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Adjustment of medical insurance policy in Xiamen
It will be implemented from 1 next year.
Recently, in order to implement the unified deployment of the state and Fujian Province, the Xiamen Municipal Government issued the Detailed Rules for the Implementation of Medical Insurance for Employees in Xiamen and the Detailed Rules for the Implementation of Medical Insurance for Urban and Rural Residents in Xiamen (hereinafter referred to as the Detailed Rules). The "Detailed Rules" unified the medical insurance policies of migrant workers and workers in this city, simplified the reimbursement process of outpatient service, and enhanced the economic security function of outpatient service. The Detailed Rules will be officially implemented on June 65438+1 October1day, 2023.
Medical security is directly related to the vital interests of thousands of people. The state has made systematic arrangements for the reform and development of medical insurance. Since 2020, opinions have been issued to deepen the reform of medical insurance system, establish and improve the medical insurance mechanism for employees' outpatient service and the medical insurance treatment list system, and explicitly require the establishment of a unified medical insurance system framework, adjust the structure of pooling funds and personal accounts, increase the outpatient medical insurance pooling funds, and promote the vertical unification of medical insurance policies and the horizontal balance of treatment.
Our city has established the basic medical insurance system for employees 1997, the basic medical insurance system for urban residents in 2007 and the basic medical insurance system for urban and rural residents in 20 10. In order to implement the unified deployment of the state and the province, our city initiated the medical insurance policy reform this year. On the basis of integrating the basic medical insurance, serious illness insurance and maternity insurance for former employees and residents, combined with the actual situation of our city, the detailed rules were revised and promulgated. According to the requirements of the country and our province to deepen the reform of medical insurance system, we should further improve the current medical insurance system from the aspects of unifying the insurance policy, improving the outpatient co-ordination system and raising the maximum payment limit of serious illness insurance.
"One unification, one liberalization"
Realize a more perfect system.
The "Detailed Rules" unified the basic medical insurance policy for employees, and migrant workers paid the same fees and received the same treatment as employees in this city, freeing the household registration restrictions for flexible employees to participate in employee medical insurance.
"Unification": With the development of economy and society, the proportion of migrant workers in our city is increasing, which has played an important role in the construction of special economic zones. In order to further protect the rights and interests of migrant workers, the detailed rules unified the medical insurance policies of migrant workers and employees in this Municipality, adjusted the contribution rate of migrant workers' medical insurance units to be consistent with that of employees in this Municipality, and no longer distinguished the identities of migrant workers and employees in this Municipality. All on-the-job employees shall enjoy the same medical insurance benefits with a unified unit contribution rate of 7.5% and an individual contribution rate of 2%. At the same time, from June 1 to February 1 in 2023, the unit contribution rate decreased by 1 percentage point, that is, 6.5% was paid.
"One liberalization": In order to ensure the medical needs of flexible employees who are not registered in this city, the detailed rules have liberalized the household registration restrictions for flexible employees to participate in employee medical insurance. Non-registered workers of legal working age can participate in medical insurance for employees in this city as flexible employees as long as they hold valid residence permits in this city. The payment rate is 9.5%, and they enjoy the same medical insurance benefits as employees in this city, effectively protecting the rights and interests of workers in new employment forms. At the same time, the payment rate from June 1 to February 1 in 2023 was reduced by 1 percentage point, that is, it was paid by 8.5%, which lightened the burden of flexible employees.
"One Adjustment, Two Norms"
Strengthen the economic security function of outpatient service.
In accordance with the unified arrangements of the state and the province, the "Rules" strengthen the economic security function of the overall fund by adjusting the distribution of individual accounts for employees' medical insurance, standardizing individual accounts, and coordinating the policies for primary outpatient services.
