Chapter IV Outpatient Compensation
Twelfth participants in the new rural cooperative medical system, must carry identity cards (or household registration certificate) and medical insurance cards, in the city within the scope of independent choice of designated outpatient medical institutions, and enjoy outpatient medical expenses compensation according to the provisions of this program. No compensation will be given to those who do not carry the above card at the time of outpatient treatment settlement.
Article 13 The scope of outpatient compensation: medicine fee, injection fee, operation fee, medical treatment fee, laboratory test fee, examination fee and material fee.
Fourteenth outpatient compensation standard: according to the proportion of effective outpatient medical expenses 10%. The effective medical expenses for outpatient service are specifically approved with reference to the new rural cooperative medical system in Cixi City and the relevant provisions of the basic medical insurance for urban workers in Zhejiang Province, but Class A and Class B drugs are calculated according to Class A drugs.
Fifteenth outpatient compensation method: the outpatient settlement administrator of the designated medical institution shall go through the settlement compensation procedures on the spot when the patient or his relatives pay the outpatient expenses with the patient's ID card (or household registration certificate) and medical insurance card, which is not limited by the number of patients' visits. If there is no computer charge for emergency treatment at night, you can give compensation manually, but you must enter it into the outpatient computer charge system the next day. If the report cannot be settled on the spot due to irresistible factors such as the interruption of the HIS network of the new rural cooperative medical system, the interruption of the computer network in the hospital or the interruption of power supply, the patient's ID card (or household registration certificate), medical insurance card and the original receipt of outpatient charges (attached list) can be used to go through the compensation procedures at the report window of the new rural cooperative medical system in medical institutions afterwards. Each designated medical institution shall submit the original outpatient expense receipt, settlement voucher, patient ID card (or household registration certificate), a copy of the medical insurance card stamped with the special seal for the emergency report of the new rural cooperative medical system outpatient service together with the monthly compensation form to the Municipal New Rural Cooperative Medical System Management Center.
Article 16 When a patient suffering from six kinds of chronic diseases stipulated by the new rural cooperative medical system in this municipality goes to a designated medical institution for treatment, the relevant staff of the designated medical institution shall fulfill the obligation of prior notification, and inform the patient that all outpatient medical expenses incurred shall be settled and compensated at the settlement service point of the town (street, development zone) where the household registration is located in a unified way every quarter. Each node report service point shall be implemented according to the relevant provisions of the Measures for Compensation of Chronic Diseases in Cixi New Rural Cooperative Medical System (No.4 [2006] of Cihe Medical Management).
Seventeenth other circumstances that do not fall within the scope of compensation:
1, outpatient medical expenses incurred by non-outpatient designated medical institutions.
2, has nothing to do with the disease inspection fees, treatment fees and drugs and other expenses.
3. After investigation, it is the outpatient medical expenses of the dual insured personnel of the new rural cooperative medical system and urban medical insurance, and the outpatient medical expenses of the urban medical insurance personnel who participated in the new rural cooperative medical system after the beginning of the urban medical insurance enjoyment period.
4. After investigation, it is the outpatient medical expenses caused by fraud such as card borrowing and dressing change.
5. Outpatient medical expenses other than the new rural cooperative medical system and the basic medical insurance for urban workers in Zhejiang Province.
Chapter V Service System
Eighteenth new rural cooperative medical management center and outpatient designated medical institutions signed a medical service agreement. The contents of the agreement include service population, service scope, service content, service quality, settlement method of outpatient medical expenses, payment standard of outpatient medical expenses, audit and control of outpatient medical expenses, etc. The agreement is valid for one year. If either party violates the agreement, the other party has the right to terminate the agreement, but it must notify the other party 1 month in advance and participate in the new rural cooperative medical system.
Nineteenth designated medical institutions should add outpatient medical expenses compensation module to the current HIS software of the new rural cooperative medical system according to the standard document of outpatient software interface provided by the new rural cooperative medical system software development company.
Article 20 The designated medical institutions shall set up the service window of the new rural cooperative medical system, publicize the outpatient medical service guide of the new rural cooperative medical system, equip with sufficient computer equipment and reporting personnel, and strive to provide high-quality, convenient, efficient and comfortable medical service environment for patients participating in the new rural cooperative medical system.
Twenty-first staff of designated medical institutions must adhere to the principle of identity verification when accepting patients who participate in the new rural cooperative medical system. At the same time, it is necessary to improve service quality, enhance service functions, constantly meet the needs of the masses for disease prevention and treatment, and earnestly practice medicine in a civilized and polite manner.
Twenty-second medical personnel in designated medical institutions should have good medical ethics, constantly improve their medical skills, persist in saving lives, and earnestly carry out reasonable inspection, rational drug use and reasonable treatment. It is strictly forbidden to prescribe drugs and human relations.
