What is the difference between the two grades of medical insurance?

Taking Shenzhen as an example, the main difference between different grades of medical insurance lies in reimbursement expenses such as hospitalization and outpatient service.

Difference 1. Hospitalization is different.

The first/second insured persons of basic medical insurance are treated equally. The part above the deductible line of basic medical expenses and local supplementary medical expenses shall be paid according to the following provisions: if the insured person has received the old-age insurance benefits for employees in this city and paid the basic medical insurance premium monthly, the payment ratio shall be 95%; If you don't receive the pension insurance benefits for employees in this city on a monthly basis, the payment ratio is 90%.

When the insured person is hospitalized and uses special medical materials within the scope of the basic medical insurance diagnosis and treatment project and disposable medical materials with a unit price exceeding 1000 yuan, the installation or replacement of artificial organs shall be paid by the basic medical insurance serious illness pooling fund according to the regulations, and the maximum payment amount shall not exceed the general price announced by the municipal social insurance administrative department.

The inpatient bed fee of the insured shall be paid by the basic medical insurance serious illness pooling fund according to the actual inpatient bed fee, but it shall not exceed the following standards: the maximum payment amount is the first file of the government-guided bed fee for Class A and double rooms in the general wards of non-profit medical institutions determined by the municipal price management department.

Second, outpatient treatment is different.

(1) A class of insured persons with basic medical insurance shall enjoy the following benefits when they go to the designated medical institutions in this Municipality for medical treatment and outpatient service: the personal account shall be used to pay the basic medical expenses for outpatient service of the insured persons, the local supplementary medical expenses, and the expenses for purchasing the medicines in the medical insurance catalogue at the designated retail pharmacies with the prescriptions prescribed by the doctors in the designated medical institutions in this Municipality, and the insufficient part of the personal account shall be paid by the individual.

(II) If the first-class insured of basic medical insurance has been insured continuously for 1 year, and the social security card has been used up, and the out-of-pocket outpatient expenses incurred in designated medical institutions in Shenzhen in the same medical insurance year exceed 5% of the average salary of employees in this city in the previous year, 70% of the excess will be paid by the basic medical insurance serious illness pooling fund or the local supplementary medical insurance fund according to regulations, and 80% will be paid by the insured over 70 years old.

(III) 70% of the expenses incurred by the first-class insured of basic medical insurance in the list of medical insurance drugs in the designated community health centers of this Municipality shall be paid by the individual account, and 30% by the basic medical insurance serious illness pooling fund and local supplementary medical insurance fund in accordance with the regulations, except for dental treatment expenses, rehabilitation physiotherapy expenses, large-scale medical equipment inspection and treatment expenses and other project expenses stipulated by the municipal government.

The insured persons in the second and third grades of basic medical insurance enjoy the following treatment (including emergency treatment) in the selected community health centers in this Municipality:

(1) Class A drugs and Class B drugs in the basic medical insurance drug list are paid by the community outpatient co-ordination fund according to the proportion of 80% and 60% respectively;

(2) 90% of the items of single diagnosis and treatment or medical materials in the basic medical insurance catalogue shall be paid by the community outpatient co-ordination fund, but the maximum payment shall not exceed 120 yuan.

(3) The outpatient medical expenses incurred by the insured who need to be referred to other medical institutions with the consent of the settlement hospital due to illness, or the emergency rescue outpatient medical expenses incurred in the non-settlement hospital due to business trip, shall be reimbursed by the community outpatient co-ordination fund at 90%. The total payment of the community outpatient co-ordination fund in a medical insurance year (from July of that year to June 30th of the following year) shall not exceed 1 000 yuan.

Extended data:

The main difference between the two grades of medical insurance is that the expenses reimbursed for hospitalization and outpatient consumption are different. The reimbursement standards for medical expenses incurred by urban and rural residents who meet the scope of medical insurance reimbursement are as follows:

The reimbursement rate of the first-level and below designated medical institutions is 80%, the second-level designated medical institutions are 60%, and the third-level designated medical institutions are 40%. The reimbursement rate of the second-level insured for urban and rural residents' medical insurance is 85% for the first-level and below designated medical institutions, 65% for the second-level designated medical institutions and 45% for the third-level designated medical institutions.

In addition, insured persons who meet the access standards for special diseases and have the qualifications for special disease treatment also enjoy special disease outpatient treatment. The reimbursement rate of outpatient medical expenses for special diseases and major diseases is the same as that for hospitalization, and there is no deductible for reimbursement of outpatient medical expenses for chronic diseases with special diseases, and the proportional limit method is implemented.

The proportion of reimbursement for each time is 80% for first-class medical institutions, 60% for second-class medical institutions and 40% for third-class medical institutions. The annual reimbursement limit is 1 1,000 yuan/year and person. Suffering from two or more special diseases at the same time, for each additional one, the annual reimbursement amount will be increased by 200 yuan.