There are unified regulations on reimbursement ratio, deductible line and related procedures. The scheme is as follows:
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Thoughts on unifying the compensation scheme of the new rural cooperative medical system in the whole province
Guiding opinions
In order to establish a relatively unified compensation model of the new rural cooperative medical system in our province (hereinafter referred to as the new rural cooperative medical system) and standardize the operation and management of the new rural cooperative medical system, this guidance is formulated.
I. Basic principles
The formulation of compensation model for counties (districts) of the new rural cooperative medical system adheres to the principle of fixed income, moderate security and slight savings; Give priority to hospitalization compensation and give consideration to interests; Keep relatively stable and constantly improve; It fully embodies the basic principles of overall planning for serious illness and mutual assistance.
Two, the use of strict hospitalization funds.
The hospitalization fund can only be used for farmers' hospitalization expenses, outpatient serious illness (chronic disease) medical expenses and compensation for pregnant women's hospitalization and delivery, and shall not be used for farmers' health examination, planned immunization, preventive health care, health education and other public health services and medical assistance.
Third, raise funds.
The annual subsidy funds of central finance, provincial finance, municipal finance and county (district) finance for each participating farmer are 20 yuan, 14 yuan (national designated poverty-stricken county 17 yuan), 3 yuan (national designated poverty-stricken county 0 yuan) and 3 yuan respectively, and the participating funds paid by farmers are not less than 10 yuan.
Four. allocation of funds
The new rural cooperative medical fund is divided into three parts, namely, risk fund, inpatient pooling fund and outpatient family account fund (hereinafter referred to as family account).
(1) risk fund. Risk fund is a special reserve fund extracted from the new rural cooperative fund and transferred from the balance of the new rural cooperative fund to make up for the abnormal overrun of the new rural cooperative fund. The risk fund is drawn by the county (district) according to the proportion of 3% from the total amount of the new rural cooperative medical fund raised every year, and the county (district) with more fund balance can also be included in the risk fund according to 50% of the balance fund. The scale of venture capital fund should be kept at 10% of the total annual financing. After reaching the specified scale, it will not be extracted. The management of risk funds shall be carried out in accordance with the Measures for the Management of Risk Funds in Pilot Counties of New Rural Cooperative Medical System in Jiangxi Province (No.24/KLOC-0 [2004] of Jiangxi Finance Society).
(two) the hospitalization fund. The central and local subsidies for participating farmers are all included in the hospitalization fund, and no less than 20% of the funds paid by participating farmers are included in the hospitalization fund. The hospitalization pooling fund is used for the compensation that the expenses of participating farmers' hospitalization report reach the deductible standard, the compensation for serious outpatient diseases (chronic diseases) stipulated by counties (districts) and the compensation for hospitalization delivery quota.
(3) family account. After the out-of-pocket expenses of the participating farmers are included in the overall fund, the remaining part is the participating farmers themselves, family account, and the subsidy funds of the central and local governments for the participating farmers are not included in family account. Family account is used by family members, and the amount in family account can be used up at one time. The balance of the current year can be carried forward to the next year. Outpatient expenses compensation shall not exceed the total amount of funds in family account. The funds accumulated in family account shall not be used to offset the out-of-pocket expenses of participating farmers in the next year.
Verb (abbreviation of verb) compensation mode
Our province implements the model of "family account compensation for hospitalization reportable expenses and proportional compensation for serious illness (chronic disease) in outpatient service".
Intransitive verb salary setting
(1) hospitalization deductible line
Set up a four-level deductible line, with township-level designated medical institutions as 100 yuan, county-level designated medical institutions as 300 yuan, county (district) designated medical institutions as 600 yuan, and county (district) non-designated medical institutions as 800 yuan, and the deductible line shall not be less than 100 yuan. Below the deductible line is the individual pays part. Only one deductible line is calculated for multiple hospitalizations with the same disease within one year, and only one deductible line is calculated for continuous transfer treatment with the same disease.