Twenty-third designated medical institutions should establish outpatient medical expenses compensation fund account, implement computer management, 1 month 1 day settlement, 1 month 1 day report, and report it in time.
Chapter VI Supervision and Administration
Twenty-fourth designated medical institutions should publicize the "Zhejiang Province Outpatient Charge Price Standard" and take the initiative to accept the supervision of the masses.
Twenty-fifth designated medical institutions publish a monthly summary of outpatient medical expenses compensation, including the number of visits, total outpatient medical expenses, total effective outpatient medical expenses and total compensation expenses. , so as to ensure the openness, fairness and justice of the compensation for the outpatient co-ordination fund of the new rural cooperative medical system.
Twenty-sixth the implementation of outpatient compensation audit system, designated medical institutions should be in every month 10, reported to the new rural cooperative medical management center last month to participate in the new rural cooperative medical expenses compensation, management and service, take the initiative to accept supervision and inspection.
Article 27 the city's new rural cooperative medical management center implements all-round monitoring and management of outpatient medical expenses compensation in designated medical institutions, establishes a system of investigation, visit, assessment and supervision, promptly informs the whole society about the use of outpatient co-ordination funds, and consciously accepts the supervision of financial and auditing departments.
Twenty-eighth designated medical institutions shall establish a complaint reporting system, publish the telephone number of complaints, set up a report box, and promptly investigate, handle and reply to complaints.
Chapter VII Measures for Rewards and Punishment
Twenty-ninth in the implementation of the new rural cooperative medical service outpatient diagnosis and treatment activities, the units and individuals who earnestly perform their responsibilities and obligations, actively work and achieve remarkable results, shall be notified and praised by the new rural cooperative medical management committee.
Thirtieth designated medical institutions and their staff in violation of the relevant provisions of the new rural cooperative medical system, will be ordered to improve within a time limit, or informed criticism. If the circumstances are serious, the qualification of designated medical institutions shall be cancelled, and the unit where the relevant staff members work shall be instructed to deal with it.
Thirty-first new rural cooperative medical staff fraud, the outpatient medical expenses will not be compensated, and all the compensation will be recovered. If the circumstances are serious, cancel its qualification to participate in the new rural cooperative medical system.
Chapter VIII Supplementary Provisions
Thirty-second this scheme is explained by the new rural cooperative medical management center.
Article 33 The probation period of this scheme is tentatively set as June 5438+1 October1day to February 3 1 day, 2007.
Definition scope of effective hospitalization expenses of new rural cooperative medical system in Cixi City
A, not included in the effective cost of drugs, diagnosis and treatment projects:
(1) outpatient expenses
All kinds of expenses of outpatient treatment of the insured (malignant tumor, stroke, diabetes, chronic uremia, follow-up treatment after organ transplantation and other five chronic diseases), which did not enjoy hospitalization subsidy in that year, were included in the scope of overall compensation for hospitalization, but reported uniformly at the end of the year.
(2) drugs
1, Class C drugs specified in the catalogue guide and supplementary catalogue of basic medical insurance drugs in Zhejiang Province, and all kinds of newly listed drugs not included in the supplementary catalogue of drugs;
2 blood products and protein products (except for special indications and first aid and rescue);
3. Fruity preparations and oral effervescent agents in various drugs;
4. Various wine preparations brewed with Chinese herbal medicines and Chinese herbal pieces;
5, some medicinal animals and animal organs, dried (water) fruit.
(3) Service items
1, registration fee, out-of-hospital consultation fee, family bed and medical record fee;
2. Visiting fee, transportation fee, private room fee (including the effective fee in 50 yuan), escort fee, meal fee, lounge chair fee, air conditioning fee and special medical service.
(4) Non-disease treatment projects
1, various beauty and bodybuilding projects, as well as some functional beauty and plastic surgery (such as double eyelid surgery, strabismus surgery, stuttering correction, rabbit lips, freckle treatment, tooth implantation, orthodontics, optometry and glasses, etc.). );
2. Various weight loss, weight gain and height increase projects;
3. Various health checks;
4, all kinds of prevention and health care projects;
5, all kinds of medical consultation, medical appraisal.
(5) Diagnostic equipment and medical materials.
