Proportion of hospitalization reimbursement in the first file of Shenzhen medical insurance

1. If the insured person has received employee pension insurance benefits on a monthly basis in this city and paid the basic medical insurance premium at 1.5%, the payment ratio is 95%;

2. The basic medical insurance class I insured person pays the basic medical insurance premium at 8%, and the basic medical insurance class II insured person fails to receive the pension insurance benefits for employees in this Municipality on a monthly basis, and the payment ratio is 90%.

The basic medical expenses and local supplementary medical expenses incurred by the insured in hospitalization above the deductible line shall be paid according to the following provisions:

(1) If the insured person has received employee pension insurance benefits on a monthly basis in this city and paid the basic medical insurance premium at 1 1.5%, the payment ratio is 95%;

(two) the basic medical insurance class I insured person pays the basic medical insurance premium by 8%, and the basic medical insurance class II insured person does not receive the pension insurance benefits for employees in this city on a monthly basis, and the payment ratio is 90%;

According to the latest social insurance payment ratio and payment base table of employees in Shenzhen, non-enterprise units: employees who participate in the first file of basic medical insurance pay 8.2% of their total monthly salary, of which 6.2% is paid by employers (6% for basic medical insurance and 0.2% for local supplementary medical insurance) and 2% by individuals. The part paid by individual employees shall be withheld and remitted by the employer. Payment standard: the maximum is 3 times of the monthly social wage, and the minimum is 60% of the social wage. Employees of enterprises and units: those who participate in the first file of basic medical insurance shall pay 7.2% of their total monthly salary, of which 5.2% shall be paid by employers (5% for basic medical insurance and 0.2% for local supplementary medical insurance) and 2% by individuals. The part paid by individual employees shall be withheld and remitted by the employer. Payment standard: the maximum is 3 times of the monthly social wage, and the minimum is 60% of the social wage. Individual payers with household registration in this city: the contribution rate of Class I medical insurance is 8.7%, and the base is 40%-300% of the average monthly salary; the contribution rate of Class II medical insurance is 1% (including maternity medical insurance), and the base is the average monthly salary. Outpatient treatment: 1. The first-class insured persons with basic medical insurance enjoy the following benefits when visiting the designated medical institutions in this city: the personal account is used to pay the basic medical expenses of the insured person's outpatient service, the local supplementary medical expenses, and the expenses of purchasing drugs in the medical insurance catalogue at the designated retail pharmacies with the prescriptions prescribed by the doctors in the designated medical institutions in this city. The insufficient part of the personal account is paid by the individual. 2. If the first-class insured of basic medical insurance has been insured for one year continuously and the money in the social security card is used up, the out-of-pocket outpatient expenses (excluding out-of-pocket expenses according to regulations) incurred by individuals in designated medical institutions in Shenzhen in the same medical insurance year (July of that year 1 day to June 30th of the following year), which exceeds 5% of the average wage of employees in this city in the previous year, and the excess part shall be covered by the basic medical insurance serious illness pooling fund or local supplementary medical insurance fund according to regulations. The insured person can enjoy this medical insurance treatment by swiping the social security card at the designated medical institution in Shenzhen.

Other benefits:

(a) in the city to receive monthly pension insurance or pension workers, continue to enjoy the basic medical insurance benefits of the insured, in the next month to receive pension insurance or pension, by the local supplementary medical insurance fund to pay a one-time medical subsidy 500 yuan, and according to the following standards to pay monthly medical subsidies, included in the personal account:

1, under 70 years old, 20 yuan every month;

2, more than 70 years old, 40 yuan every month.

(two) the basic medical insurance fund and the local supplementary medical insurance fund set the payment limit. The part of the basic medical expenses paid by the basic medical insurance fund in accordance with the provisions of these Measures that exceeds its payment limit shall be paid by the local supplementary medical insurance fund within its payment limit.

The basic medical expenses and local supplementary medical expenses incurred by the insured in the designated medical institutions in this Municipality exceed the payment limit of the local supplementary medical insurance fund, and the local supplementary medical insurance fund pays 50%.

Legal basis:

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

Article 2 The state establishes social insurance systems such as basic old-age insurance, basic medical insurance, industrial injury insurance, unemployment insurance and maternity insurance, so as to guarantee citizens' right to receive material assistance from the state and society in accordance with the law in case of old age, illness, industrial injury, unemployment and maternity.

Article 6 The State exercises strict supervision over social insurance funds. The State Council and the people's governments of provinces, autonomous regions and municipalities directly under the Central Government shall establish and improve the supervision and management system of social insurance funds to ensure the safe and effective operation of social insurance funds. People's governments at or above the county level shall take measures to encourage and support all sectors of society to participate in the supervision of social insurance funds.

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.

Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope:

(a) shall be paid by the industrial injury insurance fund;

(2) It shall be borne by a third party;

(three) shall be borne by public health;

(4) Go abroad for medical treatment.

Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party.