How to calculate the reimbursement ratio of outpatient medical insurance

The reimbursement rates of Class A drugs and medical treatment items for insured employees in first-class medical institutions, second-class hospitals and third-class hospitals were 75%, 65% and 55% respectively, while those for Class B drugs were 70%, 60% and 50% respectively, and the reimbursement rate for retirees increased by 5%. The part of the general outpatient expenses reimbursed by the overall fund can be paid by the insured's personal account.

Calculation of medical insurance reimbursement ratio: the first-class hospital calculates the part above the deductible line to the maximum payment limit according to 90%; Secondary hospitals calculate the minimum payment standard to 10000 yuan according to 85%, and the maximum payment limit to 10000 yuan according to 90%; The minimum qifubiaozhun for tertiary hospitals is 80% to 5,000 yuan, the minimum qifubiaozhun is 85% to 1 10,000 yuan, and the maximum payment limit is 90%. Retirees will increase by 6% on the basis of the above ratio.

Are all deductibles at your own expense?

The deductible is not at your own expense. First of all, medical insurance is first spent and then reimbursed, and self-funded drugs are not involved in the calculation. Secondly, self-funded drugs were not covered by social security from the beginning, and deductible was used in social security. Finally, if self-funded drugs need to be insured, you need to buy corresponding commercial insurance.

There is a minimum amount for medical insurance reimbursement. Generally, in 500 yuan, this part is not borne, and the part exceeding 500 yuan is compensated in proportion. The specific proportion depends on the types of insurance you insure. The proportion of general social security reimbursement is relatively low, about 55%. If commercial insurance is insured at the same time, medical insurance can compensate within the limits of commercial insurance.

Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for economic losses caused by disease risks. The medical insurance fund is established through the contributions of employers and individuals. After the insured person has medical expenses, the medical insurance institution will give certain economic compensation.

The establishment and implementation of the basic medical insurance system has gathered the economic strength of units and social members. With the government's funding, sick social members can get necessary material help from the society, reduce the burden of medical expenses, and prevent sick social members from "poverty due to illness".

In the traditional sense, medical insurance refers to raising medical insurance funds among certain insured people in a certain area through mandatory policies and regulations or voluntary contracts handled by specific organizations or institutions.

Medical insurance has the basic characteristics of social insurance, such as compulsion, mutual assistance and sociality. Therefore, the medical insurance system is usually enforced by national legislation and a fund system is established. The expenses are paid jointly by the employer and the individual, and the medical insurance premium is paid by the medical insurance institution to solve the medical risks caused by the illness or injury of the workers.

To sum up, the reimbursement rate of medical insurance outpatient service for employees: After the on-the-job employees go to the hospital for emergency treatment, the medical expenses of more than 2,000 yuan can be reimbursed, and the reimbursement rate is 50%. For retirees under the age of 70, the expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 30%. Proportion of reimbursement for residents' medical insurance outpatient service: outpatient settlement procedure: insured patients can directly settle medical expenses incurred in outpatient service at designated medical institutions with special medical insurance offices and social security cards.

Legal basis:

People's Republic of China (PRC) social insurance law

Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, 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.