What does the medical insurance limit mean?

The payment limit of medical insurance is the highest payment limit of medical insurance: it refers to the maximum amount of medical expenses paid by the basic medical insurance fund to the insured in a medical year.

The maximum payment limit of medical insurance fund refers to the upper limit of medical expenses that can be paid by the overall fund, which exceeds the maximum payment limit. Basic medical insurance will not be paid, the scope of serious diseases, uremia dialysis treatment, anti-rejection drug treatment after tissue and organ transplantation, and the maximum payment limit of the overall fund.

The maximum payment limit of medical insurance fund is the so-called "capping line", which refers to the upper limit of medical expenses that can be paid by the overall fund. Medical expenses exceeding the maximum payment limit shall not be paid by the basic medical insurance.

For example, the range of serious diseases: radiotherapy and chemotherapy for malignant tumors, dialysis treatment for uremia, and anti-rejection drug treatment after tissue and organ transplantation. Maximum payment limit of the overall fund: the cumulative maximum payment limit of the overall fund within one year is 70,000 yuan. Other diseases also have payment limits, and each place is different. You can check with the local social security network or consult a doctor.

At present, the standard is about four times the average salary of employees in the previous year. If the average salary of employees was 10000 yuan last year, the maximum payment limit was about 40000 yuan. According to the new medical reform plan, the maximum payment limit of medical insurance for urban workers or residents is gradually increased to about 6 times of the average annual salary and per capita disposable income of local workers, and the maximum payment limit of the new rural cooperative medical system is gradually increased to more than 6 times of the per capita net income of local farmers.

The upper limit of general outpatient service is about 20 thousand; The upper limit of hospitalization is around 300,000; Some major diseases are not capped; The general concept is like this, and it varies from place to place. Specific policies can be consulted with local hospitals and social security centers.

Funding standard for residents' basic medical insurance: 5 10 yuan per file, of which individual contributions 150 yuan, and government subsidies to 360 yuan; Second-grade 450 yuan, in which individuals pay 90 yuan per person and the government subsidizes 360 yuan per person. Students pay according to the second personal payment standard and enjoy the residents' medical insurance treatment with the first payment standard. The maximum payment limit of medical insurance fund is 6.5438+0.5 million yuan, and the hospitalization Qifubiaozhun first-class hospital is 200 yuan.

legal ground

Article 28 of the 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.