Out-of-pocket hospitalization expenses outside the medical insurance catalogue

1. What do you mean by out-of-pocket payment?

The medical insurance catalogue means that the medicines and tests you use can be reimbursed with personal medical insurance! On the other hand, outside the medical insurance catalogue are drugs and inspection services that cannot be reimbursed by medical insurance, but only at their own expense!

2. What does it mean to pay for expenses outside the scope of medical insurance policy? Drugs that can be reimbursed by self-funded and self-funded medical insurance are divided into Class A drugs and Class B drugs.

0/00% reimbursement for Class A drugs/KLOC, and 50%-70% reimbursement for Class B drugs in proportion.

Some self-funded drugs are beyond the scope of medical insurance reimbursement, such as imported drugs and targeted drugs, including deductible.

Some self-funded drugs belong to Class B drugs, and the excess expenses are reimbursed. Not included in medical insurance reimbursement.

3. What do you mean by taking care of yourself outside the medical insurance catalogue?

What do you mean by self-care expenses and out-of-pocket expenses?

Out-of-pocket expenses: refers to medical expenses that are not included in the scope of basic medical payment; Using drugs outside the basic medical insurance drug list; The use of basic medical insurance treatment projects, medical expenses of some treatment projects will not be paid; Medical expenses exceeding the payment standard of basic medical insurance medical service facilities; And the expenses incurred by medical service facilities that are stipulated not to be paid.

Self-care expenses: refers to the medical expenses that are included in the basic medical insurance payment scope and should be paid by individuals in advance.

4. What is self-financing within medical insurance and self-financing outside medical insurance?

If you are hospitalized and you pay medical insurance, you can use medical insurance to reimburse a part when you leave the hospital, but some drugs you use during hospitalization can be reimbursed by medical insurance, while others can't. The part that can be reimbursed by medical insurance is the amount in medical insurance, and the part that cannot be reimbursed by medical insurance is the amount outside medical insurance.

5. Expenses outside the medical insurance catalogue

Medical expenses outside the personal injury medical insurance catalogue, social security medical care and commercial hospitalization medical care are not reimbursed, while Huimin insurance can be reimbursed according to the corresponding proportion of medical expenses. After each name bears the deductible, it will be reimbursed by 30%.

Commercial million medical insurance can be reimbursed within the scope of responsibility, not limited by the social security catalogue, but only within the insured amount. Different channel insurance has different liability for payment.

6. Self-funded in the medical insurance catalogue

Accident medical insurance and self-funded drugs mainly refer to drugs outside the social security catalogue. In the insurance liability, the scope of reimbursement is limited to the social security catalogue, including medical means and medical drugs. This part of the expenses needs to be borne by individuals and cannot be reimbursed. The main drugs include imported drugs, specific drugs and innovative drugs.

7. The difference between out-of-directory and self-funded medical insurance.

First, the part paid by individuals in medical insurance coverage is guaranteed. Focus on ensuring hospitalization, outpatient treatment and the cost of using the "dual-channel" drugs negotiated by the state in the medical insurance catalogue. After the basic medical insurance, the individual pays more. The deductible for this responsible year is 654.38+00000 yuan, 65% for "exceeding the deductible by 0 to 654.38+00000 yuan", 77% for "exceeding the deductible by more than 654.38+000000 yuan", and the maximum compensation is 654.38+000000 yuan.

Second, protect the part beyond the scope of basic medical insurance. Focus on ensuring reasonable and necessary out-of-pocket expenses for hospitalization and outpatient treatment, including out-of-pocket drugs and high-value medical consumables, effectively reducing the burden of out-of-pocket expenses for patients. The annual deductible for this responsibility is 20,000 yuan. Pay 55% for "exceeding the deductible of 0 to 6,543.8+10,000 yuan", 67% for "exceeding the deductible of 6,543.8+10,000 yuan", with a maximum payment of 6,543.8+10,000 yuan.

