Proportion of reimbursement for serious illness as a whole

The proportion of reimbursement for serious illness as a whole is as follows:

1. The reimbursement scope of serious illness medical insurance mainly refers to the medical expenses that exceed the maximum payment limit of the basic medical pooling fund. The reimbursement ratio will vary according to the amount paid by the social security department in different ranges, including: 85% for reimbursement below RMB 0-40,000, 90% for reimbursement below RMB 40-80,000, and 95% for reimbursement above RMB 80,000; The maximum payment limit for each medical year is 6,543,800 yuan+0.5 million yuan;

2. The insured can identify two chronic diseases at the same time, and manage them according to the two diseases identified first, and calculate the deductible for each disease separately; The identification and management of chronic diseases and the maximum payment limit shall be adjusted by the human resources and social security department according to the overall fund income and expenditure. The standards, rules and procedures for the identification of chronic diseases shall be formulated separately by the municipal administrative department of human resources and social security.

Medical insurance reimbursement process:

1. Confirm reimbursement scope: During the treatment, you need to confirm whether your treatment items are within the scope of medical insurance reimbursement;

2. Collect reimbursement materials: collect relevant treatment records, drug receipts, medical expense lists and other relevant materials;

3. Go to the social security department for reimbursement: submit relevant materials for medical insurance reimbursement to the local social security department;

4. Pending review: The social security department will conduct relevant review and comparison to confirm the reimbursement ratio and reimbursement amount; Receive reimbursement: After approval, you can receive medical insurance reimbursement at the designated bank.

To sum up, within one year, the medical expenses for the diagnosis and treatment of serious diseases and chronic diseases within the scope of medical insurance exceed 500 yuan and two diseases exceed 700 yuan, and the medical insurance fund will reimburse 60%. Reimbursement scope of serious illness medical insurance: medical expenses exceeding the maximum payment limit of basic medical pooling fund.

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.