Social medical insurance is a social insurance system established by the state and society according to certain laws and regulations to provide basic medical needs for workers within the scope of protection. The basic medical insurance fund consists of overall funds and individual accounts. The basic medical insurance premiums paid by individual employees are all included in individual accounts; The basic medical insurance premium paid by the employer is divided into two parts, one part is included in the personal account, and the other part is used to establish the overall fund.
The composition of social overall medical insurance: the base of payment is m: wage income of employees+allowance. The unit pays 8% m every year; Individual employees pay 2% m every year;
The unit pays 8%, and the hospitalization expenses in the overall account are 6.6% to 7% (personal account 1% to1.4%);
2% and 2% of the individual contributions will go into the individual account (plus 1% to 1.4% of the unit contributions).
Suppose: a company has a 30-year-old employee with an annual salary of 20,000. After handling social medical insurance, the company pays 1.600 yuan every year; Employees themselves hand it over to 400 yuan every year.
The personal account consists of two parts: 400 yuan paid by the individual and 160 yuan paid by the company (according to the regulations, 1% is under 35 years old; For 35 yuan, it is 1.4%), and the rest 1440 yuan all goes into the overall account.
Note: hospitalization expenses are reimbursed from the overall account, and the amount is the same for everyone; Outpatient expenses are deducted from personal accounts (that is, medical insurance cards), and everyone is different.
Features: It has the characteristics of low-level and wide coverage. The payment is based on the low-level expenses that most units and individuals can bear, covering all units and employees in cities and towns, and employees in different units can enjoy the rights of basic medical insurance. The insured can enjoy it for life after completing the payment period. Secondly, the basic medical insurance has the characteristics of both parties' burden and the combination of unified accounts; Take the principle of living within our means and balancing income and expenditure.
Advantages: Enjoy treatment according to uniform standards. The same access conditions, the same fees, the same treatment, there is no difference between high and low. The employee's outpatient expenses can be deducted from his personal account and paid by the employee after deduction. The hospitalization expenses of employees shall be reimbursed in proportion: 1 1,000 yuan, and 86% of the expenses shall be reimbursed by tertiary hospitals; 65,438+0,000 to 20,000 yuan, and 88% of the expenses are reimbursed by tertiary hospitals; 20,000 to 40,000 yuan, and 92% of the expenses are reimbursed by tertiary hospitals. If employees have not been sick for several years in a row, personal account funds can be accumulated.
Disadvantages: There is a basic deductible for each hospitalization, that is, the first-class hospital 500 yuan, the second-class hospital 750 yuan, and the third-class hospital 1, 000 yuan. These expenses need to be borne by employees themselves. Class A drugs and Class B drugs are reimbursed in proportion, and imported drugs are not reimbursed. If the amount exceeds 40 thousand, you have to pay for it yourself
2 Commercial medical insurance
Commercial insurance refers to the form of for-profit insurance operated by professional insurance enterprises through the conclusion of insurance contracts; Commercial insurance relationship is a contractual relationship concluded by the parties voluntarily. The insured pays the insurance premium to the insurance company according to the contract, and the insurance company shall be liable for the property losses caused by the possible accidents agreed in the contract, or the death, disability, illness or reaching the agreed age and time limit of the insured.
Features: Commercial medical insurance is a special commodity with social security function. Enterprises or employees voluntarily participate, and all insurance costs are borne by individuals (except those that the unit is willing to bear). At present, there are two ways to pay for commercial medical insurance in Nanjing market: one is expense insurance and the other is subsidy insurance. Expense insurance means that the insurance company pays compensation according to the proportion stipulated in the contract and the total amount of all expense documents of the insured in the medical process. If it is social basic medical insurance reimbursement, the insurance company can only make up the difference in expenditure according to the principle of insurance compensation; or vice versa, Dallas to the auditorium If the insurance company reimburses, social security can only make up the difference. Subsidized insurance, also known as fixed payment insurance, has nothing to do with the actual medical expenses, and there is no need to provide invoices when making claims. The insurance company pays the insured according to the subsidy standard agreed in the contract. No matter how much money he spent on treatment and what disease he got, the compensation standard remains the same. Generally speaking, commercial medical insurance can better meet the high-level medical needs of middle-and high-income people, but its medical insurance cost is higher. Insurance companies have certain requirements for the insured's physical condition, strict restrictions on the types of diseases and certain years of enjoyment.