Third, the reinsurance part of serious diseases. In order to effectively reduce the heavy burden of medical expenses of patients with serious diseases, the medical expenses borne by individuals after the above two security responsibilities are paid again (including deductible 1 0,000 yuan and 20,000 yuan, including out-of-pocket expenses and total out-of-pocket expenses). The deductible amount of this guarantee liability is 50,000 yuan, the compensation ratio is 45%, and the maximum compensation amount is 6,543,800 yuan.

Fourth, some special and serious diseases supplement the responsibility of protection. According to the contract, the product will provide supplementary protection for some special serious diseases, with a maximum compensation of 200,000 yuan to further reduce the high cost burden of related patients.

8. Self-funded projects outside the medical insurance catalogue

"Zhenjiang Huimin Insurance" products are divided into basic models and upgrade models. The basic payment is only 99 yuan a year, and the maximum medical insurance is 265,438+10,000 yuan; The upgrade only costs 299 yuan, and the maximum medical security is 4 million yuan. The coverage of the two products covers the protection of personal out-of-pocket expenses in the medical insurance catalogue, the protection of personal out-of-pocket expenses outside the medical insurance catalogue, the protection of certain high drug expenses and the protection of high out-of-pocket expenses for rare diseases. The upgraded product also increases the additional medical expenses and the compensation for serious malignant tumor in proton heavy ion hospital, which is very characteristic of Zhenjiang.

As long as you are insured in Zhenjiang's basic medical insurance (including employees' medical insurance and residents' medical insurance) and are in the insured state, regardless of age, occupation, past medical history and no waiting period, you can use your personal medical insurance account in previous years to pay for your own insurance, and you can buy it for your parents, children and spouses.

The above information source network is for reference only!

9. What do you mean by out-of-catalog fees?

Specific drugs refer to targeted drugs and immunotherapy drugs approved by the state supervision and listed in China.

The calculation method of drug expenses borne by individuals is as follows:

1) inclusion ratio of specific drug expenses outside the medical insurance catalogue100%;

2) After medical insurance reimbursement, the remaining part of the specific drug expenses in the medical insurance catalogue will be included in the proportion100%;

3) 30% of the cost of specific drugs only included in the medical insurance catalogue but not reimbursed by medical insurance;

At present, it is more and more difficult to buy high-priced drugs in hospitals, and millions of medical insurance has also reduced the protection of purchased drugs.

In two years, the total amount of self-funded funds was 654.38+million, with an average of 50,000 a year. If targeted drugs and immunotherapy drugs are needed, this cost is not difficult to achieve.

So this guarantee is still very friendly.

10. What do you mean by medical insurance conceit?

After consultation, the difference between the individual pays and the proportion is as follows: 1. Difference in meaning 1. Conceit: refers to the medical expenses used by employees to pay for medical expenses below the deductible line of the basic medical insurance pooling fund and insufficient outpatient accounts.

2. Out-of-pocket payment refers to the accumulation of classified self-funded projects and individual self-funded, and the self-paid part does not include self-funded projects and needs to be paid by itself.

Second, self-sufficiency and self-payment belong to the expenses in the medical insurance catalogue, but the expenses outside the scope of medical insurance reimbursement need to be borne by individuals.

Third, there are many details, such as special needs wards, which are self-funded services. Four. Those who have participated in residents' medical insurance or employees' medical insurance can enjoy the relevant treatment of medical insurance reimbursement as long as they follow the "three fixed points" in the process of treatment and medical treatment. Personal payment can be selected for the part that exceeds the reimbursement ratio.

1 1.

Yes, or you can calculate the social security card at your own expense first, as follows:

1, for emergency treatment, the medical expenses of hospitals within the scope of medical insurance in the insured area can be reimbursed manually in the social security department after treatment and included in the personal medical insurance account.

2. Due to the referral from the hospital, a referral certificate is issued, and the medical expenses of hospitals outside my medical insurance scope can be reimbursed manually to the insured social security department after seeing a doctor, and included in the personal medical insurance account.

3. If the new insured does not receive a formal social security card, and the social security card is used as a temporary social security card (card certificate) after it is lost, the medical expenses incurred in the hospital within the scope of medical insurance in the insured place can be reimbursed manually to the social security department of the insured person after medical treatment and included in the personal medical insurance account.