Proportion of medical expenses reimbursed by social security

1. What is the proportion of social security medical reimbursement?

(A) the proportion of hospitalization reimbursement

1. 90% can be reimbursed for the part of the first-class hospital that exceeds the Qifubiaozhun to the maximum payment limit;

2. For secondary hospitals, 85% can be compensated for the part above the minimum threshold of 1 0,000 yuan; 1 tens of thousands? Yuan to the highest payment limit can compensate 90%;

3 tertiary hospitals, more than Qifubiaozhun to 5000 yuan, can compensate 80%; 5000 yuan to 1000 yuan, can be compensated for 85%; The part exceeding the maximum payment limit of 6,543,800 yuan can be compensated by 90%.

4. Retirees can be increased on the basis of the above reimbursement ratio? 5%。

(2) deductible for hospitalization reimbursement

1, a first-class hospital in 200 yuan;

2, the secondary hospital Wu Bai yuan;

3. 800 yuan, a tertiary hospital;

4, malignant tumor patients, in a medical year for many times due to radiotherapy and chemotherapy medical expenses, only calculate a deductible.

(III) Proportion of outpatient reimbursement for chronic diseases

Outpatient chronic diseases are divided into Class A chronic diseases and Class B chronic diseases.

1. The outpatient medical expenses that meet the requirements due to illness of patients with chronic diseases of Class A shall be compensated by the overall fund by 85%. Outpatient hemodialysis expenses, peritoneal dialysis expenses and taking cyclosporine after organ transplantation in patients with chronic renal failure (renal failure)? Answer? On the basis of the above, expenses are reimbursed, with an increase of 10%.

2. B Chronic disease deductible standard: 300 yuan. The outpatient medical expenses incurred by patients with chronic diseases of Class B due to illness can be reimbursed by 80% for the part exceeding the deductible standard, and shall not be higher than the maximum payment limit for chronic diseases within a medical year (or within the validity period).

3. The insured can identify two chronic diseases of Class B at the same time, and calculate the deductible of each disease according to the management of the first two diseases. 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.

(four) the maximum amount of medical insurance reimbursement

In a medical year, the overall fund will compensate the insured for hospitalization expenses and outpatient medical expenses for chronic diseases that do not exceed the maximum payment limit of 250,000 yuan. If necessary, the relevant departments can adjust the maximum payment limit according to the regulations.

To sum up, the basic medical insurance pooling fund and the social security individual account have their own payment ranges and are accounted for separately. The proportion of hospitalization reimbursement varies according to different hospital levels, and the deductible line is also different. What is the maximum payment limit of the overall fund in a medical year? 25? Ten thousand yuan.

2. What is the scope of reimbursement for social security and medical insurance?

The payment scope of basic medical insurance pooling fund and individual account is different, and the accounting of reimbursement is also carried out separately. Medical expenses that meet the scope of medical insurance fund payment shall be compensated according to the basic medical insurance drug list, service facilities range, diagnosis and treatment project list and payment standard.

Personal account to pay the following medical expenses:

The cost of purchasing drugs at designated retail pharmacies; Money spent on outpatient and emergency services; Medical expenses that have not reached the deductible line of the basic medical insurance pooling fund; Higher than the medical insurance fund Qifubiaozhun, the expenses shall be borne by the insured in proportion; The insufficient payment of personal account shall be borne by the insured himself.

The basic medical insurance fund pays the following medical expenses:

Hospitalization medical expenses; For emergency rescue observation and income hospitalization, the medical expenses for observation before hospitalization shall not exceed 7 days; Outpatient medical expenses for renal dialysis, radiotherapy and chemotherapy for malignant tumor and taking anti-rejection drugs after renal transplantation.

The basic medical insurance fund is not responsible for the following medical expenses:

Injuries caused by traffic accidents, medical accidents or other accidents; Buying drugs at non-designated retail pharmacies; If you don't go to the designated hospital of your choice for medical treatment, the emergency situation will not be covered; Injury caused by taking drugs, fighting or other illegal acts; Treatment expenses due to suicide, self-mutilation, alcoholism and other reasons; The expenses for medical treatment abroad or in Hongkong, Macao Special Administrative Region and Taiwan Province Province shall be borne by the insured.

The medical expenses incurred by enterprise employees due to work-related injuries and occupational diseases shall be implemented in accordance with the relevant provisions of work-related injury insurance. Medical expenses incurred by female workers during their maternity shall be reimbursed in accordance with relevant policies and regulations.

Third, social security work-related injury reimbursement

1, required materials:

The application form for work-related injury identification is in quadruplicate, and the copy is invalid;

One original and one copy of the diagnosis certificate and the diagnosis certificate of outpatient (inpatient) cases or occupational diseases;

One original and one copy of the text of the labor contract;

Copy of the injured person's ID card;

2. Submission time: 1- 10 days per month.

3. Processing flow:

Application: the unit manager submits the above materials to the social security center;

Acceptance: the work-related injury identification department will review the application within 15 days after receiving it. Those who meet the conditions should be admitted. If the application materials are incomplete, inform the unit manager to fill in the materials within 30 days;

Appraisal: within 60 days after the examination (extended for another 30 days under special circumstances), make a notice of work-related injury appraisal conclusion and inform the person in charge of the unit, inform the person in charge of the unit if it does not meet the appraisal conditions, and issue a work-related injury certificate for the work-related injury;

Appraisal: If the work stoppage expires or the injury is basically stable after treatment, the applicant shall submit the labor ability appraisal to the labor ability appraisal committee to assess the disability level;

Work-related injury insurance benefits: If it is qualified to enjoy work-related injury insurance benefits after appraisal, the unit manager will apply to the social security center for review of benefits, and the social security center will pay the benefits to the workers with work-related injuries within the specified time according to the approved benefits.