First, open up institutional channels and expand the scope of insurance.
1. Expand the scope of employees' medical insurance, and include flexible employees who meet the national and provincial regulations and have their place of employment or household registration in this city into employee medical insurance.
2. The medical insurance coverage of urban and rural residents will be expanded, and the holders of Guangdong Residence Permit who are handled in this city and are within the validity period, and the unemployed Hong Kong, Macao and Taiwan residents who live in this city and apply for residence permits of Hong Kong, Macao and Taiwan residents will be included in the medical insurance coverage of urban and rural residents in Guangzhou.
3. Expand the scope of personnel who can participate in medical insurance for urban and rural residents in the middle of the year, and stipulate that retired soldiers can participate in medical insurance for urban and rural residents in the middle of the year.
The "Regulations" have improved the types of treatment guarantees for employees' medical insurance participants when they pay back, and safeguarded the rights and interests of employees' medical insurance participants to the maximum extent.
Second, the top ten changes in employee medical insurance, * * * economic security is more powerful.
1. The maximum payment limit of general outpatient service has been changed from monthly limit to annual limit, which has been greatly improved.
Adjust the maximum payment limit of general outpatient service from the monthly limit to the annual limit, and the annual limit is: 5% of the average annual salary of employees in this city last year and 7% of the average annual salary of retirees. According to the calculation, the annual maximum payment limit of general outpatient service in 2023 is about 7 200 yuan for employees, 3 600 yuan higher than the current limit, and 10/00 yuan for retirees, 6 500 yuan higher than the current limit.
After adjusting the monthly limit to the annual limit, the insured not only greatly increases the reimbursement amount, but also has a longer time limit for the reimbursement amount to be used as a whole. Insured people can make reasonable overall use within one year according to the actual outpatient demand, so as to better reduce the burden of medical expenses.
At the same time, it is clear that the general outpatient expenses paid by the overall fund are not included in the cumulative scope of the annual maximum payment limit of the basic medical insurance for employees.
* The annual maximum payment limit is the maximum amount that the insured can get reimbursement from the medical insurance fund within one year.
2. Increase the proportion of general outpatient payment.
The proportion of medical expenses incurred by retirees from eligible selected primary medical institutions in general outpatient service will be increased from 80% to 85%, an increase of 5 percentage points. For the medical expenses incurred in general outpatient clinics of specialized medical institutions and other selected medical institutions that meet the requirements, the self-payment ratio of employees and retirees will be increased to 65% and 70% respectively.
* Payment proportion refers to the medical insurance pooling fund paying the insured's medical expenses according to a certain proportion. The higher the proportion, the more money can be reimbursed.
3. Appropriately increase the proportion of payment for specific diseases in a class of outpatient clinics.
The proportion of basic medical expenses incurred by the insured in the treatment of outpatient specific diseases such as hypertension and diabetes in non-primary medical institutions has increased from 65% to 70%, which better guarantees the treatment of outpatient specific diseases of the insured.
4. Expand the scope of general outpatient co-ordination payment.
The scope of payment shall be implemented in accordance with the provisions of the basic medical insurance drug list, diagnosis and treatment project list and medical consumables list in Guangdong Province. The nuclear magnetic resonance projects and ct projects that citizens and friends care about can now be included in the overall payment scope of general outpatient clinics.
5. Adjust the personal account entry method.
In accordance with the requirements of the Implementation Measures for the Economic Security of the Basic Medical Insurance Outpatients in Guangdong Province issued by the General Office of the provincial government in February, 20021year, the personal account is adjusted. Among them, the monthly transfer standard of employee personal accounts is 2% of the monthly base; The monthly transfer amount of retirees is 2.8% of the average monthly basic old-age pension in each city in 202 1 year, and the personal account of retirees in our city is 169.08 yuan/month. Through this reform, Guangdong Province will replace a certain amount of funds from individual accounts into the employee medical insurance pooling fund. By revitalizing the deposited personal account funds, the economic benefits of the overall fund will be enhanced, and the level of overall treatment for employees' medical insurance general outpatient clinics will be improved simultaneously.
6. Reduce employee medical insurance hospitalization Qifubiaozhun.
Adjust the threshold for hospitalization of the insured in the first, second and third level designated medical institutions to: 250 yuan, 500 yuan, 1 1,000 yuan respectively. Compared with the original standard, when hospitalized in the first, second and third-level designated medical institutions, the number of on-the-job employees decreased by 150 yuan, 300 yuan and 600 yuan respectively, and the number of retirees decreased by 30 yuan, 60 yuan and 120 yuan respectively.
