How to calculate the reimbursement ratio of medical insurance in Beijing

In Beijing, the reimbursement rate of in-service employees is over 85%, and that of retirees is over 90%. The reimbursement rate for in-service employees' outpatient service is over 70%, and that for retirees is over 85%; The reimbursement rate of urban and rural residents' basic medical insurance participants in tertiary hospitals is 78%.

The proportion of medical insurance reimbursement in Beijing is for on-the-job employees. Medical expenses above 1800 yuan can only be reimbursed if you go to the outpatient and emergency department of the hospital, and the reimbursement rate is 50%. For retirees under 70 years old, expenses above 1300 yuan can be reimbursed, and the reimbursement rate is 70%. For retirees over 70 years old,180% of the expenses above 300 yuan can be reimbursed. In case of hospitalization expenses, employees and retirees should pay the minimum amount 1300 yuan when using the basic medical insurance for the first time in a year. And the second and subsequent hospitalization medical expenses, Qifubiaozhun is determined by 50%, which is 650 yuan. 1 year The maximum payment limit of the basic medical insurance pooling fund (hospitalization expenses) is 70,000 yuan.

First, the proportion of medical insurance reimbursement in Beijing

1, the principle of supplementary medical insurance reimbursement is that the part that is not reimbursed by social security is reimbursed from supplementary medical care. For example, the part within outpatient service 1800 and the part outside social security reimbursement 1800, the part within hospitalization 1300 and the part outside social security reimbursement 1300.

2. The reimbursement amount of supplementary medical care depends on the company's own choice. For example, in addition to social security reimbursement, outpatient units can choose to reimburse 60%, 80% or even 90%, and hospitalization is the same. They can choose to reimburse 90%, 95%, etc. after reimbursement, and choose the proportion when insuring.

Beijing supplementary medical insurance benefits:

1, outpatient and emergency medical expenses

The following medical expenses that meet the reimbursement scope of basic medical insurance shall be paid by the supplementary medical insurance of the unit:

(1) Among the medical expenses accumulated in outpatient and emergency departments exceeding 1300 yuan, the personal burden of retirees is higher than 5%, and that of employees is higher than 10%, which shall be paid by the unit's supplementary medical insurance.

(2) Outpatient and emergency medical expenses shall be paid by the medical insurance fund to 2 yuan, and the rest shall be paid by the insured in cash, and no supplementary medical insurance shall be paid by the unit. The insured in the field of outpatient and emergency medical expenses is lower than that of 2 yuan, paid in full by the medical insurance fund.

2, hospitalization medical expenses

For the medical expenses below hospitalization Qifubiaozhun, the personal burden of retirees is higher than 5%, and the personal burden of employees is higher than 10%, which shall be paid by the unit's supplementary medical insurance.

For medical expenses above Qifubiaozhun, the part of retirees whose personal burden is higher than 3% shall be paid by the unit's supplementary medical insurance. The basic medical insurance reimbursement part of the personal burden is less than 3%, according to the basic medical insurance policy.

For medical expenses above Qifubiaozhun, 6% of the employees' personal burden will be paid by the unit's supplementary medical insurance. The basic medical insurance reimbursement part of the personal burden is less than 6%, according to the basic medical insurance policy.

Emergency observation fees and medical expenses for special disease clinics (radiotherapy and chemotherapy for malignant tumor, renal dialysis, aplastic anemia, hemophilia, renal transplantation, liver transplantation and anti-rejection treatment after combined liver and kidney transplantation) shall be implemented according to hospitalization standards.

Second, the concept of medical insurance

Medical insurance refers to the basic medical insurance premium paid in full and on time by employers and employees according to the principle of compulsory social insurance through national legislation. If it is not paid in full and on time, the basic medical insurance fund for its medical expenses will not be paid, regardless of personal accounts. Take the proportion of medical insurance payment in Beijing as an example: the employer pays 65,438+00% of its total payment base every month, and the individual employee pays 2%+ 120 yuan as a serious illness co-ordination.

Medical insurance is insurance to compensate medical expenses caused by diseases. Social insurance in which employees are provided with necessary medical services or material assistance by society or enterprises due to illness, injury or childbirth. For example, free medical care and labor insurance medical care in China. The medical expenses of employees in China are shared by the state, units and individuals to reduce the burden on enterprises and avoid waste. Insurance liability accidents need to be handled, and the insurance money will be paid in proportion.

Legal basis:

Article 26 of People's Republic of China (PRC) Social Insurance Law

The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Article 28 of People's Republic of China (PRC) Social Insurance Law

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Article 31 of People's Republic of China (PRC) Social Insurance Law

According to the needs of management services, social insurance agencies can sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior.

Medical institutions shall provide reasonable and necessary medical services for the insured.