2. The compensation method of medical insurance benefits is non-fixed compensation. Due to different conditions, the amount of economic compensation received by each patient is not equal. Therefore, medical insurance generally determines the amount of compensation for each patient according to the actual situation of the disease, and does not use fixed compensation.
3. Disease risk is inevitable, random and unpredictable. For various reasons, it is difficult for people to accurately judge the occurrence time, type and severity of the disease, which increases the harm of the disease risk. Therefore, all groups within the scope of the law, whether sick or not, must participate in medical insurance, so as to effectively share the unpredictable disease risks and improve the medical security capacity of the whole society.
4. Medical insurance has the characteristics of complicated relationship between all parties. The implementation of medical insurance must deal with the relationship between doctors, patients, insurance and medicine. The actual medical expenses of each person cannot be determined in advance, and the amount of expenditure depends not only on the actual situation of the injury, but also on the medical treatment methods adopted and the behavior of medical service providers. Because medical service providers are in a relatively monopoly position in medical service consumption, it is difficult to control the expenditure of medical expenses completely through market means, and patients choose the content and quantity of medical services. Therefore, the expenditure management of medical insurance is different from other social insurances such as pension and unemployment, and it is necessary to manage the medical service providers and the items and contents of medical services in order to improve the utilization efficiency of medical insurance funds.
Physical examination items involve 9 items such as blood routine, liver function, renal function and head CT, and the diseases involved are 15 and 4 1 item. For those who fail to pass the examination, the medical insurance department shall not handle the insurance procedures. For those who pass the physical examination, a waiting period of 12 months will be set from the month when the insurance payment is paid. Do not enjoy medical insurance benefits during the waiting period, and enjoy the corresponding medical insurance benefits according to the proportion of payment after the expiration.
All kinds of health checkups are not included in the scope of basic medical insurance, which is a continuation of the past medical policies of public expense and labor insurance. Physical examination is divided into general physical examination and special purpose physical examination. General health examination is a preventive disease screening measure organized by various employers for early detection and treatment of diseases. The medical examination expenses shall be borne by each employer, not from public funds and labor insurance medical expenses. Special purpose physical examination refers to the physical examination conducted by employees according to certain specific requirements, such as the physical examination conducted by employees in activities such as job hunting, going abroad and purchasing commercial medical insurance. The expenses of these physical examinations are generally borne by individuals. Therefore, after the reform of the medical insurance system, all kinds of health checkups are not included in the basic medical insurance diagnosis and treatment items, and the health checkup expenses organized by the unit are borne by the employer, while the special-purpose health checkup expenses originally paid by the individual are still paid by the individual.
Establish a new financing mechanism shared by employers and employees.
According to the principle of the unity of rights and obligations and the corresponding treatment and responsibility, the basic medical insurance system has changed the past practice of being borne by enterprises with a single source of finance or funds, and the medical insurance premium is paid jointly by employers and individual employees.
2. Establish a management model that combines pooling funds with individual accounts.
The basic medical insurance premium paid by the employer is divided into two parts, one of which is used to establish the overall fund; The other part, that is, about 30% of the unit payment, is included in the employee's personal account, and the specific proportion is determined by the overall planning area according to the payment scope of the personal account and the age of the employee. All the basic medical insurance premiums paid by employees are included in personal accounts. The principal and interest of the personal account belong to the individual, but it can only be used to pay for my medical expenses.
3. Clearly divide the payment scope and payment method of the overall fund and individual account.
The overall fund is mainly used to pay large and inpatient medical expenses, and personal accounts mainly pay small and outpatient medical expenses. Generally speaking, when making fund payments, the minimum deductible and the maximum payment limit should be determined according to the principle of "balance of payments" and the actual situation in various places and the affordability of the fund. Qifubiaozhun is controlled in principle at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled in principle at about 4 times of the average annual salary of local employees. Medical expenses below the Qifubiaozhun of the overall fund shall be paid by the individual account, and the insufficient part shall be paid by the individual; Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid from the overall fund, but individuals also have to bear a certain proportion. Medical expenses exceeding the maximum payment limit are no longer paid by the overall fund, but are solved by means of large medical expenses subsidies, civil servants' medical subsidies, enterprise supplementary medical insurance, commercial medical insurance, etc.