"One Adjustment": Like other cities in China, the employee medical insurance in our city implements the security mode of combining social pooling with personal account, and the personal account of employee medical insurance has played an active role in promoting the transformation from public labor insurance medical system to social medical insurance system. However, with the development of social economy and the improvement of people's demand, the limitations of personal account security function and economy are gradually highlighted. This reform has strictly implemented the requirements of the state and the province on adjusting the personal account method and enhancing the economic security function of outpatient service. The specific adjustments are as follows: all the individual contributions of on-the-job employees are included in the personal account unchanged, and all the unit contributions are included in the overall fund; According to the regulations, the standard of individual accounts for retirees is set at 2.5% of the average basic pension level in the year when the reform was implemented, that is, the quota is 1 10 yuan per person per month. The personal account is adjusted from the original one-time annual pre-allocation to monthly allocation.
"two norms": first, the health account is merged into the personal account, and all the funds in the health account are transferred to the personal account; The second is to use basic drugs that have been included in the national medical insurance drug list in designated public medical institutions at the grassroots level. There is no threshold for outpatient co-ordination, and it is directly reimbursed by the co-ordination fund in proportion.
In 20 12, the city issued a health account policy, and part of the surplus funds in personal accounts were transferred to health accounts, which can be used to pay the medical expenses incurred by individuals in designated medical institutions and the medical expenses of family members of the insured in this city. Under the unified deployment of the whole province, the "Detailed Rules" incorporate the function of health account into personal account, and the insured person can also pay the medical expenses incurred by the insured family members in Fujian Province for medical treatment and medicine purchase at designated medical institutions, and pay the residents' medical insurance expenses. After adjustment, the personal account can be used more widely and efficiently.
The "Detailed Rules" standardize the original "insured persons enjoy the payment policy of 500 yuan as a whole fund for outpatient treatment in designated medical institutions at the grass-roots level in our city", and make it clear that the insured persons can seek medical treatment in designated public medical institutions at the grass-roots level and use the basic drugs included in the medical insurance catalogue without paying the outpatient Qifubiaozhun first, but can be directly reimbursed by the overall fund in proportion, without setting the 500 yuan limit. After standardization, it is consistent with the policies in the province, which reduces the burden of medical expenses for insured people, especially patients with chronic diseases, frequently-occurring diseases and common diseases.
"One simplification, one improvement and one inclination"
Improve the comprehensive safety level
The "Detailed Rules" simplified the outpatient reimbursement process, raised the maximum payment limit of serious illness insurance, gave preferential policies to the special care recipients, further improved the comprehensive security level of the insured, and firmly grasped the bottom line of people's livelihood.
"One simplification": Before the reform, the reimbursement of outpatient medical expenses was implemented in a "three-stage" mode, that is, the insured must first use up the funds in his personal account, then pay the outpatient qifubiaozhun, and then enter the overall reimbursement. After the reform, the "Detailed Rules" simplified the outpatient co-ordination reimbursement model from "three-stage" to "two-stage", that is, the insured can enter the co-ordination reimbursement without exhausting the funds in his personal account and meeting the threshold. Personal account funds can be used to offset the out-of-pocket medical expenses above the outpatient qifubiaozhun. By simplifying the outpatient reimbursement process, the number of people enjoying the overall fund has been expanded, and the outpatient security level of the insured has been improved.
"One Improvement": At present, the maximum payment limit of serious illness insurance for employees and residents in our city in one year is 500,000 yuan and 400,000 yuan respectively. The detailed rules raise the maximum payment limit of employee and resident serious illness insurance to 1.654, 38+0.000 yuan and 500,000 yuan respectively. After the basic medical insurance is superimposed, the comprehensive security level reaches 1.2 million yuan and 600,000 yuan respectively, which further improves the protection of serious illness insurance.
"One tilt": The detailed rules implement a tilt payment policy for residents' serious illness insurance. For the minimum living security recipients and other medical assistance recipients who participate in residents' medical insurance, the minimum payment standard for serious illness insurance is reduced by 50%, the payment ratio is increased by 5 percentage points, and the maximum payment limit is cancelled. Through the inclined payment policy, we will build a second line of defense for the poor people who are poor due to illness.
