How to reimburse Guangzhou city medical insurance

Social medical insurance is a social insurance system established by the state and society in accordance with certain laws and regulations, in order to provide protection for the basic medical needs of workers covered by the guarantee in case of illness. In China, everyone can participate in the insurance.

I. How to get reimbursed by medical insurance

1. The amount of personal cash payment: the amount that the patient has to bear by himself.

2. The amount paid by the health insurance fund: the total amount of expenses paid by the health insurance fund. Including: outpatient large payment, retirement supplemental insurance payment and other payment methods.

3, the starting line: that is, the starting standard below the cost, the Medical Insurance Bureau according to different categories of participants and hospital level categories set the appropriate starting standard.

4. Amount covered by medical insurance: the amount of this medical expense that is covered by medical insurance reimbursement.

5. Cumulative amount covered by medical insurance: the total amount of medical expenses covered by medical insurance in the current year up to the time of settlement of this expense.

6, the annual outpatient large cumulative payment: as of the time of this cost settlement, the total amount of outpatient medical insurance for the participants in the current year, the total amount of the cumulative payment of outpatient expenses.

7. Individual payment, out-of-pocket amount: the amount that the patient has to bear, consisting of out-of-pocket one, out-of-pocket two and out-of-pocket amount.

Out-of-pocket payment: the amount to be paid by the patient in the medical expenses that can be included in the scope of reimbursement of medical insurance. It includes: the starting amount and the amount that the patient pays after exceeding the starting amount.

Out-of-pocket payment 2: the sum of the costs of drugs and tests that the patient has to pay for himself, which is labeled as "partially out-of-pocket". Assuming that a bottle of medicine costing 100 yuan is a drug with a co-payment, if the percentage of co-payment is 10%, then you have to pay 10 yuan. This would be out-of-pocket two.

Out-of-pocket expenses: the total cost of medicines and tests that are noted as "all out-of-pocket" and have to be paid by the patient.

Taking Beijing's health insurance patients as an example, the starting line for outpatient costs is 1,300 yuan for retired patients and 1,800 yuan for working patients, which means that a patient can only be reimbursed for outpatient costs that exceed the starting line.

Suming Zhang is an active patient, he incurs an outpatient expense of 2,000 yuan at a tertiary care hospital, of which 100 yuan is for all out-of-pocket medicines, and the remaining 1,900 yuan is the amount covered by his health insurance (the reimbursement rate for outpatient care at non-community health care facilities is 70 percent).

Out-of-pocket one: 1800 + (1900-1800)*30% = 1830 yuan;

Out-of-pocket two: 0 yuan (partially out-of-pocket medicines or consultations);

Out-of-pocket: 100 yuan (fully out-of-pocket medicines);

Eventually, the individual pays=Out-of-pocket one+Out-of-pocket two+Out-of-pocket = 1930 yuan, and Medicare reimburses 70 yuan.

Two examples of reimbursement

1, outpatient reimbursement:

Small Zhang, who works in Shenzhen, sees an outpatient clinic in one of Shenzhen's designated tertiary hospitals, and spends 5,000 yuan a year***, of which 600 yuan is out-of-pocket. Assuming that the minimum starting line for Shenzhen's tertiary hospitals is going to be 1,900 yuan, and the outpatient reimbursement rate for that tertiary hospital is 70%, the amount he can be reimbursed for the outpatient visit is:

(total cost of treatment - the starting line - the out-of-pocket portion of the cost) x reimbursement rate = (5,000 - 1,900 - 600) X70% = 1750 (yuan)

2, hospitalization reimbursement

Wang, who works in Shenzhen, spent 180,000 yuan on a heart transplant at a hospital, of which 150,000 yuan was for in-catalog costs and 25,000 yuan was for out-of-catalog out-of-pocket costs. Assuming a starting line of 2,000 yuan for the location, a reimbursement rate of 85 percent and an average salary of 7,480 yuan in Shenzhen in 2017, how much of Xiao Wang's expenses for the surgery are reimbursable?

Reimbursement = (total cost of treatment - starting line - out-of-pocket expenses) x reimbursement rate = (18-0.2-2.5) x 85% = 130,005 (million)

However, social security reimbursements are subject to a maximum cap of roughly four times the average annual social wage in the locality, which means that reimbursement cap = 7480 x 12 x 4 = 3,590,400 (million)

The 3,590,400 is greater than the 130,005,000, so the 130,005,000 can be fully reimbursed.

The Law of the People's Republic of China on Social Insurance

Article 28

Medical expenses that are in line with the basic medical insurance drug catalog, diagnostic and therapeutic items, and medical service facility standards, as well as those for emergencies and salvages, shall be paid out of the basic medical insurance fund in accordance with state regulations.

The Social Insurance Law of the People's Republic of China

Article 29

The portion of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly by the social insurance administration agencies with the medical institutions and drug business units. The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.