Xinxiang City basic medical insurance knowledge quiz questions
1, the establishment of urban workers basic medical insurance system principles?
Answer: The principle of establishing the basic medical insurance system for urban workers is that the level of basic medical insurance should be compatible with the level of development of productive forces at the primary stage of socialism; secondly, all urban employers and their employees should participate in the basic medical insurance, and local management should be carried out; thirdly, the costs of basic medical insurance should be borne by the employer and the employee **** the same burden; and fourthly, the basic medical insurance fund should carry out a The basic medical insurance fund is a combination of social coordination and individual accounts.
2. What is the composition of the basic medical insurance fund?
A: The basic medical insurance fund consists of a centralized fund and individual accounts.
3. Who pays the basic medical insurance premiums?
A: Basic medical insurance premiums are paid by both employers and employees.
4. What are the contribution rates for employers and employees?
Answer: The contribution rate of the employer is about 6% of the employee's gross salary, and the contribution rate of the employee is generally 2% of his/her salary.
5. What are the payment standards of the basic medical insurance fund? What is the maximum payment limit in principle?
Answer: In principle, the payment standard of the basic medical insurance fund is controlled at about 10% of the average salary of local employees, and the maximum payment limit is controlled at about 4 times of the average annual salary of local employees.
6, the basic medical insurance premiums paid by the employer, the party and government organs and fully-funded institutions, other institutions, enterprises, active employees, retirees, how to charge?
A: the basic medical insurance premiums paid by the employer, the party and government organs and fully funded institutions by the financial arrangements at all levels of finance; other institutions from the business income or operating income; enterprises in the active employees from the welfare costs; retirees from the labor insurance premiums.
7, the owners of urban individual economic organizations and their employees to participate in the local basic medical insurance, (the year of the new unit) unit and individual contributions to the base?
Answer: If the owners of urban individual economic organizations and their employees participate in the local basic medical insurance, the contributions of the units and individuals are based on the average salary of local employees in the previous year. New units in the current year unit and individual contributions to the previous year's average salary of employees as the basis.
8. What are the three catalogs of basic medical insurance?
A: The three catalogs of basic medical insurance refer to the catalog of medicines; diagnostic and treatment items; and the scope of medical service facilities.
9. What is the two management of basic medical insurance?
A: The two basic medical insurance management is the designated medical institutions and designated retail pharmacy management.
10: What are the principles of the social medical insurance agencies to determine the designated retail pharmacies?
A: social health insurance agencies to determine the principles of designated retail pharmacies, first, to ensure that the variety and quality of basic health insurance medicines; second, to introduce a competitive mechanism, reasonable control of the cost of pharmaceutical services; and third, to facilitate access to medicines for the insured and easy to manage.
11, what is the designated medical institutions?
A: A designated medical institution is a medical institution that provides medical services to urban workers' basic medical insurance participants, which is examined by the labor security administrative department of the coordinating area and determined by the social insurance agency.
12. What are the medicines listed in the Medicines Catalog of Basic Medical Insurance?
A: The medicines listed in the Medicines Catalog of Basic Medical Insurance include western medicines, proprietary Chinese medicines and Chinese herbal medicines (including ethnic medicines). The first two are divided into Class A and Class B catalogs.
13. What is the scope of basic medical insurance?
A: All urban employers and their employees in the province, including enterprises and their employees, party and government organs and their staff, institutions and their employees, social organizations and their full-time staff, and private non-enterprise units and their employees, are required to participate in basic medical insurance. Individual urban industrial and commercial households and their employees are also required to participate in basic medical insurance. Township enterprises and their employees are deferred.
14. How are basic medical insurance premiums paid?
A: Basic medical insurance premiums are paid by the employer and entrusted to the bank on behalf of the two ways to pay, the basic medical insurance paid by the individual employee by the employer from the wages of the individual employee on behalf of the withholding and payment.
15, bankruptcy, the abolition of the unit retirees of basic medical insurance premiums how to pay?
A: bankruptcy, the abolition of the basic medical insurance premiums for unit retirees, by the original unit in accordance with the local retirees per capita medical fees for a one-time payment of 10 years of basic medical insurance premiums, by the local social insurance agency responsible for their basic medical treatment.
