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during the payment of medical expenses

we often hear

"medical insurance overall payment" "individual self-payment"

and "at one's own expense"

what's the difference between them?

let me clarify it for you today

what does the total medical cost include?

total medical expenses = medical insurance overall (fund) payment + personal self-pay + personal self-pay

what is medical insurance pooled payment?

medical expenses 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 that is directly reimbursed by medical insurance and does not need to be paid out of pocket.

the scope of the medical insurance catalog is often referred to as the "three major catalogs" of medical services, drugs, and consumables.

coordinated payment of medical expenses for employee medical insuranceincludes basic payments and large payments.

coordinated payment of medical expenses for urban and rural residents’ medical insuranceincludes basic payment and critical illness payment.

to use medical insurance pooling payment, you need to meet the medical insurance pooling regional deductible standard. the specific standards vary depending on the type of medical insurance you participate in (employee medical insurance/resident medical insurance) and the level of the hospital.

what is personal out-of-pocket payment?

refers to the amount of medical expenses that need to be borne by the patient within the scope of the medical insurance catalog.

including below the threshold payment line, category b advance self-payment, pro-rata self-payment, above the cap line, and the over-priced part within the scope of the catalog, etc.

this part of the fee can be paid first from the balance in the personal medical insurance account, and the remaining part can be paid in cash.

what are personal expenses?

it refers to drugs and items that are not covered by medical insurance and must be paid in full by the insured.

give an example

xiao zhang's hospitalization in the hospital cost him a total of 4,500 yuan, including 4,200 yuan for medical expenses included in the medical insurance catalog, 3,600 yuan for medical insurance reimbursement, and 300 yuan for medical expenses outside the medical insurance catalog.

personal out-of-pocket expenses are 300 yuan for medical expenses outside the medical insurance catalog.

personal out-of-pocket expenses are the expenses that need to be paid by yourself after being reimbursed by medical insurance in the medical insurance catalog, that is, 4,200 yuan-3,600 yuan = 600 yuan.

in simple terms

medical insurance co-payment and self-payment

the objects are all projects covered by medical insurance.

"personal payment" means that in this settlement

within the scope of basic medical insurance

the portion borne by the individual

"personal expenses" means

not covered by basic medical insurance

fees paid in full by the individual