiting period, that is, you will not be able to enjoy benefits for a period of time;

Employee medical insurance is paid on a monthly basis, and the monthly payment is generally stipulated. If you pay by a certain date, there will be a late fee if you pay overdue. Moreover, if medical expenses occur during the period of non-payment, they will not be reimbursed until the payment is made.

4 Enjoy different benefits

Resident medical insurance contributions are lower, so the benefits are lower, and the reimbursement ratio is generally around 45%~~65%;

Employees Medical insurance pays monthly, the benefits are relatively high, and the reimbursement ratio is generally around 70%~~90%;

Note:

① A part of the employee payment will be transferred to the personal account (self-employed) Except for those who do not have accounts in the single construction and coordination department), residents generally do not have personal accounts. Of course, some cities and towns have better conditions and will transfer part of the payment to the social security card to buy medicine, etc., but it is usually only a few dozen yuan. money.

② Regarding the reimbursement ratio, policies vary from place to place. For specific ratios, please call 12333 to consult the local social affairs department.

(Example: Taking Beijing as an example, let’s take a closer look at the reimbursement ratio of employee medical insurance and urban and rural residents’ medical insurance in 2018.

Reimbursement for outpatient visits and hospitalization for insured persons in Beijing Medical Insurance The reimbursement is very different. Generally speaking, the "intensity" of outpatient reimbursement is smaller, as shown in the figure below. First, the deductible is higher, and secondly, the reimbursement ratio is lower.

Only medical expenses exceeding this amount can be reimbursed. The deductible for outpatient service is cumulative and calculated on a yearly basis.

For example, employee Xiao Li has gone to the hospital twice this year, and the first medical expense was 800. It cannot be reimbursed. The second medical fee is 1,000, but it still cannot be reimbursed. As long as Xiao Li goes to the hospital again in 2018, no matter how much he spends, he can be reimbursed in proportion.

In addition, many hospitals in Beijing have it. It stipulates that urban and rural residents need to go to the community (or cooperative medical point) to go through the referral procedures before going to a large hospital for outpatient treatment. Otherwise, they cannot be reimbursed.

Look at the hospitalization reimbursement and employee deductibles of the medical insurance. It is lower than outpatient reimbursement, but the deductible for urban and rural residents is higher than outpatient reimbursement. However, the reimbursement ratio for both employees and urban and rural residents is almost higher than that for outpatient reimbursement, as shown in the figure below:

The deductible for hospitalization is not cumulative and is calculated on a per-time basis. If the medical expenses for the next hospitalization are lower than the deductible, the medical expenses will not be reimbursed.

However, Beijing’s regulations are that except for students and children, other people will not be reimbursed. For the second (and subsequent) hospitalization in the same year, the deductible standard is reduced to 650 yuan for employees and retirees, and the deductible standard for urban and rural residents is also halved.

Although employee medical insurance There are so many differences from urban and rural residents' medical insurance, but in fact, the things we need to do during the entire medical treatment and reimbursement process are similar. The hospital and medical insurance center will automatically calculate the deductible and reimbursement ratio for us, so if you are willing and able, We can learn more about medical insurance. If we don’t understand it, it won’t have much impact)

5 Payment requirements are different

Resident medical insurance must be paid annually, and you cannot enjoy it if you don’t pay. treatment. There is no mention of retirement, and some prefectures and cities require residents to continue to pay contributions, otherwise they will not be able to enjoy benefits.

If it is interrupted, you may have to pay back the fees from previous years (I have always felt that this is inappropriate, and only a few prefectures and cities have this requirement)

What is the difference between the reimbursement ratios of resident medical insurance and employee medical insurance?

