Core Points - The rumor of "clearing the medical insurance account by the end of the year" is a misunderstanding, as personal account funds accumulate over the years and do not disappear [1] - The annual reimbursement limit for outpatient pooling is what is referred to as "clearing," which is a shared fund rather than personal assets [1] Summary by Sections Medical Insurance Bill Components - The medical bill consists of three main components: insurance pooling payment, personal payment, and personal expense [3] - Insurance pooling payment is the most favorable part, covering eligible expenses directly paid by the insurance fund [3] - Personal payment refers to costs within the insurance directory that require the individual to pay a portion, including amounts below the threshold and above the cap [3][5] Personal Expenses - Personal expenses are completely outside the insurance safety net, covering items not included in the insurance directory, which patients must pay in full [5] - The term "personal burden" may vary in meaning, sometimes referring to costs incurred after the personal account is exhausted or encompassing all personal payments [5] Real-World Examples - A case study illustrates that if a patient incurs a total cost of 4500 yuan, with 4200 yuan covered by insurance, the personal payment would be 600 yuan, and personal expenses would be 300 yuan, totaling 900 yuan out-of-pocket [7] - Another example shows a total cost of 10000 yuan, with 8000 yuan covered by insurance, resulting in a personal payment of 4750 yuan after reimbursement [7] Family Account Mutual Assistance - The family mutual assistance mechanism allows the use of personal account funds for family members, enhancing the efficiency of fund utilization [8] Outpatient Pooling Annual Limit - The outpatient pooling policy provides coverage for ordinary outpatient expenses, with a set annual payment limit that does not carry over to the next year, leading to the "clearing" concept [10] - The insurance fund operates as a shared risk pool, emphasizing the collective nature of contributions and reimbursements among insured individuals [10]

Core Insights - The difference in contribution years between pension and health insurance is due to the distinct nature of risks they address, with health insurance requiring longer contribution periods to manage unpredictable medical expenses [1][6] Group 1: Health Insurance Contribution Years - Health insurance requires longer contribution years (20-30 years) compared to pension (15 years) because medical expenses are unpredictable and can occur at any time, necessitating a robust fund to cover sudden high costs [1][2] - The average hospitalization rate for insured individuals is 18.7%, indicating that 1 in 5 insured individuals will require hospitalization, with an average hospitalization cost of 12,000 yuan, of which approximately 70% is covered by the insurance fund [2][5] Group 2: Fund Allocation - The funds collected for health insurance are allocated primarily to mutual medical assistance, with 68% used for hospitalization reimbursements, 22% for outpatient major illness reimbursements, and 10% for general outpatient coverage [4][5] - The funds are strictly designated for medical reimbursements and cannot be diverted for other uses, ensuring that contributions are utilized effectively for healthcare needs [5] Group 3: Risk Management - Pension insurance deals with predictable longevity risk, allowing for a stable income post-retirement, while health insurance addresses uncertain disease risk, which can lead to significant and unpredictable medical expenses [6][7] - The minimum contribution years for health insurance are calculated based on life expectancy, medical expenditure trends, and the contribution cycle of insured individuals, ensuring that the fund can support long-term medical needs post-retirement [6][7]