Advantages: strong selectivity. Units can insure different types of commercial insurance according to the different types of jobs employees are engaged in, in accordance with the principle of "more investment and more insurance, less investment and less insurance, and no investment and no insurance".
Disadvantages: Once the insurance period has passed, even if it is one day overdue, there is no guarantee for not renewing the insurance in time (for short-term insurance).
Attached is a list of welfare insurance for group employees of some insurance companies in Nanjing.
3 The main differences between social medical insurance and commercial insurance
1. Their attributes are different: commercial insurance is realized by the insurer and the insured signing a contract jointly according to the principle of voluntariness, and the insurance operators are independent in accounting, operating independently and taking responsibility for their own profits and losses for the purpose of pursuing profits. Social insurance is a national social security system, which aims to provide people with basic living security and is a non-profit social welfare undertaking backed by national financial support.
2. The objects and functions of insurance are different: commercial insurance refers to the insurance that the insured carries out according to different stages of life, different parts of the body or possible dangers, in order to obtain certain economic compensation and reduce losses. Social overall medical insurance is mainly aimed at workers. When workers pay medical expenses due to illness, the social insurance department will give them basic compensation.
3. The reciprocal relationship of rights and obligations is different: the rights and obligations of commercial insurance are based on the contractual relationship. As long as they voluntarily sign an insurance contract with an insurance company and pay the insurance premium according to the contract, their members can get the corresponding claim for insurance payment. The amount of insurance depends on the amount of insurance premium paid, that is, the relationship between the rights and obligations of the insurance company and the insured is an equivalent exchange, which shows that more insurance benefits more, less insurance benefits less, and no insurance. The relationship between rights and obligations of social pooling insurance is based on labor relations. As long as workers fulfill their obligations to work for the society, they can enjoy social insurance benefits. Their payment of insurance premiums and acceptance of guarantees are directly stipulated by national legislation, and the amount of insurance premiums received is not proportional to the amount of insurance premiums paid. More performance is low security and wide coverage.
4. The degree of protection between the two is different: the scope of protection of commercial insurance is determined by the applicant, the insured and the insurance company through consultation. Under different insurance contracts and different types of insurance, the scope and level of protection obtained by the insured are different. The scope of social medical insurance is generally stipulated by the state in advance, and the scope of risk protection is relatively narrow and the level of protection is relatively low. This is determined by the nature of its social security.
Experts suggest reasonable insurance.
Insurance experts pointed out that social medical insurance is a safe haven in a competitive society, which can provide the most "basic" medical security for workers, but the degree of protection is very limited. Commercial insurance is also a part of social security, and the insured can enjoy different premiums according to the types of insurance. Comparing the two, each has its own advantages and disadvantages.
If there are some minor illnesses in life, such as coughing and catching a cold, the outpatient expenses of social medical insurance can be solved. Once an employee has a major illness or accident, it will undoubtedly cause a huge blow to the family economy. At this time, it is not enough to rely solely on social medical insurance. At this moment, commercial medical insurance embodies its importance. It not only solves the reimbursement of medical expenses, but also provides protection.
Insurance experts said that if an enterprise has the financial strength, it is better to buy some commercial insurance as a supplement besides social medical insurance for employees, which is undoubtedly good news for employees. If we must weigh the advantages and disadvantages of the two, we can only say that it is very important to choose the appropriate commercial medical insurance for occupations with relatively high risks, because insurance is an effective way to transfer risks.
According to relevant persons of Nanjing Insurance Company, professionals who are engaged in relatively high risks are generally insured by the company, and few individuals have insurance awareness. Because of the high probability of danger in high-risk occupations, it is suggested that individuals can insure themselves on the basis of company insurance if conditions permit, and it is certainly not a bad thing to insure more.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.