Provinces, cities, counties (cities) directly under the jurisdiction of the province, Medical Security Bureau, Civil Affairs Bureau, Finance Bureau, Health and Wellness Committee, Poverty Alleviation Office, Banking Supervision Branch (including Jiyuan Supervision Group), Jiyuan Human Resources and Social Security Bureau, and relevant commercial insurance institutions:
In order to further improve the supplementary insurance system for serious illness, consolidate the responsibilities of all parties, improve the supervision mechanism, and do a good job in supplementary medical insurance for people with serious illness (hereinafter referred to as supplementary insurance for serious illness), with the consent of the provincial government, we hereby notify you as follows.
The first is to improve the dynamic adjustment mechanism of security objects.
Before April 10 of each year, the county-level medical insurance department will take the lead in conjunction with the poverty alleviation, civil affairs, finance, health and other departments at the same level to verify the list of local people with difficulties and related information. After the needy people go through the insurance payment procedures, the county-level medical insurance department will identify their identity, household registration type and poverty alleviation status of the poor people in the urban and rural residents' medical insurance information system in time.
According to the Notice of the Office of the Leading Group for Poverty Alleviation in Henan Province on Further Standardizing the Labeling of "Stable Poverty Alleviation" in the whole province (No.201717 of Henan Poverty Alleviation Office) and the Notice of Henan Provincial Finance Department of Henan Provincial Health and Wellness Committee of Henan Provincial Insurance Regulatory Bureau on Further Implementing the Medical Security Treatment for the Poor Population (Yu Renshe Office [20 18). Before kloc-0/0, the county-level medical insurance department will take the lead in conjunction with the poverty alleviation, finance and health departments at the same level to verify the newly identified list of stable poor people (hereinafter referred to as "quitters") and the newly-established poverty-stricken people (hereinafter referred to as "new people") and related information. At the same time, the county-level medical insurance department should identify the newly added personnel in the urban and rural residents' medical insurance information system in time, and enjoy the supplementary insurance policy for serious illness and the preferential policies for basic medical insurance and serious illness insurance in that year after the newly added personnel in the "guarantee category" are verified by the poverty alleviation department, and the medical expenses incurred before will not be retroactively reimbursed. Withdrawal personnel should adjust the identification of poverty-stricken people with "security category" file. If the retirees are poor people in poverty relief, urban and rural minimum living security, children in distress and other categories at the same time, the "security category" will be revised to the corresponding category; If the quitter only belongs to the category of poor people, he will no longer enjoy the supplementary insurance policy for serious illness and the preferential policies for basic medical insurance and serious illness insurance from the date of quitting, but the medical expenses that have occurred but have not been reimbursed can continue to be reimbursed through the system.
Second, improve the way of financing.
Critical illness supplementary insurance will continue to carry out differentiated financing. According to the actual expenditure of the serious illness supplementary insurance fund, the growth of medical expenses, the adjustment of policies and the expenditure of funds in all areas as a whole, the financing standards for the serious illness supplementary insurance in 20 19 years are 130 yuan, 165438 yuan, 90 yuan and 70 yuan respectively (see the annex for details). Before June 20th of each year 1, the provincial finance department will allocate the provincial burden funds to the provincial financial accounts according to the number of people covered by supplementary insurance for serious illness in the previous year and the annual financing standard. After the number of guarantees is determined, the financial departments at all levels will share the funds in full and on time to the provincial financial accounts according to the number of serious illness supplementary insurance guarantees and the financial sharing standard approved by the provincial medical insurance agency. The funds needed for new personnel in that year shall be raised by governments at all levels when raising funds in the next year.
Third, strengthen risk sharing and responsibility.
From 20 19, the profitability (including operating costs) of commercial insurance institutions undertaking supplementary serious illness insurance is consistent with that of urban and rural residents undertaking serious illness insurance, and it is controlled within 3% of the total fund-raising in that year. Serious illness supplementary insurance fund when the balance exceeds the prescribed profit rate, the excess is transferred to the provincial financial accounts. In principle, the losses of that year shall be borne by commercial insurance institutions. Indeed, due to the adjustment of the scope of payment and the standard of treatment, the commercial insurance institution will submit an audit report, which will be reported to the Provincial Medical Insurance Bureau after being verified by the provincial medical insurance agency. The Provincial Medical Insurance Bureau will propose a fund solution in consultation with the Provincial Department of Finance, and after being approved by the provincial government, the financial departments at all levels will give subsidies according to regulations.
Fourth, continue to promote graded diagnosis and treatment.
According to the Guiding Opinions of the General Office of the State Council on Promoting the Construction of Graded Diagnosis and Treatment System (Guo Ban Fa [2015] No.70) and the Implementation Opinions of the General Office of the People's Government of Henan Province on Promoting the Construction of Graded Diagnosis and Treatment System (Yu Ban Fa [2016] No.53), health departments at all levels should continuously improve the capacity of primary medical and health services and integrate and upgrade regional medical resources. Medical insurance departments at all levels should further promote the reform of medical insurance payment methods, improve the incentive and restraint mechanism of medical insurance to standardize medical behavior and control medical expenses, improve the enthusiasm of medical institutions at all levels to actively control fees, and improve the overall system of medical insurance outpatient service for urban and rural residents and the differential payment policy for hospitalization expenses of medical institutions at different levels. For eligible inpatients, the deductible line can be calculated continuously, guiding patients to choose primary treatment, standardizing referral and orderly seeking medical treatment.
Verb (abbreviation of verb) perfects the supervision mechanism
Establish a linkage working mechanism between the medical insurance department, the health department, the banking supervision department and relevant commercial insurance institutions, closely cooperate with each other, form a joint force, and strengthen the supervision of medical service behavior. Commercial insurance institutions, under the leadership of medical insurance agencies, undertake the responsibility of auditing and checking the occurrence of corresponding medical expenses, the payment of basic medical insurance and serious illness insurance funds, and strengthen the key verification of medical institutions' fraudulent insurance and irregular medical services. Medical insurance departments at all levels and banking supervision departments should improve the evaluation mechanism of commercial insurance institutions, and urge commercial insurance institutions to strengthen supervision over the use of medical insurance funds while improving service management efficiency. Health departments at all levels should strengthen industry guidance and supervision, improve the long-term supervision mechanism of medical institutions and their medical staff's diagnosis and treatment behavior and internal management, and standardize medical service behavior.
Six, establish a long-term mechanism for medical security and poverty alleviation.
Medical insurance departments at all levels should focus on the special poor groups and weak links of medical security in the "two worries and three guarantees" and give full play to the role of basic medical insurance, serious illness insurance, serious illness supplementary insurance and medical assistance. Medical insurance, finance, health, poverty alleviation, civil affairs and other departments at all levels should strengthen coordination and cooperation, accurately grasp all kinds of medical security policies formulated by local governments, combine the treatment standards of poor people, strictly follow the existing payment scope and established standards, ensure that they are in place, and do not blindly raise standards and keep their appetite, so as to prevent medical security commitments from being excessively divorced from reality. Establish a long-term mechanism to prevent and solve poverty caused by illness and return to poverty due to illness. Before the end of 2020, all kinds of existing medical security policies will be smoothly incorporated into the framework of the four-fold security system of basic medical insurance, serious illness insurance, serious illness supplementary insurance and medical assistance in our province.