* Qifubiaozhun is the Qifubiaozhun of medical insurance fund. The medical expenses incurred by the insured in the "three directories" of designated medical institutions shall be borne by themselves below the deductible, and the medical expenses above the deductible shall be reimbursed by the medical insurance according to the regulations and proportions.
7. The upper and lower limits of the medical insurance payment base of the insured employees are low.
This time, the upper limit of employee medical insurance payment base will be adjusted from 300% of the average monthly salary of employees in this city last year to 300% of the average monthly salary of employees in full-caliber urban units in this city last year; The lower limit is adjusted from 60% of the average monthly salary of employees in this city in the previous year to 60% of the average monthly salary of employees in all-caliber urban units in this city in the previous year. Compared with the original standard, the upper limit of the payment base from June 5438 to February 2022 is about 9928 yuan, and the lower limit is about 1.905 yuan.
8. Employees' large medical expenses subsidies do not need to be paid separately, and the treatment remains unchanged.
The original medical subsidy for major diseases of employees and supplementary medical insurance for employees are merged into a large medical expense subsidy for employees. The original "Guangzhou Social Medical Insurance Measures" stipulated that the basic medical insurance rate for employees of the employer was 8%, the medical subsidy rate for employees with major diseases was 0.26%, and the supplementary medical insurance rate for employees was 0.5%, totaling 8.76%. This time, the basic medical insurance rate for employees of the employer will be adjusted to 6%, and the insured can enjoy the original medical subsidies for major diseases and supplementary medical insurance benefits for employees without paying large medical expenses subsidies for employees.
9. Clarify the payment methods and financing policies for retired deferred personnel.
Retirement extension personnel can choose monthly or one-time payment, and the payment base is implemented according to provincial regulations. The payment standard is the employer's rate of basic medical insurance for employees in this city.
10. The policy of medical treatment in different places is more flexible.
It is more convenient and beneficial to adjust the reimbursement policy for medical treatment in different places and the reimbursement policy for medical expenses related to those who enjoy maternity insurance benefits.
Iii. 1 Add the selection point of traditional Chinese medicine, and the selection point of outpatient service does not need to be "small" before "big".
1. Add selected points of traditional Chinese medicine as general outpatient medical institutions.
On the basis of the original choice of 1 grass-roots designated medical institutions and 1 other designated medical institutions, Guangzhou employees' medical insurance participants can choose 1 traditional Chinese medicine designated medical institutions as general outpatient medical institutions, and are allowed to buy medicines from designated retail pharmacies with external prescriptions.
2. Outpatient selection does not need to be "small" before "big"
To cancel the current general outpatient medical insurance for employees, it is required to choose designated medical institutions at the grassroots level first, and then choose other medical institutions to further facilitate the insured to seek medical treatment.
3. Support the development of primary medical institutions and promote primary medical services.
Community health service centers, community health service stations, town health centers and village health stations that realize integrated management will be managed according to unified selection. After the insured chooses the community health service center as the general outpatient medical institution, they can also go to the community health service station under the integrated management of medical institutions for outpatient treatment, so as to ensure the residents to seek medical treatment nearby.
4. Open up medical channels and support the development of medical associations.
Get through the medical channels of all designated medical institutions in the medical association, and the insured will be treated uniformly in the medical insurance association, that is, all grassroots designated medical institutions in the medical insurance association are regarded as 1 grassroots designated medical institutions, and other designated medical institutions in the medical insurance association are regarded as 1 other designated medical institutions.
5. Promote the development of "internet plus" medical care and facilitate online follow-up.
Further optimize the current medical insurance "internet plus" follow-up regulations, and the designated medical institutions approved by the health administrative department to carry out Internet diagnosis and treatment activities voluntarily apply to the medical security agency for signing a supplementary agreement to provide medical insurance Internet follow-up services for the insured who enjoy the treatment of outpatient specific diseases, and gradually expand the scope of medical insurance Internet follow-up services from a class of outpatient specific diseases to all outpatient specific diseases.
6. Optimize the reimbursement of sporadic medical expenses to better protect the rights and interests of the insured.
Further optimize the materials to be submitted by the insured for reimbursement of sporadic medical expenses, effectively reduce materials and increase convenience. At the same time, the time limit for applying for reimbursement of sporadic medical expenses of medical insurance was extended from 1 year to 3 years.