What is the outpatient reimbursement ceiling

1. The annual reimbursement ceiling for outpatient medical insurance for urban workers: 20,000 yuan. Starting line: 1,800 RMB for active employees, reimbursement rate: 70% onwards. Retirees 1,300 yuan, reimbursement rate: 85% onwards. Annual reimbursement limit for inpatient hospitalization: 300,000 RMB. Starting line: regardless of active employees or retirees, first hospitalization from $1,300, reimbursement rate: from 85%. For the second hospitalization, the reimbursement rate starts from RMB 650, 85% reimbursement rate. Major Diseases: The portion of out-of-pocket medical expenses exceeding the per capita disposable income of urban residents of the city in the previous year will be calculated in segments and paid cumulatively. under 50,000 RMB, the reimbursement rate starts from 50%, and above 50,000 RMB, the reimbursement rate starts from 60%, with no ceiling.

2. The annual reimbursement limit for outpatient medical insurance for urban and rural residents: 3,000 yuan. Starting line: Level 1 hospitals from 100 RMB, reimbursement rate 55%. Second-class and above hospitals from 550 yuan, reimbursement rate: from 50%. Hospitalization: 200,000 RMB. Starting line: children from RMB 150, adults from RMB 300, reimbursement rate from 75%. Note: The above fees do not include expenses that are not counted as part of the medical insurance, such as out-of-pocket and self-paid expenses. Also, the registration fee (medical service fee) is not included in the starting and capping line.

Legal basis:

Social Insurance Law

Article 26 The standards of treatment for basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.

Article 28 Medical expenses that conform to the basic medical insurance drug catalog, diagnostic and treatment items, standards of medical service facilities, as well as those for emergencies and salvages, shall be paid out of the basic medical insurance fund in accordance with state regulations.

Article 29 The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.

The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.