16. What expenses are not included in the scope of basic medical insurance premiums?
Answer:The medical expenses required for work-related injuries and childbirth of enterprise employees are not included in the scope of basic medical insurance premiums.
17What kind of personnel's medical treatment remains unchanged, and medical expenses are settled according to the original funding channels?
Answer: the medical treatment of the four categories of personnel: retirees, the Old Red Army, soldiers with revolutionary disabilities above the second class B, and college and university students at school will remain unchanged, and medical expenses will be settled in accordance with the original funding channels.
18, the province to establish a basic medical insurance system for urban workers to take what approach?
Answer: The province's work to establish a basic medical insurance system for urban workers has taken the approach of first pilot, steadily advancing, and comprehensively expanding.
19. What are the three counties and one city in our province where the reform of the basic medical insurance system for urban workers has been piloted first?
A: the province's basic health insurance system for urban workers to reform the pilot three counties and one city is Xinmi City, Fugou County, Luanchuan County, Anyang City.
20, basic medical insurance medical service facilities costs mainly include what?
A: Basic medical insurance medical service facilities costs mainly include hospitalization beds and outpatient (emergency) beds.
21. What are the two fixed points, three catalogs and settlement methods?
A: Determination of the two fixed-point clarifies the object of payment of the basic medical insurance fund. Determine the three directories to clarify the scope of payment of the basic medical insurance fund. The determination of the settlement method specifies the payment method of the basic medical insurance fund.
22, the basic medical insurance does not pay the cost of diagnosis and treatment programs are mainly?
A: Basic medical insurance does not pay the cost of diagnostic and treatment programs are mainly non-clinical treatment is necessary, the effect of the diagnostic and treatment programs are uncertain, as well as belonging to the special medical services of the diagnostic and treatment programs.
23. What are the basic medical insurance service facilities?
A: Basic medical insurance service facilities refer to the living service facilities provided by the designated medical institutions, which are necessary for the participants in the process of receiving diagnosis, treatment and care.
24. What are the main ways of settling basic medical insurance expenses?
A: The main settlement methods for basic medical insurance fees are service item settlement, total prepayment settlement and service unit settlement.
25: In the early stage of the establishment of the basic medical insurance system, under what circumstances can the coordinating regions adopt the method of establishing a risk fund for the transition?
Answer: In the early stage of the establishment of the basic medical insurance system in the integrated regions, in the event that more than 95% of the urban workers do not participate in the insurance system, and in the event that the number of retirees of the insured units exceeds the number of active workers by more than 30%, the method of establishing a risk fund can be adopted for the transition.
26, China's medical insurance system reform in the pilot of the three "united accounts" approach?
Answer: China's health insurance system in the reform of the pilot three kinds of "united accounts" approach, namely, channel, plate and three gold type.
27. What are the three types of accounting statements for social health insurance?
A: Social health insurance accounting statements are divided into monthly, quarterly and annual statements.
28, according to the source and flow of health insurance fund, health insurance business management is divided into which basic links?
A: According to the source and flow of medical insurance fund, the management of medical insurance business is divided into six basic links: contribution approval, cost collection, cost record processing, treatment approval, treatment payment, fund accounting and financial management.
29. What is the social medical insurance system?
A: is the state through legislation, mandatory by the state, units and individuals to pay medical insurance premiums, the establishment of a medical insurance fund, when individuals need to obtain necessary medical services due to illness, by the social health insurance institutions in accordance with the provisions of the medical cost compensation of a social insurance system.
30. What is the difference between the basic medical insurance system and the public and labor insurance medical system?
Answer: The establishment of the basic medical insurance system for urban workers is a systematic innovation and mechanism transformation of the current public and labor insurance medical system:
One is to change the state's unlimited responsibility in the past to protect the basic medical care of workers, and to realize the change from welfare protection to social insurance.
The second is to change the past state and enterprises to take over the workers' medical expenses for the unit and individual **** the same contributions, increased individual self-insurance responsibility to realize the unity of rights and obligations.
Thirdly, it has changed the past decentralized management of each unit to socialized management, realizing the integrated **** relief of the medical insurance fund.
Fourth, the implementation of the combination of social coordination and individual accounts, the establishment of medical, patients and insurance tripartite constraints mechanism.
