Benxi City urban workers basic medical insurance outpatient *** relief protection mechanism implementation rules
Chapter I General Provisions
Article 1 According to the On the Establishment of a Healthy and Complete Urban Workers Basic Medical Insurance *** Relief Mechanism
According to the On the Establishment of a Healthy and Complete Urban Workers Basic Medical insurance outpatient *** relief protection mechanism of the implementation of the views "(LiaoZhengBanFa 202139) and" on the issuance of Benxi City to establish and improve the implementation of basic medical insurance outpatient *** relief protection mechanism of the notice "(BenZhengBanFa 202219) of the relevant provisions of the city, combined with the actuality of the city, the formulation of these rules.
Second Since November 1, 2022, the establishment of Benxi City urban workers basic medical insurance (hereinafter referred to as "employee health insurance") outpatient co-ordination system, general outpatient expenses into the co-ordination fund to pay the scope of the reform of the individual account credit method, adjust the scope of use of the individual account, adjust the individual account. The system will include general outpatient expenses in the scope of the integrated fund, reform the method of crediting individual accounts, adjust the scope of use of individual accounts, improve the efficiency of fund use, gradually reduce the burden of medical expenses on insured persons, and realize a fairer and more sustainable system.
Article 3 departments to establish and improve the employee health insurance outpatient *** relief protection mechanism as an important livelihood work to grasp, strengthen the coordination, ensure the implementation of the place.
The city's medical insurance department is responsible for the city's outpatient coordination of the organization, management, guidance and supervision. The counties (districts) medical insurance department is responsible for the implementation of outpatient co-ordination fund supervision and management within the administrative region, and do a good job of related publicity work. Medical insurance agencies at all levels are responsible for outpatient integrated medical service management, medical treatment payment and integrated fund settlement and other management services. The municipal finance department is responsible for the supervision and use of the medical insurance fund within the scope of responsibility, with the medical insurance department to settle the costs of the designated medical institutions in a timely manner. Municipal social welfare departments are responsible for timely provision of basic pension insurance average level of retirees in our city and other relevant data. Health departments at all levels are responsible for supervising medical institutions to timely purchase of drugs for the treatment of common and frequent diseases, strengthen the supervision and evaluation of medical institutions, and promote the standardization of diagnostic and treatment behavior of the designated medical institutions to improve the level of medical technology to provide quality medical services for the insured.Market supervision and management departments at all levels are responsible for strengthening the production and circulation of drugs supervision, crack down on illegal activities such as selling drugs.
Chapter II Outpatient Coordination System
Article 4 On the basis of doing a good job to protect the public burden of outpatient special medical expenses, the establishment of employee health insurance outpatient coordination system, will be the fixed-point medical institutions in line with the basic medical insurance scope of the disease, the common illnesses, the general outpatient expenses, the city's medical insurance, and the medical insurance system. The outpatient medical expenses of common diseases and emergency treatment in the city are included in the scope of payment by the coordinated fund. Outpatient special and chronic diseases, high-value medicines, and out-of-town and out-of-area long-term residents outside the place of record of the emergency rescue and hospitalization of medical costs are not included in the scope of outpatient co-ordination of the Employees' Medical Insurance, in accordance with the implementation of the original policy.
Article 5 These rules are applicable to all participants of the city's employee health insurance.
Article Outpatient co-ordination fund to implement a separate account, and hospitalization and outpatient special illnesses and other co-ordination fund can be used in a coordinated manner, according to the operating conditions of the general outpatient co-ordination of the treatment and payment policy can be adjusted appropriately. Participants do not need to pay separately.
Article 7 Outpatient coordinated medical expenses are not included in the participants of the basic medical insurance ceiling line accumulation, large insurance does not pay. Outpatient outpatient medical expenses below the threshold and within the limit of individual out-of-pocket expenses are included in the scope of reimbursement of state civil servants' medical subsidies, and the reimbursement rate is 50%.
Article 8 In a natural year, the outpatient outpatient starting standard is 300 yuan per person per year, the maximum payment limit is 3000 yuan per person per year. The outpatient expenses below the maximum payment limit above the starting standard are paid by the integrated fund. For outpatient services of the three-level comprehensive designated hospitals, the payment ratio for active employees and retirees is 50% and 55% respectively; for the three-level traditional Chinese medicine and the two-level and the following designated hospitals, the payment ratio is 60%; and for outpatient services of the grassroots designated medical institutions that have implemented the management of basic medicines, and of the designated medical institutions specializing in psychiatric and infectious diseases, the payment ratio is 70%.
Article 9 long-term residents living in a different place of residence in the outpatient network settlement of outpatient outpatient medical expenses incurred by the designated medical institutions with reference to the above outpatient outpatient coordinated treatment standards, of which the coordinated fund to pay the proportion of the level of implementation of the designated medical institutions, without distinguishing between traditional Chinese medicine and specialties. In the event that immediate settlement is not possible for a long period of time due to system maintenance, epidemic control, etc., the insured person can advance the full amount of the medical expenses first, and then declare to the municipal and county medical insurance agencies by himself or by proxy to reimburse the outpatient medical expenses manually according to the date of outpatient medical expenses and the relevant provisions of outpatient co-ordination.
Article 10 The general outpatient expenses incurred by the temporary medical personnel (including those who have been referred to other places for medical treatment, those who have been rescued from other places in case of emergency and those who have been temporarily out of the country) for medical treatment in other places shall not be included in the scope of payment of the outpatient co-ordination.
Article 11 The scope of payment of outpatient treatment is unified in accordance with the national and provincial basic medical insurance drugs, diagnosis and treatment, medical service facilities and medical consumables and other items of the scope of the payment standards and management methods.
