Proportion and regulation of social security reimbursement

The reimbursement rate of social insurance for medical treatment is: the threshold for tertiary hospitals is 500 yuan, and the reimbursement rate is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; The reimbursement rate of first-class hospitals is 65%.

(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; The part exceeding the maximum payment limit of 6,543,800 yuan can be compensated by 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 increase 5% on the basis of the above reimbursement ratio.

(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 cyclosporine A expenses for patients with chronic renal failure (renal failure) after organ transplantation shall be reimbursed on the above basis, and then increased by 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.

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; Does not meet the basic medical insurance fund deductible medical expenses; 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.

To sum up, it is Bian Xiao's relevant answer about the proportion and regulations of social security reimbursement, hoping to help you.

legal ground

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

Article 64 Social insurance funds include basic old-age insurance funds, basic medical insurance funds, industrial injury insurance funds, unemployment insurance funds and maternity insurance funds. In addition to the basic medical insurance fund and maternity insurance fund combined accounting, other social insurance funds are accounted for separately according to social insurance types. Social insurance funds implement a unified accounting system throughout the country.

The social insurance fund is earmarked for special purposes, and no organization or individual may occupy or misappropriate it. The basic old-age insurance fund will gradually implement national overall planning, and other social insurance funds will gradually implement provincial overall planning. The specific time and steps shall be stipulated by the State Council.