31. What are the tasks and principles of the reform of the medical insurance system?
Answer: The main task of the reform of the medical insurance system is to establish a basic medical insurance system for urban workers, i.e., to adapt to the socialist market economic system, and to establish a social medical insurance system that insures the basic medical needs of workers in accordance with the affordability of finances, enterprises and individuals.
The four principles for the establishment of a basic medical insurance system for urban workers are as follows:
First, the level of basic medical insurance should be commensurate with the level of development of productive forces at the primary stage of socialism.
The second is that all urban employers and their employees should participate in basic medical insurance, and local management should be practiced.
Third, basic medical insurance premiums are borne by both employers and employees***.
Fourthly, the basic medical insurance fund is a combination of social coordination and individual accounts.
32. What is the source of funds for individual accounts?
Answer: Individual account funds come from two parts:
One is that all the medical insurance premiums paid by individual employees are credited to the individual account.
The second is the basic medical insurance premiums paid by the employer are transferred to the individual account at about 30%, the specific proportion is determined by the coordinating area according to the scope of payment of the individual account and the age of the employee and other factors.
The principal and interest of the individual account are owned by the individual and can be carried forward and inherited.
33. How does the basic medical insurance system take care of retirees?
Answer: First, it is clearly stipulated that retirees do not pay basic medical insurance premiums, in order to reduce their burden.
The second is to require localities to determine the proportion of the employer's contribution to the individual account to take into account the age factor, the older the age, the higher the proportion of the unit's contribution to the individual account, the proportion of the retiree's individual account is higher than that of the active workers.
Thirdly, the proportion of medical expenses borne by individuals should be taken care of by the localities for the retirees when they are paid by the centralized fund.
34. What principles should be followed in reviewing and determining the designated medical institutions for basic medical insurance?
Answer: In order to implement the fixed-point effectively introduce a competitive mechanism to strengthen and standardize the management of the fixed-point institutions, reasonable control of medical cost growth to protect the basic medical needs of employees, while also with the supporting reform of health care institutions and related policies, the review to determine the fixed-point institutions should be guided by the following principles: First, it should be convenient for the insured personnel to seek medical treatment and facilitate the management; the second to take into account the specialties and comprehensive, Chinese medicine and Western medicine, pay attention to play the role of community health service institutions; third is conducive to promoting the optimal allocation of medical and health resources, improve the efficiency of the use of medical and health resources, reasonable control of medical service costs and improve the quality of medical services.
35, try to describe the main advantages and disadvantages of the three settlement methods?
Answer: the total prepayment is a relatively strong planned cost settlement. There are three main advantages: First, the workload and cost of medical service providers have a high degree of control, is a reliable and effective way to control medical costs, it can make the medical institutions can not arbitrarily expand the services, hospitalization days and the number of patients; Second, is conducive to the role of the medical supply side of the change. As the total prepayment prescribes the total amount of costs, so that the medical supply side not only to control costs, but also to improve the quality of services on the initiative of efforts to struggle, in order to make gains in the economy, so that the medical supply side from the control of health care consumption of the negative party, or even to engage in the party, into a proactive participant in the party to achieve the purpose of the rational use of health resources and health costs; Third, because of the control of health care consumption and the cost of Thirdly, as the initiative of controlling medical consumption and costs is given to the medical service providers, the payment work of the medical insurance organizations mainly focuses on the formulation of budgets and the review of budget execution, which makes the management costs of medical insurance decrease while the supervision is more effective.
The development of the total budget and the audit of budget execution have reduced the management cost of health insurance and made the supervision more effective at the same time.
The disadvantages of the total budget approach are: first, it is difficult to formulate a scientific and reasonable budget amount, the budget is set at a high level, which will lead to unreasonable growth in the medical supply; the budget is set at an insufficient level, which will affect the enthusiasm of the hospitals and the interests of the patients; secondly, after the implementation of the total control, if there is a lack of corresponding supervision measures, the medical supply side may have unreasonable behavior to reduce the expenditures, such as obstructing the Patients hospitalized for treatment, subtracting some necessary medical services, etc.; Third, the budget method will reduce the role of the market, will affect the vitality of medical suppliers to proactively provide services and develop business, the quality of services, service attitude may decline, and queuing up for medical treatment and hospitalization may occur.