1, the application of examination and treatment items such as positron emission tomography (PET), electron beam CT, ophthalmic excimer laser therapeutic instrument and human information diagnostic instrument;
2. Rehabilitation appliances such as dentures, artificial eyes, artificial limbs and hearing AIDS;
3, all kinds of self-use health care, massage, qigong, examination and treatment equipment;
4. Chinese medicine decoction fee;
5. Pacemaker costs more than 20,000 yuan;
Disposable medical materials that cannot be charged separately as stipulated by the competent pricing department;
7. Disposable articles: patient identification belt, cotton swab, disposable puerpera, disposable mattress, disposable oral care, disposable water cup, disposable medicine cup, disposable toothbrush, disposable bed brush, disposable dressing change bowl, disposable therapeutic towel, disposable diaper, disposable garbage bag, disposable latex gloves, blood pressure cuff, wetting paper, list fee, thermometer and urinal;
8. Ultraviolet rays and air purifiers.
(6) Treatment items
1, organ source or tissue source of all kinds of organ or tissue transplantation (except skin transplantation of burn patients);
2. Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow;
3. Some items of operation and anesthesia treatment: disposable surgical gown, laminar flow operating room, OB glue, medical sodium hyaluronate, procalcitonin (PCT), three-way extension tube, blood jumper, analgesic pump, skin suture device, negative pressure drainage device, anesthetic absorbent for inhalation, heparin cap, 3M bandage, breathing threaded catheter, intravenous hypernutrition therapy, medical fibrin glue, anti-tumor chemical drug configuration, surgical specimen fee, etc.
4, radiation, special inspection department part of the project, endoscopic graphic report, film fee, digital processing fee;
5. Orthopedic surgery for myopia;
6, Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects.
(7) Others
1, pregnancy, abortion, abortion and normal delivery (medical expenses caused by dystocia hospitalization, effective expenses reduced 1500 yuan, and then entered the hospitalization overall compensation procedure, except those violating family planning);
2. Various infertility (pregnancy) and sexual dysfunction diagnosis and treatment projects (such as the treatment of male infertility and female infertility);
3. The expenses that should be borne by the third party according to law because the third party participates in the cooperative medical care hospitalization to pay for the work injury of the co-ordinator. (For example, after a traffic accident, the expenses that should be compensated by the responsible party);
4. Hospitalization medical expenses paid for accidental injuries such as work-related injuries;
5. Hospitalization medical expenses caused by fraud such as not being hospitalized in front or being hospitalized as an impostor;
6, due to illegal, criminal, suicide, fighting, drug abuse, alcoholism, medical accidents and other intentional acts and their families' intentional acts caused by the injury paid by the hospitalization expenses;
7. Medical expenses incurred in non-designated medical institutions without approval;
8, unauthorized high-precision, precision medical equipment inspection and special treatment costs;
9 major public health emergencies required hospitalization expenses.
Two, can be partially included in the effective cost of drugs, diagnosis and treatment projects and not included in the compensation ratio (hereinafter referred to as the "proportion"):
(1) drug
Hospitalization in designated medical institutions in the province, according to the "Zhejiang Province basic medical insurance drug directory guide and supplementary directory" provisions of class B drugs responsible for 5%.
(2) Diagnostic equipment and medical materials.
1, using large medical equipment such as CT (including ECT and SPECT), magnetic resonance imaging (MRI), cardiac angiography, color Doppler ultrasound, dynamic electroencephalogram, ultrasonic gastroscope, digital subtraction X-ray examination, linear accelerator, etc.15%;
2, extracorporeal shock wave lithotripsy, hyperbaric oxygen chamber therapy, radio frequency therapy and other projects,10%;
3. Stereotactic radiotherapy devices X knife (X knife), Gamma knife (R knife) and photon knife. , 40%;
4. Disposable medical materials (including implantable materials) such as pacemakers (with a maximum payment limit of 20,000 yuan), intraocular lenses, artificial joints, artificial larynx, artificial femoral heads, etc., which are used for in-vivo replacement at a single price above 1.500 yuan (including 1.500 yuan) as stipulated by the competent pricing department. The proportion of self-sufficiency is domestic products 10%, Sino-foreign joint venture products 15%, and imported products 20%.
(3) Treatment items
1, hemodialysis and peritoneal dialysis projects,10%;
2, cardiac laser drilling, anti-tumor cell immunotherapy, fast neutron therapy,15%;
3, kidney, heart valve, cornea, skin, blood vessels, bones, bone marrow transplantation, heart bypass surgery and balloon dilatation of cardiac catheter, etc. , 15%;
4, interventional therapy fee,10%; The cost of interventional surgery is15%; 20% of the cost of intervention materials.
Three, on the province's designated medical institutions in-patient drugs, effective diagnosis and treatment projects.
Cost definition:
Hospitalization in designated medical institutions outside the province, if the list of expenses provided has been clearly classified, it shall be included in the effective expenses according to the categories indicated in the list, and the proportion of self-sufficiency shall refer to the local area; If the category is not specified, the category shall be determined according to the provincial standards, and the proportion of conceit shall refer to the provincial standards.
