Article 1 In order to conscientiously implement the spirit of the Third Plenary Session of the Seventeenth Central Committee of the Communist Party of China, effectively improve the rural medical security system, improve the health level of farmers, alleviate the problem of "poverty caused by illness and returning to poverty due to illness", and promote the harmonious development of rural economy and society, according to the Decision of the Central Committee of the Communist Party of China and the State Council on Further Strengthening Rural Health Work, the Implementation Opinions of the Provincial and Municipal Governments on Establishing a New Rural Cooperative Medical System, and the Decision of the District Party Committee and the District Government on
Article 2 The new rural cooperative medical system is a system of mutual medical assistance and economic assistance for farmers, which is organized, supported and guided by the government, appropriately funded by the collective, and voluntarily participated by farmers.
Article 3 The new rural cooperative medical system shall follow the following principles:
Principles of government organization and multi-party financing;
(two) the principle of fixed income and appropriate support;
(3) the principle of caring for farmers' health;
(four) the principle of unified policy and town (street) management;
(five) the principle of adapting to the economic and social development of our region.
Article 4 These Measures shall apply to rural residents who have not participated in the basic medical insurance for urban workers and rural market town residents who have not participated in the medical insurance for urban residents (excluding those who work, do business or go to school outside the district). ).
Chapter II Organizational Structure
Article 5 The district government shall set up a new rural cooperative medical management committee, with the principal responsible person of the district government as the director, relevant departments of the district and representatives of insured farmers as members, and set up an office in the district health bureau (hereinafter referred to as the joint management office) with full-time staff. The office and personnel funds shall be included in the budget by the district finance.
Article 6 The town government (street office) shall set up a new rural cooperative medical management committee, with the main person in charge of the town government (street office) as the director, relevant departments and representatives of insured farmers as members, and set up an office in the town cultural and health department (street social affairs department) with 2-3 full-time staff, and the office and personnel funds shall be included in the budget by the finance at the same level. Financial and fund management can be entrusted to the town (street) accounting service station or finance office for implementation.
Seventh district, town (street) level set up by the relevant departments and representatives of the insured farmers of the new rural cooperative medical supervision committee, responsible for the supervision of fund raising, use and management.
Chapter III Raising and Use of Funds
Article 8 The new rural cooperative medical system in the whole region implements unified financing standards, unified security policies, unified reimbursement ratio and unified fund management, which are raised by districts and towns (streets) respectively, and each town (street) establishes separate accounts, and the district health bureau, finance bureau, audit bureau and joint management office are responsible for management verification and guidance and supervision.
Article 9 The new rural cooperative medical system adopts a financing mechanism that combines individual contributions, collective support, government support and social assistance.
(1) District Finance arranges the budget according to the standard of 60 yuan per person per year. Among them, 50 yuan is included in the special account of the new rural cooperative medical fund in each town (street); 2.5 yuan as a regional risk reserve adjustment fund; 2.5 yuan as a serious illness co-ordination and medical assistance fund; The district finance set up an incentive fund according to the number of insured persons in 5 yuan in that year, which is mainly used for the reimbursement of insured persons in towns (streets) with a participation rate of more than 95%. For the town (street) with the balance of the cooperative medical fund in that year, 15% can be extracted from the district-level award fund to subsidize the work funds of the same level joint management office.
(two) the town (street) finance provides supporting facilities according to the standard of 30 yuan per person per year.
(three) the insured family as a unit of all members of the insurance, each person to pay the 30 yuan insurance fund every year, not selective insurance and surrender. Students of all levels and types of schools in the whole region must participate in the new rural cooperative medical system with their families, and schools may not uniformly organize students to participate in other forms of commercial medical insurance. Those who fail to pay within the time limit shall be deemed to have given up insurance automatically, and shall not be surrendered beyond the prescribed financing period. People who study, work and do business all the year round may temporarily not participate in the new rural cooperative medical system.
(four) the insured with a fixed work unit, in addition to the annual payment of 30 yuan by individuals, the unit shall provide financial assistance according to the standard of not less than 30 yuan per person per year. Enterprises and institutions that provide financial support for the new rural cooperative medical system enjoy preferential policies stipulated by the state.
(5) The personal insurance expenses of rural "minimum living security" and "five guarantees" personnel shall be raised and paid by the town (street) and village level where the household registration is located.
(VI) The funds raised by the town (street) and below must be paid into the district financial accounts in time within the specified time, and the district financial budget funds are also included in the town (street) accounts.
(seven) the new rural cooperative medical fund must be earmarked, closed operation, and accept the supervision of the township government, street offices, district civil affairs departments, the insured and the society.