Settlement by service item is one of the most traditional and widely used ways of settling medical expenses, and it is the traditional form of postpaid system. Its advantages are: easy to operate, low administrative costs, wider scope of application, applicable to outpatient medical services, suffering from the outpatient services of large hospitals. The disadvantages are: since this form of fee settlement is characterized by a direct link between the hospital's income and the amount of medical services it provides, it is easy to induce the provider of medical services to provide excessive medical services. Hospitals or doctors have the right to decide whether a pathogenic person needs intensive care, all kinds of tests, and expensive imported drugs, and hospitals may increase the number of services and the amount of services, and prolong the length of hospitalization in order to obtain more reimbursement. In addition, since both hospitals and patients are not concerned about cost savings, there is also the possibility of joint fraud by the two to deceive health insurance organizations. This is not only one of the main factors causing the price of medical services to rise, but also one of the main factors causing the cost of medical care to rise. Since medical insurance organizations can only review the service items and charge bills reported by hospitals after the fact, it is difficult to control medical costs effectively, and thus they are weak in controlling medical costs.
Settlement by service unit is to divide the process of medical service into identical parts according to a specific parameter, and each part becomes a service unit. For example, an outpatient visit, an inpatient bed day, and so on. In this kind of settlement, the hospital can get more reimbursement through two ways: one is to reduce its own service unit cost so that it is lower than the average standard, which can be realized by strengthening the management, improve the level of technology, and may be achieved by shirking the heavy patients, and more patients with light diseases as well as reducing the service; the second is to increase the number of services, which can be achieved by sending services to attract patients, and can be realized by breaking down the number of services. The impact of the highly democratic settlement method on the quality of medical care varies according to the different responses of hospitals, which can stimulate hospitals to improve their services and raise the standard of medical care, or stimulate hospitals to shirk patients with serious illnesses, break down the number of services, and provide excessive medical care, resulting in inconvenient access to medical care for patients and lowering the quality of medical services.
36. How should the operator pay for the beds?
Answer: If the actual bed fee standard of the insured person is lower than the payment standard of the basic medical insurance hospitalization sparrow leap fee, the actual bed fee standard shall be paid according to the provisions of the basic medical insurance; if it is higher than the payment standard of the basic medical insurance hospitalization bed fee, the cost within the payment standard shall be paid according to the provisions of the basic medical insurance, and the exceeding portion shall be paid by the insured person himself/herself.
37. What are the principles of basic medical insurance expense settlement management?
Answer: the basic medical insurance fee settlement management for urban workers should mainly follow three principles: firstly, it is necessary to have control over medical costs to ensure the balance of income and expenditure of the integrated fund; secondly, it is necessary to facilitate the behavior of medical services to protect the basic medical care for workers; thirdly, it is necessary to have to improve the level of basic medical social management services to facilitate the workers' access to medical care and purchase of medicines.
38, the medical insurance fund how to calculate interest?
A: the basic medical insurance fund raised in the year, the interest rate on demand deposits; the previous year's carry-over of the fund principal and interest, according to the three-month period of whole deposit bank deposit rate interest rate; deposited in the social security financial account of the deposited funds, compared to the three-year zero deposit savings deposit rate interest rate; and not less than the level of the rate of interest of the grade. The principal and interest of the individual account are owned by the individual and can be carried forward for use and inheritance.
39. What are the principles of medical benefits for state civil servants?
Answer: the implementation of medical subsidies for national civil servants, the purpose is to protect the reasonable medical needs of national civil servants, to maintain civil servants to participate in the basic medical insurance after the original medical treatment basically does not decline; "on the implementation of medical subsidies for national civil servants," the views on the implementation of medical subsidies for national civil servants clearly the implementation of the four principles of medical subsidies for national civil servants: First, to ensure that the national civil service of the reasonable medical needs; the second subsidy level to be with the financial capacity to afford. The first is to ensure that the reasonable medical needs of national civil servants are met; the second is that the level of subsidies should be commensurate with the financial burden, and should not excessively increase the financial burden; the third is that medical subsidies should be linked to basic medical insurance; and the fourth is that medical subsidies should be utilized in a rational manner, and that they should be used in a prudent and economical manner.
40, basic medical insurance why the implementation of designated medical institutions management?
