Why is the reimbursement rate of NCMS so low? Reasons for this.
Preface. In China, resident medical insurance is a widely used medical insurance system, which provides important health protection for urban and rural residents. However, some people have begun to question why the reimbursement rate of resident medical insurance is so low. The reason for this is closely related to many factors such as consumption level, personal direct payment, and medical threshold. This article starts from the reasons for the low reimbursement rate of residents' medical insurance, and analyzes the main factors one by one to help readers better understand this problem.
The level of domestic medical insurance contributions is low.
The payment standard of resident medical insurance is relatively low, only a few hundred yuan a year, which is obviously much lower than the payment standard of employee medical insurance, so the reimbursement level is low. In some areas, the payment is as low as 380 yuan, which affects the reimbursement ratio to a certain extent.
For example, if a medical expense is $10,000, $5,000 should be reimbursed at a 50% rate. However, this is not the case, as the limits imposed by the hospital force you to bear some of the costs, and there are also expenses that cannot be reimbursed during the reimbursement process, such as the cost of drugs that are not covered by the medical insurance list. Low assessments are also a direct consequence of low reimbursements.
Enriching your life: The home health insurance threshold is one of the most important factors affecting reimbursement ratios. The starting line varies from hospital to hospital, but is generally between $1,000 and $2,000. This means that expenses beyond the threshold must be paid out of pocket and cannot be included in the reimbursement scope, thus reducing the actual reimbursement rate.
In addition, some hospitals also provide drugs that are not covered by medical insurance, which are very important for ** diseases, but because they are not covered by medical insurance, patients can only buy them at their own expense. These expenses are also not included in the reimbursement process, further reducing the overall reimbursement ratio.
From this perspective, although the reimbursement rate of domestic medical insurance is 50%, the actual reimbursement ratio is often lower than this ratio, and the actual reimbursement amount may only be a small part of the total cost. For patients, this means that they have to bear more medical expenses, and lower reimbursement rates have become a common phenomenon.
It is difficult to reimburse expenses that are not covered by health insurance.
During the course of medical treatment, many patients may need to use drugs that are not covered by Medicare, which are beneficial for the disease** but are not eligible for reimbursement. The cost of these drugs must be borne by the patient, reducing the overall reimbursement rate.
In addition, not all expenses are covered by the health insurance plan, and some special medical expenses may not be reimbursed. This means that even if the threshold is reached, there are still some expenses that cannot be reimbursed, which will eventually further reduce the effective reimbursement rate.
For example, if a patient needs to spend an extra one or two thousand yuan to buy drugs outside the medical insurance catalogue in the first process, this part of the cost will not be reimbursed by the medical insurance, and the effective reimbursement ratio will be reduced again. Based on the above factors, it can be seen that the existence of out-of-catalogue expenses is also one of the important reasons for the decline in the reimbursement ratio of residents' medical insurance.
Set medical thresholds.
In addition to determining the reimbursement ratio of medical insurance, determining the medical threshold is also one of the important factors that lead to the reduction of the reimbursement ratio. When a patient's medical expenses exceed the threshold, the excess must be paid out of pocket and the patient will not be eligible for reimbursement.
It is important to note that different hospitals set different thresholds, some hospitals may be lower, others may be higher. If the threshold is exceeded, it means that this part of the cost cannot be reimbursed by medical insurance, which will ultimately directly affect the actual reimbursement ratio.
Abstract:The reimbursement ratio of residents' medical insurance is relatively low, which is mainly affected by the level of medical insurance payment, the cost of medical insurance outside the catalog, and the medical payment line. Although Medicare stipulates a 50% reimbursement rate, the actual reimbursement rate for patients is often much lower than this figure, which is why many people think that the reimbursement rate is low. In contrast, although the reimbursement ratio of employee medical insurance is high, the corresponding payment level is also significantly higher, which in turn affects the actual reimbursement cost. In the future medical reform, it may be possible to appropriately adjust the reimbursement ratio and the setting of the minimum payment line to improve the level of medical security for residents.
Conclusion: The low reimbursement ratio of residents' medical insurance is caused by many factors, such as the low level of payment, the inability to reimburse the expenses outside the medical insurance catalog, and the setting of the medical payment threshold. In the future, these factors can be reasonably adjusted to improve the level of domestic medical insurance.