(eight) the district and town (street) joint management office shall regularly announce the use of funds to the public. The audit department conducts special audits on the management and use of funds every year. No unit or individual may intercept or misappropriate funds.
Chapter IV Proportion, Procedure and Scope of Reimbursement
Tenth outpatient medical expenses reimbursement ratio: the insured person to the designated community health service station for medical treatment, after deducting the expenses of drugs, inspection and treatment items that will not be reimbursed, 40% will be reimbursed every month; In the designated level medical institutions for medical treatment, reimbursement of 30%; In the designated secondary medical institutions for medical treatment, reimbursement of 20%; The total reimbursement of outpatient medical expenses per person per year shall not exceed that of 500 yuan. Outpatient expenses for medical treatment in medical institutions outside the district will not be reimbursed.
Insured persons can independently choose designated medical institutions in the area for outpatient treatment, without going through outpatient referral procedures.
Article 11 Proportion of reimbursement of hospitalization medical expenses: After deducting the expenses of drugs, examinations and treatment items that are not reimbursed according to the regulations, the insured's hospitalization medical expenses will be reimbursed at the designated first-class medical institutions in the whole year at the rate of 70%; Approved by the designated secondary medical institutions for medical treatment, reimbursement of 55%; If the designated tertiary medical institutions agree to seek medical treatment, the reimbursement will be 45%.
The insured is neither emergency nor referral, and goes directly to the designated or designated medical institutions at or above the second level for hospitalization. The reimbursement ratio of medical expenses is 50% of the reimbursement ratio stipulated by the designated or designated medical institutions at the same level.
Article 12 If the family members of a person who has been insured for three consecutive years have not been reimbursed for medical expenses, the medical expenses incurred in the following year shall be reimbursed 10% according to the prescribed reimbursement ratio (the corresponding limit remains unchanged).
Article 13 Proportion of reimbursement for medical expenses identified as chronic diseases at district level: After the outpatient expenses reach the limit, the medical expenses of patients with chronic diseases who are not hospitalized in designated medical institutions or designated medical institutions in the district shall be reimbursed according to the proportion of hospitalization.
Fourteenth insured persons in the local prevention and protection institutions to vaccinate rabies vaccine costs, should be reimbursed in accordance with the proportion of outpatient medical expenses reimbursement.
Fifteenth insured persons in the local statutory premarital examination institutions for premarital examination in the local designated medical institutions (including caesarean section) to give a fixed subsidy of 300 yuan/person.
Article 16 The outpatient and inpatient medical expenses of the "minimum living allowance", "five guarantees", disabled soldiers and other entitled groups in designated hospitals in the local area shall be directly reduced by 30%, and the rest expenses shall be reimbursed according to the prescribed proportion. The reduced part is subsidized by the new rural cooperative medical fund to designated hospitals.
Seventeenth approved the implementation of the medical expenses of specific insured groups by the new rural cooperative medical fund to provide free medical assistance to medical institutions.
Eighteenth in the town (street) joint management office per person per year outpatient and inpatient medical expenses reimbursement maximum of 20 thousand yuan.
Article 19 Reimbursement procedures: After the town (street) completes the fund-raising task, it can be reimbursed according to the prescribed procedures on the following month 1 day. The medical expenses incurred by the insured holding the "New Rural Cooperative Medical Insurance Card" in the designated medical institutions in the local area and the designated medical institutions in this Municipality shall be reimbursed and settled online in medical institutions according to the corresponding reimbursement regulations; Medical expenses incurred by trauma or participants in commercial insurance and medical institutions designated outside the city shall be declared by the town (street) joint management office where the household registration is located. Outpatient medical expenses will be reimbursed in the current month, and will not be reimbursed after the deadline.
Article 20 The scope of non-reimbursement:
(a) Jiangsu Province, the new rural cooperative medical care drug list and the district joint management office according to the new drug list outside the drugs and medical insurance for urban workers in the provisions of non reimbursement costs;
(2) Medical expenses incurred by the insured due to injuries caused by others;
(3) Medical expenses for traffic accidents, industrial accidents and occupational diseases;
(four) medical expenses for childbirth and family planning operations and complications and sequelae;
(five) drinking, suicide, fighting and other rescue and medical expenses;
(six) beauty, dental prosthetics, glasses and other expenses, special inspection and other expenses;
(seven) medical expenses incurred in non-designated (designated) medical institutions;
(eight) nutritional supplements, aftercare products, registration fees, escort fees, ambulance fees, medical transportation fees and other expenses;
(nine) medical expenses incurred in medical institutions in Hong Kong, Macao, Taiwan and abroad;
(ten) unable to provide unified and standardized medical expenses reimbursement bills of medical institutions and unable to obtain relevant reimbursement materials according to regulations.