(B) the proportion of hospitalization compensation
Medical institutions at the same level only set up a compensation ratio. 60% of township-level designated medical institutions, 50% of county-level designated medical institutions, 40% of designated medical institutions outside the county (district) and 30% of non-designated medical institutions outside the county (district). Counties (districts) can float 5% up and down on the county-level designated medical institutions and hospitals outside the county on this basis. In principle, the proportion of hospitalization compensation is higher in township-level designated medical institutions than in county-level designated medical institutions, and higher in county-level designated medical institutions than in medical institutions outside the county. The difference of hospitalization compensation ratio at all levels should be controlled within 10%. When calculating the actual compensation amount of participating farmers, deduct the deductible amount from the reportable expenses, and then compensate according to the prescribed compensation ratio.
(three) hospitalization compensation cap line
The capping line of hospitalization compensation is 6,543,800 yuan+0.5 million yuan, calculated based on the actual compensation amount obtained during the year.
(4) Minimum compensation for hospitalization.
After the hospitalization medical expenses of the participating farmers reach the deductible line, the minimum compensation amount of the participating farmers is not lower than that of 30 yuan. If the participating farmers are hospitalized many times in 1 year, they can only enjoy the minimum compensation amount of 1 time.
(5) Others
1, insist on taking the agricultural population as the unit to participate in the new rural cooperative medical system, and no longer accept individual farmers' requests to participate after the prescribed payment period.
2 counties (districts) will be part of the outpatient treatment of serious diseases (chronic diseases) into the overall fund compensation. The specific selection of diseases, compensation procedures and compensation standards shall be implemented with reference to the Guiding Opinions on Adjusting the Implementation Plan of the New Rural Cooperative Medical Scheme in Pilot Counties (No.8 [2004] of Gansu Medical Office) and the Compensation Provisions on Incorporating Serious and Serious Diseases (Chronic Diseases) into the Compensation Scope of the New Rural Cooperative Medical Scheme.
3, participating farmers in the county (District) designated medical institutions for medical treatment and in the nearby counties designated medical institutions for medical treatment do not need to go through the transfer procedures; In addition, to seek medical treatment outside the county (district), you must go to the county agricultural medical bureau for transfer procedures; Emergency and migrant farmers need to inform the county (District) Agricultural and Medical Bureau within 7 working days when they are hospitalized locally, otherwise they will not be compensated.
4. The farmers participating in the hospital delivery quota compensation in designated medical institutions 150 yuan, and the surgical delivery, obstetric complications and complications are compensated according to the hospitalization standard.
5, in the designated medical institutions using traditional Chinese medicine and traditional Chinese medicine technology to treat diseases, the compensation ratio of the same level of medical institutions is higher than that of western medicine treatment 10%.
6. For the participating farmers who have participated in commercial insurance, when they need both commercial insurance compensation and compensation from the new rural cooperative medical system after discharge, the participating farmers can go to the commercial insurance company to perform the payment procedures with the original hospitalization invoice, and the Agricultural Medical Bureau will pay the participating farmers with the copy of the invoice and the original payment list marked "consistent with the original" by the commercial insurance company and stamped with the official seal. The Agricultural Medical Bureau should sign a cooperation agreement with the county (district) commercial insurance company, establish a good information exchange mechanism, and check the copy of the invoice with the original regularly to ensure the authenticity of the copy.
7. The participating farmers were hospitalized immediately after the outpatient examination. On the same day, the outpatient examination and treatment expenses can be included in the compensation scope of the overall fund. During hospitalization, due to illness, the examination expenses incurred are calculated according to the compensation ratio corresponding to the examination hospital level and included in the compensation scope.
8, the overall fund does not pay and pay part of the cost of diagnosis and treatment projects, according to the "Jiangxi Province, the new rural cooperative medical care fund does not pay and pay part of the cost of diagnosis and treatment projects and medical service facilities" implementation.
Seven, apply for compensation should carry materials.
(a) participating farmers should carry the new rural cooperative medical certificate, hospitalization invoice, discharge summary, household registration book, cost list, transfer certificate and other local regulations to the designated place for compensation procedures.
