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┃Source: Rambling Medical Insurance
After dinner, the little brother-in-law family of four leaned neatly on the sofa and chatted...
Listening to these successive questions, Brother Bao raised his eyebrows, the corners of his mouth rose, revealing a confident smile, as a "medical insurance pass", it was more than enough to answer these small questions...
Knowledge Point 1: What is Critical Illness Insurance?
Major illness insurance is actually the abbreviation of urban and rural residents' major illness insurance. It is an extension and extension of the basic medical insurance system, mainly for the high medical expenses of patients with serious illnesses, and gives further protection on the basis of the payment of basic medical reimbursement.
To put it simply, major illness insurance is an "additional insurance" for the basic medical insurance of urban and rural residents, a national policy to benefit the people, and a medical supplement to the basic medical security, the purpose of which is to avoid the broad masses of people from becoming poor due to illness and returning to poverty due to illness.
Knowledge point 2: How to reimburse major illness insurance?
To know how to reimburse for a serious illness, here are 4 elements to understand:
Protection object: urban and rural residents medical insurance participants (employee medical insurance is not within the scope of their protection)
Whether to pay separately: There is no need to pay a separate fee to participate in the insurance. The basic medical insurance fees for urban and rural residents paid by the insured already include the cost of major illness insurance, and there is no need to pay additional separate fees.
Reimbursement threshold and reimbursement ratio: Major illness insurance, like basic medical insurance, has a minimum payment standard, and medical expenses that do not exceed the threshold line are not reimbursed, and the part above the threshold is reimbursed according to the prescribed proportion.
Generally speaking, the threshold of major illness insurance is after the reimbursement limit of the basic medical insurance reaches the cap line, and then pay a certain amount of medical expenses by yourself, and the specific threshold amount and reimbursement ratio are stipulated by each coordinating region, and there will be differences in various places. In addition, major illness insurance has increased its tilt towards the poor, with a 50% reduction in the threshold, a 5% increase in reimbursement, and the abolition of the payment cap.
Reimbursement method: The reimbursement method of major illness insurance is also similar to that of basic medical insurance, and the medical expenses that meet the scope of the medical insurance directory after reaching the threshold of major illness insurance can be reimbursed according to the prescribed proportion; similarly, the part exceeding the cap line of major illness insurance is not reimbursed. However, this situation is very rare, because the amount of general critical illness insurance is sufficient for the vast majority of people.
The following is the reimbursement of uncle Li, a resident medical insurance participant in XX City, to talk about how the reimbursement for serious illnesses is settled.
At present, the threshold of major illness insurance in XX City is 12,000 yuan
The standard is divided into three levels according to the accumulated amount of personal out-of-pocket payment:
Between 12,000 and 30,000 yuan, 60% of the major illness insurance benefits
Between 30,000 yuan and 100,000 yuan, 65% of the loss
More than 100,000 yuan pay 75%
Suppose that Uncle Li spent 100,000 yuan on the first admission to the hospital this year, of which 10,000 yuan was spent on the fully self-funded project, and the part included in the medical insurance reimbursement was 100,000 yuan - 10,000 yuan = 90,000 yuan. According to the medical insurance policy of XX City, the basic medical insurance reimbursement is 90,000 yuan×50% = 45,000 yuan. Personal out-of-pocket payment is 90,000 yuan - 45,000 yuan = 45,000 yuan.
45,000 yuan exceeds the minimum payment standard of XX city major illness insurance of 12,000 yuan, according to the principle of cumulative reimbursement of major illness insurance:
60% of the reimbursement of 12,000 yuan or more than 30,000 yuan (inclusive) or less, that is, (30,000 yuan - 12,000 yuan) × 60% = 10,800 yuan.
65% of the reimbursement of more than 30,000 yuan and less than 100,000 yuan and below, that is, (45,000 yuan - 30,000 yuan) ×65% = 0.975 million yuan.
In other words, Uncle Li can eventually get 10,800 yuan + 0.975 million yuan = 20,550 yuan of serious illness reimbursement.
Finally, with the addition of the basic medical insurance of urban and rural residents, Uncle Li reimbursed a total of 20,550 yuan + 45,000 yuan = 65,550 yuan for medical treatment, and the actual personal out-of-pocket payment was 34,450 yuan.
China Medical Insurance Official WeChat ID: zgylbxzzs