Upper limit of medical insurance reimbursement

Medical insurance refers to social medical insurance. Social medical insurance is a social insurance system established by the state and society according to certain laws and regulations to provide basic medical needs for workers within the scope of protection. 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 included in the personal account, and the other part is used to establish the overall fund.

Maximum reimbursement amount of medical insurance:

1. Annual reimbursement limit of outpatient medical insurance for urban workers: 20,000 yuan. Deductible: On-the-job personnel 1.800 yuan, with the reimbursement rate starting from 70%. Retirees 1300 yuan, the reimbursement rate is 85%. Upper limit of annual reimbursement for hospitalization: 300,000 yuan. Deductible line: No matter whether employees or retirees are hospitalized for the first time1.From 300 yuan, the reimbursement rate is 85%. Second hospitalization, since 650 yuan, reimbursement rate: 85%. Major diseases: The part of self-paid medical expenses that exceeds the per capita disposable income of urban residents in this city last year shall be calculated by stages and paid cumulatively. Under 50,000 yuan, the reimbursement rate starts from 50%, and over 50,000 yuan, the reimbursement rate starts from 60%, with no upper limit.

2. Upper limit of annual reimbursement for outpatient medical insurance for urban and rural residents: 3,000 yuan. The deductible line: level-1 hospital 100 yuan, and the reimbursement rate is 55%. Reimbursement rate from 550 yuan, 50% for hospitals of level 2 and above. Hospitalization: 200,000. Deductible: 75% for children 150 yuan and adult 300 yuan.

Legal basis:

Article 28 of the Social Insurance Law conforms to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue medical expenses, and shall be paid by the basic medical insurance fund in accordance with state regulations. According to the basic requirements of the payment of basic medical insurance benefits in China, the insured person who goes to the medical insurance institution to reimburse the medical expenses incurred by himself for medical treatment generally meets the following conditions:

(1) The insured must go to the designated medical institution of basic medical insurance or to the designated retail pharmacy determined by the social insurance institution with the medical prescription issued by the doctor in the designated hospital.

(2) The medical expenses incurred by the insured in the process of medical treatment must conform to the basic medical insurance drug list, diagnosis and treatment items, the standard scope of medical service facilities and payment standards, and be paid by the basic medical insurance fund according to regulations. (III) Among the medical expenses that the insured meets the scope of payment of basic medical insurance, the part that is higher than the Qifubiaozhun of the social medical co-ordination fund and lower than the maximum payment limit shall be paid by the social medical co-ordination fund in a unified proportion.