4. Socialization of basic medical insurance management and service.
First, the overall planning area should establish a medical insurance agency independent of enterprises, institutions and governments, responsible for the collection, management and payment of basic medical insurance funds. Socialized management and service of basic medical insurance is a basic principle of social insurance. Its purpose is to break the boundaries between free medical care and labor insurance, between different ownership units and different employee identities, expand the coverage of medical insurance and reduce the social burden of enterprises. The second is to make overall planning in a larger geographical scope. Within this scope, all units and their employees shall participate in the basic medical insurance in the overall planning area in accordance with the principle of territorial management, implement a unified policy, and raise, manage and use funds in a unified manner. The overall planning scope of basic medical insurance (hereinafter referred to as the overall planning area) is based on the administrative area at or above the prefecture level or the county (city) as the overall planning unit in principle, and the three municipalities directly under the Central Government, namely Beijing, Shanghai and Tianjin, implement overall planning in the whole city.
5. Improve the management and supervision mechanism of medical insurance funds.
The basic medical insurance system has changed the situation that the risk of fund management shared by employers in the past was mainly borne by the government, so it is particularly important to strengthen the management of fund expenditure. The basic medical insurance fund must be included in the financial account management, so as to be earmarked, and no unit or individual may misuse or misappropriate it. The business expenses of insurance agencies shall be solved by the financial budgets at all levels and shall not be extracted from the basic medical insurance fund. The overall fund should not have a deficit, and it should be based on income and expenditure, living within its means and making ends meet. We must establish and improve the fund budget and final accounts system, financial accounting system and internal audit system of social insurance agencies.
6. Strengthen the management of medical services and actively develop community health services.
Medical institutions are the providers of medical services for employees and the source of controlling medical expenses, and their behavior directly affects the level of medical expenses for employees. Therefore, it is necessary to strengthen the management of medical services. The main policies include: the basic medical insurance is managed by designated medical institutions and retail pharmacies, and scientific and reasonable medical expenses settlement methods are formulated. Workers can go to designated medical institutions for medical treatment or to designated retail pharmacies with prescriptions; Formulating the drug list, standards of diagnosis and treatment items and medical service facilities of basic medical insurance and corresponding management measures. Medical expenses that do not meet the standards of drug list, diagnosis and treatment items and medical service facilities are not included in the payment scope of basic medical insurance; Separate accounting and management of medicines shall be implemented. At the same time, in accordance with the requirements of regional health planning, we will promote the structural adjustment of medical and health service system, accelerate the reform of medical institutions, standardize medical behavior, reduce staff and increase efficiency, and improve the utilization efficiency of health resources. It is necessary to speed up the development of community health services, establish a two-way referral system between community health service institutions and hospitals, and gradually form a medical and health service network with reasonable layout and convenience for employees. Basic medical services in community health services can be included in the scope of basic medical insurance payment.
7. Properly solve the medical problems of relevant personnel.
The medical treatment of retired personnel, the old Red Army and disabled revolutionary soldiers above Grade B remains unchanged, and the medical expenses are solved according to the original funding channels. Payment is indeed difficult, by the people's government at the same level to help solve. Retirees participate in the basic medical insurance, and individuals do not pay the basic medical insurance premium; Appropriate care should be given to the amount included in the personal account of retirees and the proportion of medical expenses borne by individuals. National civil servants participate in basic medical insurance, implement unified basic medical insurance policies and treatment standards, and enjoy civil servants' medical subsidies on this basis. In addition, we should solve the problem of medical insurance for laid-off workers. The basic medical insurance premium for laid-off workers from state-owned enterprises shall be paid by the re-employment service center at 60% of the average salary of local employees in the previous year, and they shall enjoy the corresponding medical insurance benefits.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.