(two) participating farmers in the county designated medical institutions for outpatient treatment, should carry the new rural cooperative medical certificate, designated medical institutions directly reduce outpatient medical expenses.
(III) Participating farmers suffering from outpatient serious illness (chronic disease) shall go through the compensation procedures at the designated place with the new rural cooperative medical certificate, household registration book, outpatient serious illness (chronic disease) certificate issued by the Agricultural Medical Bureau, outpatient medical records, outpatient invoices and lists within the specified time (generally in 65438+February).
Eight. Compensation program
Participating farmers are hospitalized in designated medical institutions at the county (district) level, and go through compensation procedures at the compensation window of the new rural cooperative medical system after discharge. Designated medical institutions shall review the medical expenses incurred and advance the compensation amount according to the standards stipulated in the implementation plan. In the township (town) designated medical institutions or hospitals outside the county (district), the hospitalization expenses are less than 2,000 yuan, and the agricultural medical institute where the farmers' household registration is located is responsible for reviewing the medical expenses incurred, and paying compensation to the farmers according to the standards stipulated in the implementation plan. If the hospitalization expenses are more than 2000 yuan (including 2000 yuan) or the hospitalization information is in doubt, the agricultural hospital shall report it to the Agricultural Medical Bureau for examination and approval, and the agricultural hospital shall implement it.
Nine. Approval procedure of compensation scheme
The compensation scheme of each new rural cooperative medical system county (district) needs to be reported to the municipal joint medical office for preliminary examination, then to the provincial joint medical office for review, and finally to the county (district) government for approval. Once the plan is determined, it is generally not appropriate to make new adjustments during the year. If it is really necessary to adjust the plan, it shall be implemented with the prior consent of the municipal and provincial joint medical offices.
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The following expenses are not included in the reimbursement scope of cooperative medical care in Jiangxi Province:
One is not to pay the cost of diagnosis and treatment projects.
(1) service items
1, registration fee, consultation fee, home visit fee, remote consultation fee, family bed fee, etc.
2. Special medical service fees such as self-invited special nursing fees, on-site service fees, high-quality priority fees, expedited fees for examination and treatment, and surcharges for roll-call surgery.
3. Medical record fee, disease certificate fee, computer inquiry and management fee, various bills fee, magnetic card fee, etc.
(2) Non-disease treatment projects
1, freckles, acne, warts, acne, freckles, pigmentation, alopecia (including alopecia areata), white hair, mole removal, ear piercing, saddle shape, breast augmentation, single eyelid to double eyelid, massage, beauty and other beauty projects.
2, all kinds of plastic surgery, orthopedics (except polio sequelae) and treatment of physical defects such as cutting body odor, stuttering, correcting squint, O-leg, X-leg, ametropia, vision correction and other surgical projects.
3, diabetes decision support system, sleep breathing monitoring system, trace element detection, bone mineral density determination, human information diagnosis, computer selection of the best pregnancy, fetal sex and fetal development examination and other diagnosis and treatment projects.
4, all kinds of weight loss, weight gain, height increase, bodybuilding, smoking cessation diagnosis and treatment projects.
5, all kinds of preventive health care diagnosis and treatment (except perinatal care) and other projects.
6, all kinds of medical consultation (including psychological consultation, health consultation, diet consultation, disease consultation), all kinds of prediction (including stroke prediction, health prediction, disease prediction), all kinds of identification (judicial identification, work injury identification, medical identification, paternity test), health guidance and other projects.
(3) Diagnostic equipment and medical materials.
1. Inspection and treatment projects with large medical equipment such as positron emission tomography (pet), electron beam ct and ophthalmic excimer laser therapeutic instrument.
2. Glasses, artificial eyes, dentures, prosthetic limbs, hearing AIDS, brain-strengthening devices, leather (steel) vests, steel vests, steel head and neck, stomach supports, kidney supports, scrotum supports, uterine supports, crutches, wheelchairs, deformed insoles, medicated pillows, pads, hot compress bags, pulse compression belts, infusion nets, testicular lifting belts and hernia belts.
