Medical insurance reimbursement rate formula for tertiary care hospitals

Tertiary hospital medical insurance reimbursement rate formula:

Medical insurance reimbursement formula = total cost - the starting line - the out-of-pocket portion of medicines and examinations * reimbursement rate.

The standard of medical insurance reimbursement ratio for tertiary hospitals is as follows:

1. The outpatient medical expenses incurred by patients with chronic diseases of category A in compliance with the regulations will be paid by the integrated fund at 85%. The outpatient hemodialysis cost, peritoneal dialysis cost and the cost of taking cyclosporine A after organ transplantation for patients with chronic renal failure in the stage of renal failure will be increased by ten percentage points on the basis of the above;

2. The standard of the starting line for category B chronic diseases: 300 yuan. The outpatient medical expenses incurred by patients with Class B chronic diseases in accordance with the regulations shall be paid at 80% of the portion above the starting line standard, and the maximum payment limit for chronic diseases shall not be exceeded in a medical year or within the validity period;

3. Participants can be recognized with two Class B chronic diseases at the same time, and the management of the two diseases shall be based on the first recognized, and the starting line shall be calculated separately for each disease type. The management of the identification of chronic diseases and the maximum payment limit will be adjusted by the human resources and social security department in due course according to the income and expenditure situation of the integrated fund. The criteria, rules and procedures for the identification of chronic diseases will be formulated separately by the municipal human resources and social security administration.

Medical insurance reimbursement process:

1, confirm the scope of reimbursement: in the process of treatment, you need to confirm whether your treatment items belong to the scope of reimbursement of medical insurance;

2, collect reimbursement materials: collect the relevant records of treatment, drug receipts, list of medical expenses and other related materials;

3, to the social security department for reimbursement: submit the relevant materials to the local social security department to handle reimbursement.

4. Waiting for the audit: the social security department will carry out relevant audits and comparisons to confirm the reimbursement rate and reimbursement amount; receiving the reimbursement payment: after the audit is approved, you can receive the reimbursement payment of the medical insurance at the designated bank.

What items can be reimbursed by medical insurance:

1. Hospitalization: medical insurance can reimburse the hospitalization due to illness or accident, including medical service fee, medicine fee, material fee, examination fee, etc.

2. Outpatient treatment: medical insurance can reimburse the medical fee for outpatient treatment, including registration fee, consultation fee, examination fee, medicine fee, etc.

3. 3. Medical checkups: Medical insurance can reimburse individuals for medical checkups at their own expense.

It is important to note that regulations may vary from region to region and policy to policy, and the specific reimbursement scope and standards are subject to local policy.

In summary, the reimbursement rate for major chronic illness medical insurance is determined by local policies and regulations, and may vary from region to region. Generally speaking, the reimbursement ratio of chronic disease medical insurance includes two aspects: the basic medical insurance payment ratio: the basic medical insurance payment ratio refers to the proportion paid by the medical insurance fund, generally ranging from 70% to 80%; the individual out-of-pocket payment ratio: the individual out-of-pocket payment ratio refers to the proportion of medical expenses that the individual needs to bear, generally ranging from 20% to 30%.

Legal basis:

Article 28 of the Social Insurance Law of the People's Republic of China

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

Article 29

The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and 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.