Twenty-first insured persons who participate in other commercial medical insurance at the same time, the total reimbursement of the same medical behavior in various insurance institutions shall not exceed the total medical expenses at that time.
Those who have participated in medical insurance for urban workers and residents shall not participate in the new rural cooperative medical system. When filling in the audit report, it is found that the insured has participated in the medical insurance for urban workers and residents, and the personal insurance premium paid should be refunded in full, and the refunded personal insurance premium should be borne by the town (street) finance.
Chapter V Overall Planning of Medical Assistance for Serious Illness
Twenty-second in the establishment of a new rural cooperative medical system at the same time, the implementation of district-level serious illness planning and medical assistance system.
Twenty-third districts to set up a serious illness medical assistance fund, and separate accounts, unified management by the district management office. Main sources of funds:
(a) the district finance subsidies from 60 yuan to 2.5 yuan per person per year;
(two) the designated medical institutions below the local level (including the first level) provide part of the funds in the subsidy according to 2% of the total medical expenses incurred by the insured in this medical institution last year;
(three) two or more designated or designated medical institutions inside and outside the region provide part of the funds in the subsidy according to 5% of the total medical expenses incurred by the insured in this medical institution last year;
(4) The social welfare lottery public welfare fund retained by the district10%;
(5) donations from all walks of life.
Article 24 Measures for overall planning of serious illness: If the insured (except the rural "low-income" and "five-guarantee" personnel) can reimburse the hospitalization medical expenses of more than 35,000 yuan in the current year, 70% of them will be reimbursed in the district serious illness overall planning fund (after the highest limit is reported to the town where they are located), and the annual cumulative reimbursement limit (district and town levels) is 60,000 yuan.
The rural "minimum living allowance" and "five guarantees" of the insured are reimbursed 80% in the district serious illness co-ordination fund after the highest limit is reported in the town where they are located, and the cumulative reimbursement limit for the whole year (district and town levels) is 80,000 yuan.
Medical assistance: If the accumulated hospitalization medical expenses exceed 80,000 yuan in the whole year, 80% will be reimbursed from the district medical assistance fund, and the annual accumulated reimbursement limit (district and town levels) is 654.38+10,000 yuan.
Twenty-fifth the implementation of secondary compensation. The accumulated balance of the cooperative medical fund with towns (streets) as the unit exceeds 20% or 10% of the total fund-raising in that year, which can be used for the secondary compensation of low-income and vulnerable groups in need of assistance, and can also be used for the health examination of insured persons over 60 years old and under 55 years old. The secondary compensation or health examination plan shall be drawn up by the town government (street) and implemented after being approved by the district government.
Chapter VI Designated Medical Institutions and Their Supervision and Administration
Article 26. Medical institutions at all levels in the region and medical institutions at or above the first level outside the region, which are established according to law, have complete facilities and standardized management, and can provide high quality and low price, convenient, fast and warm and thoughtful services, can be determined as the designated or designated service institutions of the new rural cooperative medical system in our region after the evaluation of the district joint management office.
The community health service stations in the region that implement the integrated management of township medical services can also be identified as the designated service institutions of the new rural cooperative medical system in our region after evaluation by the district joint management office.
Twenty-seventh insured patients can go directly to the nearest medical institution for treatment. Need to be hospitalized in two or more (including two) medical institutions, must go through the referral procedures before discharge. In the emergency hospitalization of medical institutions in the city, the town (street) joint management office shall compensate; Emergency hospitalization in medical institutions outside the city shall be compensated by the town (street) and district two-level joint management office.
Twenty-eighth designated medical institutions must strengthen internal management, standardize medical procedures, adhere to reasonable treatment, put an end to arbitrary charges, large prescriptions and unreasonable inspections, and earnestly safeguard the interests of insured persons. If violations are found, unreasonable medical expenses and fraudulent insurance money will be recovered, and the responsibility of the parties will be investigated until the designated qualification is cancelled.
Twenty-ninth of the lent insurance certificates, forged documents and impersonator of the relevant personnel, once verified, will recover the fraudulent insurance money, and cancel the household's eligibility for reimbursement that year.
Chapter VII Supplementary Provisions
Thirtieth new rural cooperative medical fund to the town (street) as a unit to establish a separate accounting, the balance rolled into the next year. When the fund overspent, 50% of the overspent part was made up by the town (street), and the remaining 50% was subsidized by the district risk reserve adjustment fund. The district risk reserve adjustment fund can be used in advance according to the average monthly declaration amount of the town (street).
Article 31 These Measures shall be implemented as of June 65438+1October 65438+1October 2009.
Thirty-second approach by the District Health Bureau is responsible for the interpretation of.