Reimbursement amount of employee social security serious illness insurance

Reimbursement scope of serious illness medical insurance: when the medical expenses exceed the maximum payment limit of the basic medical co-ordination fund, the social security department will reimburse 85% for those below RMB 0-40,000, 90% for those below RMB 40-80,000 and 95% for those above RMB 80,000. The maximum payment limit for each medical year is 6.5438 yuan +0.5 million yuan.

According to the relevant regulations, local enterprises (hereinafter referred to as enterprises) and their employees and retirees who are applicable to cities, districts and counties within the administrative area of this Municipality can enjoy medical insurance for serious illness. Retirees who do not pay the basic medical insurance premium and continue to enjoy the basic medical insurance benefits are not in the "serious illness medical insurance coverage".

Serious illness medical care can be divided into two types from the form of insurance. One is serious illness social insurance, which is a special medical insurance fund set up to ensure the medical needs of urban workers for major diseases. It is used to pay the medical expenses that the insured person has accumulated over the maximum payment limit of the basic medical insurance for urban workers during the year. The other is the serious illness medical treatment in commercial insurance, which is the major illness protection that the insurance company underwrites for a specific insurer according to the insurance clauses.

At present, people are plagued by hypertension, hyperlipidemia, hyperglycemia and fatty liver everywhere, and the age of illness is getting younger and younger. It is reported that the youngest hypertensive patient is only 6 years old! Moreover, some diseases that were originally major diseases began to become common. Many insurance institutions' medical insurance for serious illness has also been adjusted accordingly.

The actual medical expenses incurred in the reimbursement of social security serious illness within the scope of medical insurance need to be invoiced, which can be divided into ordinary outpatient and emergency expenses reimbursement and hospitalization expenses reimbursement, as well as large medical co-ordination, with a certain limit; The serious illness expenses within the medical insurance coverage of commercial insurance are paid in advance, that is, as long as the serious illness on the policy is diagnosed in the hospital, it will be paid in full according to the contract immediately.

The medical insurance for major diseases does not cover the following areas:

1. See a doctor in a non-designated hospital without approval (except for emergency rescue);

2. Suffering from occupational diseases, work-related injuries or recurrence of old injuries;

3. Injuries caused by traffic accidents;

4. Injuries caused by my illegal acts;

5. Food poisoning caused by accidents;

6. receiving treatment for suicide;

7. Injuries caused by medical accidents;

8. According to the regulations of the state and this Municipality, medical expenses should be taken care of.

Legal basis:

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

Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.

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

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.

Thirty-first social insurance agencies may, according to the needs of management services, 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.