Reimbursement standard and proportion of urban medical insurance

The reimbursement standard and proportion of urban medical insurance vary according to different situations, including hospitalization, outpatient chronic diseases and accidental injuries of students.

1, hospitalized. Qifubiaozhun varies according to different levels of hospitals, namely, the first-level hospital in 50 yuan, the second-level hospital 100 yuan, and the third-level hospital in 300 yuan. More than Qifubiaozhun part of the medical expenses, a hospital to pay 20%, medical insurance fund to pay 80%; Secondary hospitals are responsible for 25%, and medical insurance funds pay 75%; Third-level hospitals are responsible for 40%, and the medical insurance fund pays 60%.

2. Outpatient chronic diseases. In a medical year, the individual's accumulated compliance medical expenses of more than 6.5438+0.4 million are included in the residents' serious illness insurance. 1.4 million to 1 10,000 is 60%, 1 10,000 to 200,000 is 65%, 200,000 to 300,000 is 70%, and over 300,000 is 75%. The maximum payment for a medical year is 400,000 yuan.

3. Students' accidental injuries. 80% of outpatient medical expenses are reimbursed by medical insurance, and hospitalization is reimbursed according to the proportion of ordinary hospitalization.

4. Resident outpatient co-ordination. First-class public designated medical institutions are not higher than 100 yuan per day, and village clinics are not higher than 70 yuan, and 75% and 85% are paid by outpatient medical care as a whole respectively.

5, different age groups and people have different reimbursement rates and qifubiaozhun. The qifubiaozhun for outpatient and emergency treatment for people aged 60 to 69 is 300 yuan, 30% for first-class hospitals and 70% for medical insurance funds; The threshold for outpatient and emergency treatment for the elderly over 70 years old is 300 yuan, 30% for the first-class hospital and 70% for the medical insurance fund.

There are several main differences between urban medical insurance and employee medical insurance:

1, the payment subject and standard are different. Urban medical insurance is mainly aimed at unemployed residents; Employee medical insurance is aimed at employees, flexible employees, individual industrial and commercial households and retirees, and the monthly payment is relatively high. Generally, the annual payment is 1000 yuan, which is jointly paid by units and individuals, among which the unit pays a large proportion.

2. Coverage and treatment are different. The proportion and upper limit of urban medical insurance reimbursement are relatively low, generally 40% to 80%, and the upper limit of reimbursement is about 10 to 200,000. The proportion and upper limit of employee medical insurance reimbursement are relatively high, generally 70% to 90%, and the upper limit of reimbursement is about 200,000 to 400,000.

3. The medical insurance account is different. There is no personal account for urban medical insurance, and all the money paid by the insured person is included in the overall account, so the resident medical insurance card does not refund the money, but the insured person enjoys the reimbursement of outpatient expenses through the overall outpatient service; Employee medical insurance is divided into individual account and overall account, and individual account will return a certain amount of money for medical deduction every month according to the situation.

4. The minimum payment period is different. There is no minimum payment period for urban medical insurance, which needs to be paid once a year; Employee medical insurance has set a minimum payment period. Usually, men need to pay for 25 years and women need to pay for 20 years. When the employee's medical insurance payment period reaches the minimum payment period, he can enjoy lifelong medical security treatment.

To sum up, the Qifubiaozhun and reimbursement ratio of basic medical insurance for urban residents are determined according to the categories of insured persons.

Legal basis:

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

Article 23

Employees should participate in the basic medical insurance for employees, and employers and employees should jointly pay the basic medical insurance premiums in accordance with state regulations. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.