3, all kinds of home inspection detector (device), therapeutic instrument (device), physiotherapy instrument (device), massager and magnetic therapy supplies and other therapeutic instruments.
4, the provisions of the provincial price department can not be charged separately for disposable medical materials.
(4) Treatment items
1, the human organ source or tissue source of various organ or tissue transplants, and related operations to obtain organ source and tissue source, etc.
2, in addition to the kidney, cornea, skin, blood vessels, bone, bone marrow and other organs or tissues transplantation.
3, prostate hyperplasia microwave (radio frequency) treatment, He-Ne laser intravascular irradiation (blood therapy), new technology of analgesia after anesthesia (analgesic bed), endoscopic retrograde appendectomy and other diagnosis and treatment projects.
4, dental implant, tooth cleaning, orthodontics, yellow and black teeth, tooth defects, colored teeth, porcelain teeth and other diagnosis and treatment projects.
5, qigong therapy, music therapy, hypnosis, magnetic therapy, water bar therapy, oxygen bar therapy, posture therapy, psychotherapy and suggestion therapy (except mental patients), diet therapy, nutrition therapy and other auxiliary treatment projects.
6, all kinds of infertility (pregnancy), sexual dysfunction diagnosis and treatment projects.
7, around scientific research, teaching, clinical verification of diagnosis and treatment projects.
(5) Others
1, diagnosis and treatment items caused by fighting, alcoholism, self-injury, self-mutilation, suicide, drug rehabilitation, sexually transmitted diseases, medical accidents and other accidents.
2. All medical expenses incurred during the period of going abroad.
3, refused to follow the doctor's advice to leave the hospital and hang the bed in the hospital medical expenses.
4, not included in the price policy management of diagnosis and treatment projects.
Two, pay part of the cost of diagnosis and treatment projects
(a) diagnosis and treatment equipment and medical materials
1, using gamma knife, χ knife, χ-ray computed tomography device (ct), cardiac and angiographic X-ray machine (including digital subtraction equipment), magnetic resonance imaging device (mri), single photon emission computer scanning device (spect), color Doppler instrument, medical linear accelerator, color B-ultrasound, brain topographic map and other large-scale medical treatment.
2, extracorporeal shock wave lithotripsy and hyperbaric oxygen treatment project.
3, the provisions of the provincial price department can be charged separately for disposable medical materials.
(2) Treatment items
1, hemodialysis and peritoneal dialysis treatment items.
2, kidney, cornea, skin, blood vessels, bones, bone marrow transplantation surgery project.
3. In vivo replacement, internal materials and installation or placement of artificial organs such as pacemakers, artificial valves, artificial joints, intraocular lenses, various stents, various staplers, various catheters and implantable drug delivery devices.
4, cardiac bypass, cardiac catheter balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5, coronary angiography, cardiac laser drilling, T lymphocyte infusion in tumor biotherapy, tumor hyperthermia and other diagnosis and treatment projects.
6, all kinds of microwave, spectrum, far infrared and other auxiliary treatment projects.
Three, do not pay the cost of medical service facilities.
(1) Transportation expenses for outpatient service (referral).
(2) Compensation for damage to air conditioning, heating, television, telephone, electric stove, refrigerator, food incubator, public property and water, electricity and gas.
(3) Escort fee, nursing fee, bath fee, medicated bath fee, disinfection fee, haircut fee, washing fee, etc.
(four) outpatient decocting fees, Chinese medicine processing fees.
(five) entertainment activities, newspapers and magazines, fitness activities.
(6) meals.
(7) flowers and plants.
(eight) the cost of disposable articles such as sanitary tableware, washbasins, cups, toilet paper, sheets, pillowcases, bed towels and diapers.
(nine) the cost of soap and water, garbage bags, mosquito killers and other daily necessities.
(ten) medical institutions to improve the standard of medical service facilities or self charging standards.
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Problems needing attention
Go through relevant formalities first and collect relevant bill information as required.
Second, pay attention to the cooperative medical drug list when using drugs. Off-list drugs are an important factor affecting reimbursement.