Source: Warm Heart Finance said
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In recent years, with the gradual implementation of the mutual aid mechanism of medical insurance outpatient for employees in mainland China, our employees can directly enjoy reimbursement treatment for outpatient medical treatment and medicine, and individuals only need to pay part of the money themselves. However, in the specific operation, due to various situations such as the starting line, reimbursement ratio, and Class B medication, there may still be some elderly friends who can't understand it, so let's analyze it through an example today.
This friend said that he just went to the hospital yesterday to prescribe medicine, and spent 237.9 yuan, showing a reimbursement of 112.74 yuan, so it seems that the reimbursement ratio is only 47% (112.74 yuan÷ 237.9 yuan). Some people say that the reimbursement rate is 70%, right?
I took a look, and this retired old man is a retiree from Shanxi Province. Shanxi Province will fully implement the outpatient mutual aid mechanism for employees' medical insurance from January 1, 2023, and the monthly medical insurance personal account of retired employees will be transferred to 85 yuan. In this way, it can be regarded as achieving equal retirement medical insurance treatment for everyone.
The reimbursement rules of the outpatient mutual aid mechanism in Shanxi Province are as follows: in a medical year, the reimbursement limit for active employees and retired employees is 1,800 yuan and 2,000 yuan. The reimbursement ratio of insured employees in the relevant designated medical institutions is 50% for the first category, 55% for the second category and 60% for the third category according to the category of charging price (the reimbursement ratio for retired employees will be increased by an additional 5 percentage points). Everyone knows that there is a starting line for medical treatment, and the outpatient reimbursement line in Shanxi Province is borne on a per-time basis, 80 yuan/time for the first class, 50 yuan/time for the second class, and 30 yuan/time for the third class.
Based on the above situation, we can deduce that this retiree should be treated in a medical institution with a second-class fee, and the starting line is 50 yuan. It cost 237.9 yuan, and the part that can be reimbursed is only 187.9 yuan. Since the reimbursement ratio for retirees is 55%+5%, the reimbursement amount is 187.9 yuan ×60%=112.74 yuan.
To be honest, after the implementation of the outpatient mutual aid mechanism, the reimbursement scope of outpatient treatment is the same as that of hospitalization, and the full implementation of the three catalogs of medical insurance (drug catalog, diagnosis and treatment project directory and service facility catalog) can make it easier for everyone to see a doctor, and also prevent the rent-seeking of hospitalization power in popular departments.
In the above example, there is a situation where the minimum payment line is deducted, but there is no situation where the personal medication is a Class B drug or a non-basic list drug item and needs to be borne at your own expense.
Shanxi Province's model of undertaking the payment line on a per-time basis has actually greatly lowered the threshold for people to enjoy reimbursement treatment. For example, the outpatient mutual aid reimbursement threshold of the first, second and third level medical institutions in Qingdao City, Shandong Province is 0 yuan, 500 yuan and 800 yuan, but the advantage is that it is accumulated in a medical year.
Qingdao, Shandong Province, has a higher reimbursement ratio and a higher reimbursement amount for employee outpatient clinics. The reimbursement ratio of retirees is also 5 percentage points higher than that of in-service employees, and the reimbursement ratios of grassroots (including first-level), second-level and third-level medical institutions are 85%, 75% and 65% respectively. In addition, the reimbursement limit for retired employees in a medical year is 1,000 yuan higher than that of active employees, reaching 7,000 yuan.
If a retired employee spends 3,000 yuan on medical examination in Qingdao, all of them are expenses within the scope of reimbursement. If it is in a tertiary medical institution, the actual reimbursement amount is (3,000 yuan-800 yuan)× 65% is equal to 1,430 yuan, and the reimbursement ratio is only about 47%, but in fact, the individual still needs to bear 1,570 yuan.
But then again, if it is only the situation encountered by the retired old man in Shanxi Province above, which costs 237.9 yuan, the secondary and tertiary medical institutions in Qingdao will not be able to enjoy insurance treatment, and even the first-level medical institutions can only be reimbursed 202.21 yuan.
Generally speaking, the outpatient mutual aid mechanism in each place still has its own characteristics and advantages. I hope that in the future, with the improvement of the overall level of medical insurance, the national medical insurance overall planning can come as soon as possible. #文章首发挑战赛#