What is the difference between medical insurance payment and out-of-pocket payment?

The difference between medical insurance payment and out-of-pocket payment is as follows:

1, the payment entity is different. Medical insurance payment is shared by medical insurance funds and individuals; Pay expenses at one's own expense;

2. The payment standard is different. Medical insurance payment is implemented according to local regulations, and different urban and rural residents have different payment standards; There is no limit to the self-funded payment standard;

3. The scope of payment is different. The scope of medical insurance payment includes outpatient expenses, hospitalization expenses and medicine expenses. The self-funded scope is not limited by the social security catalogue.

Medical insurance reimbursement conditions:

1. Confirm the insured status: before seeking medical treatment, you need to confirm that you have participated in local medical insurance, which can be confirmed by means of social security card and medical insurance certificate;

2. Medical category: Medical insurance generally only reimburses therapeutic medical behaviors, such as outpatient service, hospitalization, surgery and examination. Some cosmetic medical behaviors, such as dental beauty and plastic surgery, are usually not covered by medical insurance reimbursement;

3. Medical expenses: Medical insurance will only reimburse medical expenses that meet the requirements, such as medical expenses, medicine expenses, examination expenses, operation expenses, etc. Personal expenses, medical insurance will not be reimbursed;

4. Hospital qualification: Medical insurance will only reimburse the medical expenses of legally operated medical institutions, such as public hospitals and qualified private hospitals. Medical insurance will not be reimbursed for illegal medical institutions or clinics.

To sum up, medical insurance payment is subject to certain restrictions in terms of payment subject, payment standard and payment scope, while self-funded payment can be decided by individuals themselves.

Legal basis:

Article 28 of People's Republic of China (PRC) Social Insurance Law

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.