1. What are the minimum hospitalization payment standards for local hospitalization years?

The deductible payment standard refers to the "threshold" that can be paid by the basic medical unified fund according to regulations. That is to say, before the unified fund pays for hospitalization expenses, individual employees must first pay a certain amount of medical expenses. The pooled funds have just begun to pay. Our city stipulates that the minimum payment standards for first-, second-, and third-level hospitals within a medical year are 300 yuan, 500 yuan, and 700 yuan respectively. The deductible payment standard for the second hospitalization is reduced by half, and there is no deductible payment standard for the third hospitalization.

2. How is the medical expense settlement for local hospitalized employees calculated?

The maximum payment limit of the basic medical co-ordination fund is 200,000 yuan. After deducting out-of-range medical expenses (self-pay, partial self-pay), and above the minimum payment standard, reimbursement will be based on a step-by-step progressive system. Within 10,000 yuan (including 10,000 yuan), the personal burden is 9%, 13%, and 15% in first-, second-, and third-level hospitals respectively; for the part from 10,000 yuan to 20,000 yuan (inclusive), the personal burden is in first-, second-, and third-level hospitals. The rates for first-level hospitals are 7%, 9%, and 11% respectively; for the portion from 20,000 yuan to 30,000 yuan (including 30,000 yuan), the individual bears 7%; for the portion from 30,000 yuan to the maximum payment limit, the individual bears 5%.

3. How are the medical expense settlements for local hospitalized retirees calculated?

The personal burden ratio of retirees is half that of active employees. The personal burden ratio of old workers before the founding of the People's Republic of China is half that of retirees. The minimum payment standard and maximum payment limit are the same as those of active employees.

Resident Medical Insurance

Are all medical expenses covered during hospitalization? What is the minimum payment standard?

Answer: Not all medical expenses during hospitalization are included in the scope of reimbursement. Only medical items that comply with the provisions of the residents’ medical insurance policy are included in the scope of reimbursement. Specifically, they are the drug catalog of the residents’ basic medical insurance, the catalog of diagnosis and treatment items and the medical expenses. Only services within the catalog of service facilities will be reimbursed.

The hospitalization deductible standards are divided into the following situations:

1. Local hospitalization deductible standards. The minimum payment standards for the first hospitalization during the year are: 200 yuan for first-level medical institutions (including community health service centers), 500 yuan for second-level medical institutions, and 700 yuan for third-level medical institutions; the minimum payment standards for the second hospitalization are reduced by 100 yuan respectively; implementation The minimum payment standard for township health centers under the National Essential Drug System is 100 yuan for both times; for private designated medical institutions with undetermined levels, the minimum payment standard for second-level medical institutions shall be implemented; for the third hospitalization, there will be no minimum payment line.

The payment ratio for inpatient medical expenses within the policy scope from above the minimum payment standard to below the maximum payment limit: township health centers and county-level hospitals that implement the national essential drug system are 85% and 70% respectively, and other 75% for first-level medical institutions, 65% for second-level medical institutions, 60% for third-level medical institutions, and 60% for undetermined private medical institutions.

(Source: Laiwu City Human Resources and Social Security Bureau)

I originally paid 80,000 yuan for employee pension insurance, and it is still two years before I can start receiving the money. Now I don’t want to continue to enjoy it. Can the previous money be refunded?

Reply from the Municipal Human Resources and Social Security Bureau Pension Insurance Division: Employees cannot withdraw from pension insurance benefits under normal circumstances. In special circumstances such as repeated payments, employees settling abroad or immigrating, or employees passing away before retirement, you can apply for pension insurance with relevant materials. Surrender procedure.

I have a first-level visual disability and a five-guarantee household. The town has bought residents’ pension insurance. Why is it that I have reached the age and are not receiving pension insurance subsidies?

Nonggao District Human Resources and Social Security Bureau responded: After checking the ID card information, the pension insurance information of Chen Yongzeng in Yangzhuang Town has been registered. However, because the pension insurance will add new people receiving benefits every month, so all It is processed in batches and requires registration of personal information, bank account and other procedures. It will take a certain period of time, but it will be reissued from the month when the benefits are received. Chen Yongzeng's pension insurance will be distributed in the near future.

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