How to reimburse Huizhou medical insurance

Social medical insurance is a social insurance system established by the state and society according to certain laws and regulations to provide basic medical needs for workers within the scope of protection. In our country, everyone can participate in insurance.

First, how to reimburse medical insurance

1, personal cash payment amount: refers to the amount that patients need to bear.

2. Payment amount of medical insurance fund: refers to the total amount of expenses paid by medical insurance fund. Including: outpatient payment, retirement supplementary insurance payment and other payment methods.

3. deductible: that is, the expenses below the deductible standard, and the medical insurance bureau has formulated the corresponding deductible standard according to different types of insured persons and hospital grades.

4. Amount in medical insurance coverage: the amount of this medical expense that falls within the scope of medical insurance reimbursement.

5. Cumulative amount within the scope of medical insurance: the total amount of medical expenses included in the scope of medical insurance reimbursement this year as of this expense settlement.

6. Annual large-sum accumulative payment for outpatient service: As of this expense settlement, this year's medical insurance is the total accumulative payment for outpatient service of the insured.

7. Personal payment and out-of-pocket expenses: refers to the amount that patients need to bear, which consists of out-of-pocket expenses 1, out-of-pocket expenses 2 and out-of-pocket expenses.

Out-of-pocket 1: refers to the amount of medical expenses that patients need to pay and can be included in the scope of medical insurance reimbursement. Including the minimum payment and the amount paid by the patient after exceeding the minimum payment.

Out-of-pocket 2: the sum of the drugs marked as "partial out-of-pocket" and the expenses that patients need to pay during the examination. Suppose a bottle of medicine with a price of 100 yuan belongs to self-funded medicine. If the out-of-pocket ratio is 10%, you have to bear 10 yuan. This is at my own expense.

At one's own expense: the total amount of drugs and examination expenses marked as "all at one's own expense" shall be paid by the patient himself.

Taking the medical insurance patients in Beijing as an example, the deductible line of outpatient expenses for retired medical insurance patients is 1.300 yuan, while that for active medical insurance patients is 1.800 yuan, which means that a patient can only be reimbursed after the accumulated expenses in medical insurance exceed the deductible line.

Suppose Xiao Zhang is an on-the-job medical insurance patient. He incurred outpatient expenses of 2,000 yuan in a tertiary hospital, of which 1 1,000 yuan was paid by himself, and the rest 1 was covered by medical insurance in 900 yuan (70% of outpatient expenses were reimbursed by non-community medical institutions).

Out of pocket1:1800+(1900-1800) * 30% =1830 yuan;

Out-of-pocket 2: 0 yuan (some out-of-pocket drugs or medical care);

Self-paid: 100 yuan (all self-paid drugs);

Final individual payment = self-payment+self-payment+self-expense = 1930 yuan, and medical insurance will be reimbursed to 70 yuan.

Second, the reimbursement examples

1, outpatient reimbursement:

Xiao Zhang, who works in Shenzhen, spent a total of 5,000 yuan a year in a designated 3A hospital in Shenzhen, including 600 yuan at his own expense. Assuming that the minimum deductible line of Shenzhen 3A hospital is 1.900 yuan, and the outpatient reimbursement rate of this 3A hospital is 70%, then the amount of outpatient reimbursement he can make is:

(Total cost of treatment-self-paid part-self-paid part) × reimbursement ratio = (5000-1900-600) x70% =1750 (yuan)

2, hospitalization reimbursement

Xiao Wang, who works in Shenzhen, spent 6.5438+0.8 million yuan on a heart transplant, including 6.5438+0.5 million yuan in the catalogue and 25,000 yuan out of the catalogue. Assuming that the local deductible is 2000 yuan, the reimbursement rate is 85%, and the average salary in Shenzhen is 7480 yuan, how much can Xiao Wang's surgery expenses be reimbursed?

Reimbursement amount = (total cost of treatment-self-paid part-self-paid part) x reimbursement ratio = (18-0.2-2.5) x 85% =13.005 (ten thousand)

However, there is a maximum reimbursement limit for social security, which is about four times the annual average wage of local society, that is to say, the reimbursement limit is = 7480× 12× 4 = 359.04 (ten thousand).

3,590,400 yuan is more than 130050 yuan, so it can be fully reimbursed 130050 yuan.