Guizhou province has fully implemented the serious illness insurance scheme for urban and rural residents.
Serious illness insurance for urban and rural residents (hereinafter referred to as serious illness insurance) is an extension of the basic medical security system and a new institutional arrangement to further protect seriously ill patients from high medical expenses. In order to implement the spirit of Opinions of General Office of the State Council on Full Implementation of Serious Illness Insurance for Urban and Rural Residents (Guo Ban Fa [2015] No.57) and Opinions of Guizhou Provincial Party Committee and Guizhou Provincial People's Government on Vigorously Promoting the Reform and Development of Medical and Health Services (Qian Ban Fa [20 15] 18), we will accelerate the promotion of serious illness insurance.
First, the target requirements
Before the end of the year, serious illness insurance will cover all urban residents' basic medical insurance and the new rural cooperative medical insurance (hereinafter referred to as the basic medical insurance for urban and rural residents), effectively reducing the medical burden of seriously ill patients. By 20 17, a relatively perfect serious illness insurance system will be established, which will be closely linked with medical assistance and other systems, * * * will play the role of all-out protection, effectively prevent catastrophic medical expenses for families, and significantly improve the fairness of medical security for urban and rural residents.
Second, the basic principles
(a) adhere to the people-oriented, to ensure serious illness. Establish and improve the serious illness insurance system, continuously improve the level of serious illness protection and service accessibility, focus on safeguarding people's health rights and interests, and effectively prevent people from becoming poor and returning to poverty due to illness.
(2) Adhere to overall coordination and policy linkage. Strengthen the convergence of basic medical insurance, serious illness insurance, medical assistance, disease emergency assistance, commercial health insurance and charity assistance, play a complementary role, output abundant help kinetic energy, and form a joint force of help.
(three) adhere to the government-led, professional contractors. While strengthening the government's responsibilities in policy formulation, organization and coordination, supervision and management, we should take the form of undertaking serious illness insurance by commercial insurance institutions, give play to the role of market mechanism and the professional advantages of commercial insurance institutions, and improve the operational efficiency, service level and quality of serious illness insurance.
(4) Insist on steady progress and continuous implementation. The level of serious illness insurance should adapt to economic and social development, medical consumption level and social affordability. Strengthen social mutual assistance and form a mechanism for the government, individuals and insurance institutions to share the risk of serious illness. Adhere to local conditions and standardize operations to achieve stable operation and sustainable development of serious illness insurance.
Three. Financing mechanism
(1) funding criteria. According to the level of economic and social development, the financing ability of medical insurance, the high medical expenses caused by serious illness, the compensation level of basic medical insurance and the protection level of serious illness insurance, the financing standard of serious illness insurance is scientifically and reasonably determined. The basic medical insurance for urban residents in our province (hereinafter referred to as urban residents' medical insurance) and the new rural cooperative medical system (hereinafter referred to as the new rural cooperative medical system) are not less than 5% of the total annual per capita financing in principle. Under the guidance of the provincial departments of human resources and social security, health and family planning, cities and counties have gradually adjusted the funding standards for serious illness insurance and established a dynamic adjustment mechanism for the funding standards for serious illness insurance in combination with local conditions and the financing level of urban residents' medical insurance and the new rural cooperative medical system and its fund operation.
(two) the overall level and source of funds. Serious illness insurance shall be co-ordinated at the city and state levels, with unified fund management, unified security policies, unified organization and implementation, and actively promote provincial co-ordination. Draw a certain proportion or quota from the basic medical insurance fund for urban and rural residents as a serious illness insurance fund, and no additional fees will be charged to the insured. In areas where the basic medical insurance fund for urban and rural residents has a balance, use the balance to raise a serious illness insurance fund; Areas with insufficient balance or no balance shall be arranged in the funds raised every year. Improve the multi-channel financing mechanism of basic medical insurance for urban and rural residents to ensure the sustainable development of the system.
Fourth, the content of protection.
(1). The object of serious illness insurance is the insured of urban residents' medical insurance and new rural cooperative medical system in that year. In accordance with the provisions of the basic medical insurance for urban residents and the new rural cooperative medical treatment, and enjoy the treatment of serious illness insurance.
(2) scope of protection. The insured suffers from serious illness and incurs high medical expenses. Serious illness insurance will guarantee the compliance medical expenses borne by individuals after the basic medical insurance for urban and rural residents is paid according to regulations. Compliance medical expenses refer to all medical expenses actually incurred after deducting non-payment items, which are determined by the provincial human resources and social security, health and family planning departments. According to the income changes of urban and rural residents, establish a dynamic adjustment mechanism, study and refine the scientific definition standard of serious illness, which will be determined by the human resources and social security, health and family planning departments according to the actual situation. In areas where serious illness protection and supplementary insurance for urban and rural residents have been carried out, it is necessary to gradually improve the mechanism and make a good connection.
(3) Protection level. After reimbursement by the basic medical insurance, if the annual cumulative burden of compliance medical expenses exceeds the deductible line of critical illness insurance, it will be included in critical illness insurance. Qifubiaozhun can be used as the main basis for calculating that the annual cumulative burden of compliance medical expenses by individuals exceeds the annual per capita disposable income of urban residents and rural residents published by the statistics department in the previous year. Pay not less than 50% of the compliant medical expenses. With the continuous improvement of financing ability and management level of serious illness insurance, the proportion of payment will be further increased to reduce the burden of personal medical expenses more effectively. According to the level of medical expenses, the payment ratio of serious illness insurance is formulated. The higher the medical expenses, the higher the payment ratio. We will comprehensively implement and improve the level of medical assistance for the rural poor and promote precise poverty alleviation.
(4) service process. Further improve the information system, standardize the service process, and realize the "one-stop" settlement of medical expenses for basic medical insurance and serious illness insurance.
1. See a doctor in the province. The insured person holds a card (certificate) for medical treatment in designated medical institutions in the province, and the medical expenses incurred in hospitalization are automatically accumulated by the information system. When discharged from the hospital, the insured person only settles the personal burden, which belongs to the payment part of the serious illness insurance fund, and is settled by the serious illness insurance contractor and the designated medical institution on a monthly basis. Insured patients seeking medical treatment in different places in the province need to go through relevant medical treatment procedures in different places according to regulations.
2. seek medical treatment outside the province. For hospitals that have achieved inter-provincial network settlement, the insured can take a card (certificate) for medical treatment, and the medical expenses incurred in hospitalization only settle the personal burden, which belongs to the payment part of the serious illness insurance fund, and the serious illness insurance contractor shall settle with the designated medical institutions according to the relevant regulations; In the designated medical institutions that have not realized remote online settlement, the medical expenses incurred by the insured shall be paid in advance by personal cash, and shall be reimbursed to the insured place according to the regulations after discharge. The data required for reimbursement shall be implemented according to the relevant provisions of urban residents' medical insurance or new rural cooperative medical system.