The reason is so important
The hospital threshold fee generally refers to the threshold of medical insurance.
In the social security treatment, not all expenses are reimbursed for our hospitalization reimbursement, and there are generally “three non-reimbursements”.
Not covered outside the scope of medical insurance reimbursement All reimbursement contents must comply with the “three catalogs” of basic medical insurance, including basic medical insurance drug catalog, diagnosis, and treatment item catalog, and medical service facility standards.
If it is an item outside the three categories, it will not be reimbursed.
The part of the personal burden will not be reported
For some medicines or services, only a part of the reimbursement can be reimbursed, and the individual has to pay part of it. This part of the personal burden is not included in the scope of reimbursement. Usually, the proportion of hospitalization reimbursement is not 100%, and the general employee medical insurance is only 85% to 95%, and the pensions for retired elderly can be higher. But in most cases, individuals also need to bear a certain proportion, and the proportion other than reimbursement can only be paid by themselves.
The part in the starting payment line is not reported
Even if the medicines and services used are within the scope of reimbursement, the amount spent below the threshold will not be reimbursed, and only the part exceeding the threshold will be reimbursed according to the prescribed proportion. The standard of the threshold is different for hospitals at all levels. Generally, the first-level hospital is lower, only one or two hundred yuan, the second-level hospital is four or five hundred yuan, and the third-level hospital is nearly 1,000 yuan.
For example, the total cost of hospitalization is 20,000 yuan, the reimbursement is only 15,000 yuan, and the reimbursement ratio is 90%. If the starting payment line is 800 yuan, the actual expense that can be reimbursed is only 14,200 yuan, and the actual reimbursement is 90%, then the individual needs to pay 1,420 yuan. Overall, this hospitalization individual bears 7,220 yuan.
What is the function of setting the Payline?
First, it is necessary to enhance the patient’s awareness of costs and reduce waste. At least a few hundred yuan for each hospitalization needs to be borne by themselves, and a few hundred yuan is not unaffordable for most people. Many people spend money on hospitalization like running water. Once they spend more, they will take it easy.
Second, reduce the burden on medical insurance funds. The basic principle of the medical insurance fund is to determine the income and expenditure, balance the income and expenditure, and have a slight balance, and the money is spent almost every year. Allowing individuals to properly bear part of the burden will reduce the pressure on the medical insurance fund. The medical insurance fund is not only for inpatient reimbursement but also for outpatient and emergency and outpatient chronic diseases. Assuming that the number of hospitalizations is 60 million and the average threshold for hospitalization is 500 yuan, the burden on the medical insurance fund will be reduced by at least 30 billion yuan.
Third, prevent unethical things such as minor illnesses and major care. Some people indeed have high medical insurance reimbursement, and they will be hospitalized for a long time, occupying beds and medical resources. Our medical resources are very unbalanced, and it is difficult to meet people’s medical and health needs. If this continues, many patients will not receive timely treatment due to a lack of beds. Think about it, if the 800 yuan threshold is canceled, and after a minor illness is reimbursed for 800 yuan, only a few tens of yuan will be paid, and people will be hospitalized. Even if there is a deductible now, many people are still trying to get hospitalized to check their health.
In fact, in addition to basic medical reimbursement, there are also major illness medical insurance and medical insurance assistance. These two types of insurance also have corresponding thresholds. For example, the threshold for the serious illness of urban and rural residents medical insurance, the state requires a unified reduction to 0.5 times the per capita disposable income of local urban and rural residents.
Commercial medical insurance also has a minimum payment line, generally speaking, it is 5,000 yuan to 10,000 yuan, which is also calculated by commercial insurance companies based on payment risks. The threshold of commercial medical insurance directly affects the level of premiums. The lower the threshold, the higher the premium.