Answer: the implementation of basic medical insurance sentinel medical institution management, is to strengthen the fund expenditure management, strengthen the management of medical services, control the growth of medical costs is an important means. If the implementation of a wide range of fixed-point, patients at any medical institutions, there will be patients "flying all over the place", so that the medical management out of control; such as the staff of the medical restrictions are too rigid, the provisions of the staff can only be a fixed-point medical institutions, and most of them are set in the level of high hospitals, not only is not convenient to the staff of the medical treatment, but also high-cost medical services millions of dollars! This not only makes it inconvenient for employees to seek medical treatment, but also reduces the efficiency of utilizing the medical insurance fund by wasting money on high-cost medical services. Therefore, it is necessary to implement the management of designated medical institutions, which is also a clear requirement put forward by the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Employees.
41. What are the main levels of the multi-level medical insurance system?
Answer: The multi-level medical insurance system should mainly include three levels: first, the basic medical insurance; second, the enterprise supplementary medical insurance and commercial medical insurance; third, the social medical assistance; in addition, it also includes the civil servants' medical subsidies, employees' medical mutual aid protection and special groups of people's medical insurance and other forms of auxiliary system.
42. How to improve the management and supervision mechanism of the basic medical insurance fund?
Answer: The management of the fund is related to the normal Qaibao of the entire basic medical insurance system and the immediate interests of the employees, to strengthen the supervision of the fund and improve the system from five aspects:
One is that the basic medical insurance fund into the management of the special account of the treasury, earmarked for special purposes, and shall not be squeezed or misappropriated.
The second is to establish and improve the social insurance agency budget system, financial accounting system and audit system.
Third, the social insurance agency's business expenses can not be summarized from the fund by the local financial budget.
Fourth, labor security departments at all levels and financial departments to strengthen the supervision of the fund, the audit department should be regularly on the social insurance agency fund income and expenditure and management audit.
Fifth, the coordinating regions should set up medical insurance fund supervision organizations with representatives of the relevant government departments, employers, medical institutions, trade unions and relevant experts to strengthen social supervision.
43. What is a designated retail pharmacy?
A: A designated retail pharmacy is a retail pharmacy that has been examined by the labor security administrative department of the coordinating area and determined by the social insurance agency to provide prescription dispensing services for urban employee medical insurance participants.
44. What are basic medical insurance medical service facilities? What does its cost mainly include?
Answer: Basic medical insurance medical service facilities are the living service facilities provided by designated medical institutions, which are necessary for the participants to receive diagnosis, treatment and care.
The cost of basic medical insurance medical service facilities mainly includes hospitalization beds and outpatient (emergency) observation beds. The basic medical insurance fund does not pay for the daily necessities, in-hospital transportation supplies, water and electricity that are already included in the in-patient bed charges or out-patient (emergency) observation bed charges, and the designated medical institutions are not allowed to charge the insured persons separately.
45. What is prescription dispensing?
Answer: It refers to the behavior of insured persons who purchase medicines at designated retail pharmacies with prescriptions after seeking medical treatment at designated medical institutions.
46: What is the Early Warning Reporting System for Overspending of the Coordinated Fund?
A: The integrated fund overspending early warning reporting system mainly includes: First, when the integrated fund overspending, the basic medical insurance agency shall immediately report to the social security administrative department and the competent leadership of the government to seriously analyze the reasons and study the countermeasures. If necessary, the people's government will coordinate with the relevant departments and *** with the measures taken. Secondly, if the integrated fund exceeds its expenditure by more than 5% in the current year or by more than 10% cumulatively over a period of three years, the government shall instruct the relevant departments to earnestly find out the reasons, strictly control expenditures and strengthen management. For policy reasons caused by the overspending, should be appropriate high-speed policy, the cost of its overspending, coordinated by the local government to solve the problem. Specific measures, developed by the local governments.
47, the basic medical insurance contribution base is what? How is the employee's gross salary determined?
Answer: The contribution base for basic medical insurance is: the employer takes the total salary of the employee as the contribution base as stipulated by the state; the employee takes his/her salary income of the previous year as the contribution base.
According to the relevant regulations of the National Bureau of Statistics, the total wages of employees refers to the total amount of labor remuneration paid directly to all employees of each unit during a certain summer period. The calculation of the total wages of employees should be based on the total labor remuneration paid directly to the employees. It includes six parts: hourly wages, piecework wages, bonuses, allowances and subsidies, overtime and overtime wages, and wages paid under special circumstances.
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