What Is Hospital Medicare Reimbursement?

Medical insurance is one of the basic social security policies in China, which provides basic protection for the health of our residents. ^[1]

Medicare reimbursement ratio

For urban residents who have been hospitalized more than twice in a settlement year, starting from the second hospitalization treatment, no standard fee will be charged. In case of transfer to hospital or more than two hospitalizations, the difference shall be made up in accordance with the prescribed threshold for transfer or re-hospitalization.

Students, children

In a settlement year, medical expenses below 180,000 yuan that meet the reimbursement scope will be paid at a level of 650 yuan for a tertiary hospital, with a reimbursement ratio of 50%, and an upper limit of 2,000 yuan; for a second-tier hospital, the payment standard is 300 yuan, and the reimbursement ratio 60%; first-level hospitals do not set a minimum payment standard, and the reimbursement ratio is 65%.

70 years and older

In a settlement year, medical expenses below 100,000 yuan that meet the reimbursement scope will be paid at a level of 650 yuan for a tertiary hospital, with a reimbursement ratio of 50% and an upper limit of 2,000 yuan; for a second-tier hospital, the payment standard is 300 yuan, and the reimbursement ratio 60%; first-level hospitals do not set a minimum payment standard, and the reimbursement ratio is 65%.
Other urban residents

In a settlement year, medical expenses below 100,000 yuan that meet the reimbursement scope will be paid at a level of 659 yuan for a tertiary hospital, with a 50% reimbursement cap of 2,000 yuan; a hospitalized minimum payment of 300 yuan for a secondary hospital, reimbursement The proportion is 55%; the first-level hospital does not set a minimum payment standard, and the reimbursement ratio is 60%. ^[3]

On January 12, 2016, the State Council issued the "Opinions on the Integration of the Basic Medical Insurance System for Urban and Rural Residents", which requires the integration of urban residents 'basic medical insurance (hereinafter referred to as urban residents' medical insurance) and new rural cooperative medical care (hereinafter referred to as NCMS). System to establish a unified basic medical insurance system for urban and rural residents (hereinafter referred to as the medical insurance for urban and rural residents). ^[4]

Generally speaking, the economic development of different regions is different, so the reimbursement ratio is also different. The following explains the situation of the employee medical insurance coverage in Beijing.
After getting medical insurance, if you are an in-service employee, you can be reimbursed for medical expenses of more than 1,800 yuan after going to the hospital's outpatient and emergency department, and the reimbursement rate is 50%. If it is a retiree under the age of 70, expenses over 1300 yuan can be reimbursed, and the reimbursement rate is 70%. If it is a retiree who is over 70 years old, the proportion of expenses that can be reimbursed for more than 1,300 yuan is 80%.
Regardless of the type of person, the maximum amount of outpatient and emergency medical expenses is 20,000 yuan. For example, if you are a working employee and the cost of seeing a doctor in an outpatient clinic is 2,500 yuan, then the part of 700 yuan can be reimbursed for 50%, which is 350 yuan. ^[7]

If it is the cost of hospitalization, when using the basic medical insurance for the first time in a year, the starting amount is 1300 yuan for both working and retirees. The medical expenses for the second and subsequent hospitalizations are set at 50%, which is 650 yuan. The maximum payment for the basic medical insurance pooling fund (hospital expenses) in one year is 70,000 yuan.
The standard of hospital reimbursement is related to the level of the hospital where the insured person lives. For example, if they are living in a tertiary hospital, from the standard payment to 30,000 yuan, the employee pays 15%, which is 85% reimbursement; 30,000 to 4 For the expenses of 10,000 yuan, employees pay 10% and reimburse 90%; if the expenses exceed 40,000 yuan to the maximum payment limit, 95% can be reimbursed, and employees only need to pay 5%. The retiree's personal payment is 60% of the working (that is, the above-mentioned) employees, but those below the minimum payment standard are paid by the individual.
The medical treatment items that are not paid by the employee's basic medical insurance are mainly non-clinical necessary, uncertain effect treatment items and special treatment medical treatment items, including service items such as registered fees, non-disease treatment items such as beauty, etc. Therapeutic equipment and medical materials such as hearing aids, treatment items such as magnetic therapy, and other categories such as infertility treatment. According to the "Scope of National Basic Medical Insurance Diagnosis and Treatment Project", the details are as follows:
(1) Service item category. (1) Registration fees, out-of-hospital consultation fees, medical record costs, etc .; (2) Out-patient fees, expedited fees for examinations and treatments, surcharges for named operations, premium premiums, special nurses and other special medical services.
(2) Non-disease treatment items. (1) Various cosmetic and bodybuilding items, as well as non-functional cosmetic and orthopedic surgery; (2) Various weight loss, weight gain, and heightening items; (3) Various health checks; (4) Various preventive and health-care products (5) various medical consultations and medical appraisals.
(3) Diagnosis and treatment equipment and medical materials. (1) Examination and treatment items using large-scale medical equipment such as positron emission tomography (PET), electron beam cT, and ophthalmic excimer laser treatment instruments; (2) rehabilitation of glasses, dentures, prosthetics, prosthetics, hearing aids Sexual appliances; (3) various self-use health care, massage, inspection and treatment equipment; (4) one-off medical treatment that can not be charged separately by the provincial price department.
(4) Treatment items. (1) Organ or tissue source for various organ or tissue transplants; (2) Organ or tissue transplants other than kidney, heart valve, corneal skin, blood vessel, bone, and bone marrow transplants; (3) orthopedic myopia; (4) Supplementary treatment items such as qigong therapy, music therapy, health nutrition therapy, and magnetic therapy.
(E) other. (1) Various diagnosis and treatment items for infertility (pregnancy) and sexual dysfunction; (2) Various scientific research and clinically validated diagnosis and treatment items. ^[8]