In order to improve the * * * economic security system for provincial-level employees' basic medical insurance outpatient service, Gansu Provincial Medical Security Bureau and Gansu Provincial Department of Finance have formulated the * * * Economic Security Implementation Rules for Gansu Provincial-level employees' basic medical insurance outpatient service, and from June 5438 to 1 October1day, 2023, the outpatient medical expenses will be included in the payment scope of the employee medical insurance pooling fund.
The proportion of on-the-job employees' overall fund payment is 60%.
On the basis of doing a good job in outpatient medical security for chronic diseases and special diseases, we will establish an overall security mechanism for outpatient medical expenses of employee medical insurance, and include medical expenses for frequently-occurring diseases and common diseases in the scope of payment of the overall fund. Medical expenses for co-ordination of outpatient medical insurance for employees, outpatient chronic diseases and special diseases, and negotiated drugs shall be reimbursed separately according to the policy.
Adjust the income structure of the overall fund and individual accounts, and all the basic medical insurance premiums paid by the unit will be included in the overall fund. The increased overall fund is mainly used to enhance the outpatient economic security function and improve the outpatient treatment of the insured. The insured person can enjoy outpatient reimbursement after payment; After the insured person who has interrupted the payment pays the medical insurance premium, he can enjoy the outpatient co-ordination reimbursement treatment from the month of payment.
Within a natural year, the medical expenses above Qifubiaozhun and below the maximum payment limit accumulated by the insured in the general outpatient department of designated medical institutions shall be included in the payment scope of the overall fund. The annual cumulative Qifubiaozhun for outpatient co-ordination is 200 yuan, and the payment limit is 2500 yuan. The proportion of on-the-job employees' overall fund payment is 60%, and the proportion of retirees' overall fund payment is 65%. Qifubiaozhun, maximum payment limit and fund payment ratio can be dynamically adjusted according to the situation of provincial medical insurance fund for employees. The maximum payment limit is calculated on an annual basis and is not carried forward to the next year. It is for personal use only.
The payment scope of outpatient medical expenses is strictly in accordance with the national basic medical insurance, industrial injury insurance, maternity insurance drug list, Gansu Province Basic Medical Insurance Medical Service Price Item List (2022 Edition) and Gansu Province Basic Medical Insurance Medical Consumables List. The medical expenses such as examination, treatment and medicines of the insured in the outpatient service of designated medical institutions shall be included in the payment scope of the overall fund. For drugs, medical service price items and medical consumables that belong to Class B, the individual shall pay 10% first, and then be reimbursed according to the prescribed proportion.
Personal accounts can be used by oneself, spouse, parents and children for medical treatment.
These regulations have reformed personal accounts. Personal accounts of employees are included in the basic medical insurance premiums paid by individuals, and the inclusion standard is 2% of the base of my payment. The basic medical insurance premium paid by the original unit is no longer included in the personal account; The amount of individual account for retirees is 120 yuan per person per month; Insured personnel to pay arrears (including insufficient payment period) according to my insurance payment base of 2% included in the personal account.
The scope of use of employee medical insurance personal accounts includes:
1. It is mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies;
2. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies;
3. It can be used for spouses, parents and children to participate in the basic medical insurance for urban and rural residents and other individual contributions.
Personal accounts shall not be used to pay expenses outside the basic medical insurance coverage. Before the reform, the balance of individual accounts over the years still belongs to the insured and can be carried forward and inherited. If the employee's medical insurance relationship is transferred to other areas as a whole, the personal account will be transferred with the medical insurance relationship; After the death of the insured, the balance of the personal account can be distributed to his legal heir.
Eligible "internet plus" outpatient medical services can be included in the scope of protection.
Insured persons with medical insurance electronic certificate, social security card or ID card in the local designated medical institutions for outpatient treatment, the implementation of immediate settlement. The provincial medical insurance service center and designated medical institutions shall settle accounts on a monthly basis. When visiting a general outpatient clinic in different places, you should choose a designated medical institution that has opened online settlement of medical expenses in different places for direct settlement.
When the insured can't meet the outpatient drug demand in the designated medical institutions, they can make prescription adjustment and settlement in the designated retail pharmacies determined by the Provincial Medical Insurance Bureau. After meeting the relevant conditions, eligible Internet plus outpatient medical services can be included in the scope of protection.
Due to the following medical expenses, the overall fund will not pay:
1. should be paid from the industrial injury insurance fund;
2. Should be borne by a third party;
3. Should be borne by public health;
4. Go abroad for medical treatment;
5. It belongs to fitness, health care consumption and health examination;
6 other expenses that are not paid by the basic medical insurance stipulated by the state.