Can personal conceit be reimbursed?

Related expenses involving self-expense can be reimbursed.

The difference between self-funded and conceited:

Out-of-pocket: refers to medical expenses that are not included in the scope of basic medical payment; Using drugs outside the basic medical insurance drug list; The use of basic medical insurance treatment projects, medical expenses of some treatment projects will not be paid; Medical expenses that exceed the payment standard of medical service facilities of basic medical insurance and the expenses incurred by medical service facilities that are stipulated not to be paid.

Conceit: refers to the medical expenses used by employees to pay the medical expenses below the deductible line of the basic medical insurance pooling fund and insufficient outpatient accounts (excluding enterprise employees at present); When the basic medical insurance co-ordination fund and medical treatment for major diseases (i.e. medical assistance) are subsidized, individuals will pay part of the medical expenses in proportion.

Individual pays: refers to the expenses that are within the scope of the policy but need to be borne by the individual, and usually consists of four parts.

(1) The part below the medical insurance deductible line and above the capping line;

(2) Class B out-of-pocket expenses refer to the out-of-pocket expenses of Class B drugs and medical treatment items. Although they are included in the scope of medical insurance policies, the insured must pay a certain proportion first, such as Class B drugs 10% and Class B medical treatment items 20%.

(3) The over-limit amount refers to the over-limit amount, which is the standard unit price paid by medical insurance for nails, Class B drugs, diagnosis and treatment items and consumables, although they are included in the scope of medical insurance policy.

(4) The rest shall be included in the reimbursement amount of medical insurance according to the corresponding proportion.

Personal expenses: refers to expenses that are not covered by the medical insurance policy, including self-funded drugs, self-funded medical items and self-funded services.

Personal conceit: it is the cost that you need to bear after medical insurance reimbursement in the total medical expenses, that is, individual pays+individual pays.

Basic medical insurance reimbursement scope:

1. The actual reimbursement rate of hospitalization medical expenses in designated hospitals due to diseases and some accidents is 20 ~ 60%;

2. The medical insurance card can buy medicine and pay for outpatient and emergency expenses, but it does not belong to reimbursement;

3, in the city's medical insurance designated medical institutions, in line with the provisions of the city's medical insurance personal responsibility, into the scope of payment of residents' serious illness insurance, 50% by the serious illness insurance fund reimbursement.

Several situations of reimbursement for hospitalization at one's own expense:

1. Individuals who enjoy basic medical reimbursement need not pay the settlement fee for each hospitalization. For example, 50,000 yuan, the individual is responsible for 1 10,000 yuan, then the individual only pays 1 10,000 yuan, and the remaining 40,000 yuan is settled by the hospital and social security center. However, there are still many personal benefits, and the large mutual assistance of medical insurance can also be reimbursed. In other words, if the personal conceit exceeds 1300 every time (after the second time, the pay line becomes 650), you can also take the bill to the company, and the company will declare it again. The part that exceeds 1300/650 this time will be reimbursed according to the proportion of segments.

2. There is a deductible line for hospitalization reimbursement (the deductible line standard is generally 10% of the average annual salary of employees in the city last year), which means that you need to pay the deductible line yourself, and the part that exceeds the deductible line can be reimbursed according to local medical insurance regulations. The reimbursement rate varies from place to place, and different projects in different hospitals are different, about 80%. You can go to the local labor and social security online for details. The principles of establishing the basic medical insurance system for urban workers in China are as follows: the level of basic medical insurance should be adapted to the development level of productive forces in the primary stage of socialism; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The basic medical insurance premium is shared by both the employer and the employee; The basic medical insurance fund combines social pooling with individual accounts.

It is necessary to establish the basic medical insurance pooling fund and individual account. The basic medical insurance fund consists of overall funds and individual accounts. The basic medical insurance premiums paid by individual employees are all included in individual accounts. The basic medical insurance premium paid by the employer is divided into two parts, one part is used to establish the overall fund, and the other part is included in the personal account.

The proportion of individual accounts is generally about 30% of the employer's contribution, and the specific proportion is determined by the overall planning area according to the payment scope of individual accounts and the age of employees. The overall fund and individual account shall delimit their respective payment ranges, and shall be accounted for separately, and shall not occupy each other. Determine the qifubiaozhun and the maximum payment limit of the overall fund. In principle, the qifubiaozhun is controlled at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled at about 4 times of the average annual salary of local employees.

Medical expenses below Qifubiaozhun shall be paid by personal account or borne by individuals. Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid from the overall fund, and individuals also have to bear a certain proportion. Medical expenses exceeding the maximum payment limit can be solved by means of commercial medical insurance. The specific qifubiaozhun, maximum payment limit and personal burden ratio of medical expenses above the qifubiaozhun and below the maximum payment limit of the overall planning fund shall be determined by the overall planning area according to the principle of balance of payments.

Legal basis:

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

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.

Article 29

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, 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.