In the invoice details of medical expenses, people often find items such as "medical insurance pooling payment", "personal self payment", and "personal self payment". What do these nouns mean and what are the differences?
The total medical expenses for basic medical insurance insured persons seeking medical treatment at designated medical institutions are generally composed of items such as medical insurance pooling (fund) payment, personal self payment, and personal self payment. That is to say, the total medical expenses=medical insurance pooling (fund) payment+personal out of pocket payment+personal out of pocket payment.
Among them, medical insurance pooling payment refers to the medical expenses incurred during the medical treatment process that fall within the scope of the medical insurance catalog and are paid by the basic medical insurance pooling fund according to regulations, that is, the part directly reimbursed by medical insurance, which does not require the insured to pay out of their own pockets.
Here is also an explanation of the medical insurance catalog. The reimbursement scope of China's basic medical insurance is managed by a directory, and medical expenses within the directory are included in the medical insurance reimbursement. According to regulations, they are shared proportionally between the medical insurance fund and individual patients. Medical expenses outside the directory will not be paid by the medical insurance fund. The drug catalog, medical consumables catalog, and medical service project catalog included in the scope of medical insurance payment are commonly referred to as the "three catalogs" of medical insurance.
The overall payment of medical expenses for employee medical insurance is slightly different from the overall payment of medical expenses for urban and rural residents' medical insurance. The former includes basic payments and large payments, while the latter includes basic payments and major illness payments. To use medical insurance pooling payment, it is necessary to meet the deductible standard in the medical insurance pooling area, and this standard varies among different pooling areas. At the same time, corresponding standards should be implemented according to the type of medical insurance participated (employee medical insurance/resident medical insurance) and the different levels of hospitals. For example, the outpatient pooling deductible for employee medical insurance in Beijing is 1800 yuan for current employees and 1300 yuan for retired employees. The overall fund payment is within 20000 yuan, and the payment ratio for community medical institutions is 90%. The payment ratios for in-service and retired employees of secondary and above hospitals are 70% and 85%, respectively; For medical treatment of over 20000 yuan, regardless of which level of medical insurance designated medical institution, the payment ratio for in-service employees is 60%, and for retired employees it is 80%.
The personal out of pocket items in medical expense invoices refer to the amount of medical expenses that need to be borne by patients within the scope of the medical insurance catalog. Including below the minimum payment line, Class B advance payment, proportional payment, above the ceiling line, and exceeding the limit price within the catalog. Personal out of pocket expenses can be paid from the balance in the medical insurance personal account first, and the remaining amount can be paid in cash or other forms.
In medical expense invoices, personal self funded items often appear, which refer to drugs, items, etc. outside the scope of medical insurance that are fully paid by insured persons at their own expense.
An example can help you better understand the entries in medical expense invoices. Beijing employee Xiao Zhang was hospitalized at a designated secondary medical insurance hospital due to illness, with a total cost of 6000 yuan, including 5600 yuan of medical expenses included in the medical insurance catalog. According to regulations, the first hospitalization deductible is 1300 yuan, and the hospitalization reimbursement ratio for in-service employees in secondary hospitals is 87%. Therefore, the payment of Xiaozhang's hospitalization expense pooling fund is (5600-1300) × 87%=3741 yuan. Xiaozhang has a deductible of 1300 yuan, 13% outside the pooling fund payment ratio within the medical insurance catalog, and 400 yuan for self funded expenses, totaling 2259 yuan.