Article 12 All levels of designated hospitals (including unclassified hospitals), the implementation of basic drug management of the primary designated medical institutions can undertake outpatient co-ordination business, included in the management of the Benxi City Medical Insurance designated medical institutions service agreement.
Article 13 Participants can choose their own outpatient coordinated fixed-point medical institutions to enjoy real-time outpatient coordinated treatment. Outpatient expenses at non-outpatient designated medical institutions will not be reimbursed.
Article 14 Participants with social security cards, identity cards or health insurance electronic vouchers in the designated medical institutions outpatient medical care, the designated medical institution doctors must check the patient and the relevant documents, verification is correct before giving treatment. Chronic disease prescription is controlled within 4 weeks, due to epidemic prevention and control and other special circumstances may be appropriate to extend the maximum of 12 weeks.
Article 15 The outpatient coordinated fund shall pay for the outpatient medical expenses incurred by the participants in accordance with the regulations. The medical expenses paid by the coordinated fund shall be settled between the medical insurance agency and the designated medical institution in accordance with the relevant provisions of the basic medical insurance settlement management methods of Benxi City, and the specific settlement management shall be carried out in accordance with the provisions of the medical insurance service agreement.
Chapter 3 Individual Account Management
Article 16 Reform of the unified account combined with the individual account of the insured. Starting from January 1, 2023, the individual accounts of active employees will be credited according to 2% of their contribution base, and the individual accounts of retirees will be credited according to a fixed amount of 2% of the average basic pension of retirees in 2022 (the point of reform in our city), i.e., 60 yuan per person per month.
Article 17 standardize the scope of use of personal accounts. Individual account funds (including the cumulative balance of the original individual account before the reform) is mainly used to pay the insured person in the designated medical institutions within the scope of the policy of out-of-pocket expenses. It can be used to pay for the medical expenses incurred by the insured person, his/her spouse, parents and children at the designated medical institutions, as well as the expenses incurred by the insured person at the designated retail pharmacies for the purchase of medicines, medical equipments and medical consumables within the scope of the policy. Gradually realize the use of individual accounts for the personal contributions of spouses, parents, and children to participate in urban and rural residents' basic medical insurance, long-term care insurance, employees' large medical subsidies, and health commercial insurance filed with the municipal medical insurance administrative department. Individual accounts shall not be used for public **** health expenses (except those permitted by national policy), sports and fitness or health care consumption, and other expenditures that do not fall within the scope of basic medical insurance protection. Improve and perfect the management of the use of individual accounts, and do a good job of statistics on income and expenditure information.
Article 18 the individual account fund has been paid by the medical expenses, the employee health insurance fund, employee medical subsidy insurance, civil service medical subsidies, medical assistance and other medical insurance funds will not be repeated reimbursement.
Chapter IV Strengthening Fund Management
Article 19 Medicare departments should rationalize the budget of the health insurance fund, and do a good job in the outpatient coordinated fund-raising and payment management, to strengthen the intelligent monitoring of the health insurance, strengthen the day-to-day supervision, and together with the financial, health care and other departments to combat fraudulent insurance fraud, to ensure that outpatients are not subjected to any fraudulent behavior. Fraudulent insurance behavior, to ensure the safe operation and rational use of the outpatient coordinated fund. Medical insurance agencies should strengthen the audit work, the violation of outpatient co-ordination provisions resulting in unreasonable outpatient co-ordination cost expenditure, according to the relevant provisions of the health insurance service agreement.
Article 20 the designated medical institutions in the service place, staffing, technical equipment, services, service time and other aspects should be in accordance with the relevant provisions of the requirements should be improved hospital information management system, and according to the city's unified outpatient outpatient co-ordination of real-time settlement of the software interface requirements, and the basic medical insurance electronic settlement system to achieve data docking to realize the medical expenses real-time settlement. Real-time settlement of medical expenses.
Article 21 the designated medical institutions and staff must strictly implement the relevant departments of the state to formulate the diagnosis and treatment norms, reasonable and lawful practice of medicine, shall not collude with the patient fabrication of medical records and inspection information, the series of drugs, illegal outpatient co-ordination fund; once found, that is, to recover the outpatient co-ordination fund obtained in violation of the law, and by the municipal healthcare Security department depending on the severity of the case ordered to rectify, notify and criticize, cancel the qualification of the fixed-point, until the pursuit of legal responsibility.
Article 22 Participants should respect the medical staff's diagnostic and treatment decisions, shall not interfere with the medical staff's diagnostic and treatment behavior, shall not be false, impersonation, private alteration of documents, etc., once found, the person directly responsible for the recovery of outpatient outpatient coordination fees have been paid, and depending on the severity of the case, suspension of outpatient coordination of their treatment. Anyone who disagrees with the payment of the outpatient coordinated treatment can make inquiries or reflect the disagreement to the medical insurance agency or the designated medical institution, or file a complaint with the medical insurance department.
Chapter V Supplementary Provisions
Article 23 Outpatient co-ordinated fund raising standards and methods, medical treatment payment ratio, limit, scope of adjustment, the city medical insurance department according to the city's economic development, level of health care consumption, as well as outpatient co-ordination of the fund income and expenditure to make corresponding adjustments. Adjustment.
Article 24 These rules shall come into force on November 1, 2022, and the previous policies are not in line with the spirit of these rules. If the previous policy is inconsistent with the spirit of this rule, it shall be implemented in accordance with this rule.
Article 25 These rules shall be interpreted by the Municipal Health Protection Bureau.