In the actual operation process, if some drugs and treatment items are inconsistent with the original reference standard (the scope of basic medical insurance treatment items for urban workers, etc.). ), should be implemented in accordance with the scope of this definition.
(2) Raising funds
In accordance with the principle of individual (family) payment and appropriate financial subsidies, the medical security fund for urban residents shall be established.
1. Annual financing standard
Adults raise 365 yuan per person per year, of which individuals pay 200 yuan per person per year; Minors (/kloc-under 0/8 years old) raise 245 yuan per person per year, of which individual contributions are paid per person per year in 80 yuan. The finance of town (street) and development zone will give 40 yuan subsidy per person per year according to the number of participants in the jurisdiction, the municipal finance will give 1 15 yuan subsidy per person per year according to the number of participants, and Ningbo finance will give 15 yuan subsidy per person per year according to the number of participants.
Coordinate the collection and subsidy of individual contributions and financial subsidies newly obtained by household registration personnel in this city, so as to enjoy the proportion of months in the whole year.
Individual contributions of special groups such as five-guarantee households, low-guarantee households, key entitled groups, "three seniors" and certified disabled persons, which are included in the medical security system for urban residents, shall be borne by the municipal and town (street) and development zone finance, and individual contributions of model workers (men over 60 years old and women over 55 years old) shall be borne in full by the municipal finance.
Encourage qualified employers to give full or partial subsidies to the individual contributions of employees' families (including minors). Actively encourage social organizations and individuals to fund the medical security system for urban residents.
2. Funding criteria for the pilot phase
Each adult raises 182.5 yuan, of which the individual pays 100 yuan; Minors each raise 122.5 yuan, of which individual contributions each 40 yuan. The finance of towns (streets) and development zones shall subsidize 20 yuan according to the number of participants in their respective jurisdictions, 55 yuan according to the number of participants in the municipal finance, and 7.5 yuan according to the number of participants in Ningbo finance.
Individual contributions of special groups such as five-guarantee households, low-guarantee households, key entitled groups, "three seniors" and certified disabled persons, which are included in the medical security system for urban residents, shall be borne by the municipal and town (street) and development zone finance, and individual contributions of model workers (men over 60 years old and women over 55 years old) shall be borne in full by the municipal finance.
The annual participants of the new rural cooperative medical system, adults pay 85 yuan and minors pay 25 yuan; According to the number of participants, the municipal finance will give each person a 30 yuan subsidy; According to the number of participants, the new rural cooperative medical fund is adjusted by 67.5 yuan per person, including individual contributions 15 yuan and financial subsidies for 20 yuan, 25 yuan and 7.5 yuan. Participants in the new rural cooperative medical system, adults pay 85 yuan, minors pay 25 yuan; Town (street), development zone finance according to the number of participants in the area to give each 20 yuan subsidies, municipal finance according to the number of participants to give each 55 yuan subsidies, Ningbo finance according to the number of participants to give each 7.5 yuan subsidies; The new rural cooperative medical fund transfers individual contributions according to the number of participants 15 yuan.
(iii) Use and management of funds
5% of the urban residents' medical insurance co-ordination fund is used as a risk fund to balance the profit and loss of the fund during the year, and 12% is used as a general disease outpatient fund to compensate the insured for the general disease outpatient expenses during the year; Included in the urban residents' medical insurance fund at all levels of financial subsidies, participants each year to set up a serious illness relief fund in 5 yuan, for the relief of co-ordination within the year above the top line of large medical expenses of people living in difficulties; The rest is used for hospitalization funds.
The medical insurance fund for urban residents shall be co-ordinated at the municipal level, supervised and managed financially, and accounted for separately with the new rural cooperative medical insurance fund. After the annual balance, the insufficient part is fully compensated by the municipal finance.
The medical insurance fund for urban residents should strictly implement the budget and final accounts system, financial accounting system, and implement the annual audit and publicity system for fund revenue and expenditure management.
The urban residents' medical insurance fund is collected annually, and the annual cycle is determined to be 65438+ 10/0 to 65438+3 1 2, and the annual fee is paid in one lump sum. The fund collection and storage deadline system shall be implemented, and all families who participate in the medical security system for urban residents shall pay in full before the annual deadline and enjoy it in the next year. The annual payment deadline is 65438+February 20th. Before February 25, 65438, the financial subsidy funds of towns (streets) and development zones, as well as some individual contributions collected by towns (streets) and development zones, were uniformly incorporated into the income transition account of the urban residents' medical security management center.
June 20, 2007 is the payment deadline for the trial period. Before June 25, the financial subsidy funds of towns (streets) and development zones and some funds collected from individual contributions will be transferred to the income transition account of urban residents' medical security management center.
Especially this website.