Xiamen revised and introduced medical assistance measures
It will be implemented from 1 next year.
At the end of 20021,the state issued the Opinions on Improving the Medical Security and Assistance System for Serious and Extraordinary Diseases, which made unified arrangements for improving the medical security and assistance system for serious and extraordinary diseases. At the beginning of August this year, Fujian Province issued the "Implementation Opinions of the General Office of the People's Government of Fujian Province on Improving the Medical Insurance Assistance System for Serious and Extraordinary Diseases", requiring all localities to formulate specific implementation measures.
In order to implement the unified deployment of the state and Fujian Province, Xiamen recently revised and promulgated the Measures for Medical Assistance in Xiamen (hereinafter referred to as the Measures). The "Measures" focus on "precise assistance" by unifying and standardizing the medical assistance system, and do a good job in medical security for serious and serious diseases of people in need. The Measures will be officially implemented on June 65438+1 October1day, 2023. The main contents can be summarized as the following five aspects:
0 1
Standardize the scope of five types of relief objects
Medical assistance objects are divided into five categories:
The first category, poor families and orphans (including children who are actually unattended);
The second category, key special care recipients, revolutionary "five old" personnel, family planning special family members, severely disabled people;
The third category, the minimum living security object;
The fourth category, marginal family members with minimum living security;
The fifth category, poor and seriously ill patients due to illness. At the same time, those who meet the multiple assistance status will be given assistance according to the principle of high treatment, and will not enjoy medical assistance treatment again. Medical assistance objects that are no longer included in the Measures according to the national and provincial regulations can still be guaranteed in the following three ways: First, those who meet the conditions of assistance objects stipulated in the Measures can enjoy corresponding assistance treatment according to the first to fourth types of assistance objects; Second, those who meet the conditions of the fifth category of assistance objects, such as "patients who are poor or seriously ill due to illness", can get medical assistance upon application. Third, if the basic life is really difficult, you can get temporary assistance through the civil affairs department.
02
Clearly classify and subsidize insurance policies.
Give full funding to the first and second types of relief objects; Give a fixed subsidy to the third category of relief objects according to the proportion of 90%.
03
Reasonably adjust the minimum payment standard for assistance.
There is no Qifubiaozhun for the first, second and third types of relief objects, and the current standard in our city is continued; The minimum payment standard for the relief of marginal family members of the fourth category of minimum living guarantee is determined by about 10% of the per capita disposable income of residents in our city in 202 1 year, that is, 6000 yuan; The Qifubiaozhun for the fifth category of patients who are poor or seriously ill due to illness is set at 202 1 year, which is about 25% of the per capita disposable income of residents in our city, that is, 16000 yuan.
04
Continue the current rescue ratio in our city.
The current assistance ratio in our city remains unchanged, among which: the assistance ratio of the first type of assistance object is100%; The proportion of two or three types of relief objects is 95%; The proportion of assistance for the fourth category of assistance objects is 85%; The proportion of the fifth category of relief objects is 50%.
05
Appropriately raise the annual relief limit.
The relief limit of the first category of relief objects is still not capped, continuing the current standards of our city; The relief limit for the second to fifth categories of relief objects was uniformly adjusted to 6.5438+0.3 million yuan. Moreover, outpatient and inpatient assistance can use the annual assistance quota, and the comprehensive assistance guarantee is further strengthened, effectively helping to prevent and solve the problem of poverty caused by illness.
In addition, the city has also actively established and improved the following two supporting measures. First, by strengthening the dynamic monitoring and early warning of the high medical expenses of the needy people, we will improve the long-term mechanism for preventing and resolving poverty caused by illness. Second, by continuously promoting the convenience services such as "one-stop" real-time settlement of medical assistance expenses and "diagnosis before payment", the convenience of handling services will be continuously improved.