Policy of medical insurance outpatient service for employees in Chengdu

district (city) and county governments (administrative committees), various departments of the municipal government and relevant units: "Detailed Rules for the Implementation of Establishing and Improving the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Chengdu" has been approved by the municipal government, and is hereby printed and distributed to you. Please conscientiously implement it in light of the actual situation. First, actively and steadily push forward, we should fully understand the importance of establishing and improving the economic security mechanism for employees' basic medical insurance outpatient service, make overall arrangements, improve relevant supporting measures, and ensure the timely implementation of policies and the smooth transition of the treatment of insured personnel. Second, strengthen the work to establish a coordinated supervision service mechanism for medical insurance, finance, health and market supervision departments, seriously investigate and deal with illegal acts of designated medical institutions, insured persons and medical insurance agencies, strengthen the supervision and assessment of medical institutions, and promote the standardized diagnosis and treatment behavior of designated medical institutions. Establish an exchange mechanism for data of human resources, social security and medical insurance departments, and timely enjoy the average level of basic pension for retirees in Chengdu and other related data. Do a good job in the connection between outpatient expenses and hospitalization expenses payment policies, and steadily improve the level of outpatient security treatment. Strengthen the supervision of drug circulation and use, and severely crack down on illegal activities such as drug reselling. Third, pay attention to propaganda and guide innovative propaganda methods, enrich propaganda methods, carry out extensive propaganda and accurately interpret policies. Grasp the correct direction of public opinion, reasonably guide expectations, fully publicize the important role of establishing and improving the outpatient * * * economic security mechanism for employees' basic medical insurance to reduce the burden of medical expenses for insured personnel and promote a fairer and more sustainable system, and vigorously publicize the significance of * * * building * * medical insurance and mutual assistance * * *. Establish public opinion monitoring and disposal mechanism, actively respond to social concerns, and create a good public opinion atmosphere. General Office of Chengdu Municipal People's Government On October 11th, 222, Chengdu established and improved the outpatient medical insurance mechanism for employees. Chapter I General Provisions Article 1 In order to further improve the basic medical insurance system for employees with mutual assistance and responsibility, and better solve the problem of outpatient treatment guarantee for employees insured by medical insurance in Chengdu (hereinafter referred to as insured), Effectively reduce the burden of medical expenses, according to the "Guiding Opinions of the General Office of the State Council on Establishing and Improving the Security Mechanism for Employees' Basic Medical Insurance Outpatients" (Guo Ban Fa [221] No.14) and the Notice of the General Office of Sichuan Provincial People's Government on Printing and Distributing the Implementation Measures for Establishing and Improving the Security Mechanism for Employees' Basic Medical Insurance Outpatients in Sichuan Province (Chuan Ban Fa [221] No.85), these detailed rules are formulated. Article 2 In accordance with the principle of doing your best and doing what you can, everyone should do their duty and enjoy it, improve the system and guide expectations, speed up the reform of key areas and key links of medical insurance, include outpatient expenses in the payment scope of employee medical insurance pooling fund, reform employee medical insurance personal accounts, establish and improve the outpatient medical insurance mechanism, improve the efficiency of medical insurance fund use, gradually reduce the burden of medical expenses of insured personnel, and realize a fairer and more sustainable system. Article 3 These Detailed Rules are applicable to the insured persons (including retirees and flexible employees) who participate in the medical insurance for employees in Chengdu. Chapter II Perfecting the Management of Personal Accounts Article 4 Improve the method of calculating the personal accounts of employees' medical insurance, and all the basic medical insurance premiums paid by the units shall be included in the overall fund. On-the-job employees (including flexible employees, the same below) who participate in the insurance payment by unified account, the basic medical insurance premiums paid by individuals are included in the personal account, and the inclusion standard is 2% of the base of my insurance payment. For retirees who are insured by unified account, their personal accounts are allocated by the overall fund according to the quota, and the amount allocated is 2.8% of the average level of Chengdu's basic pension in 222, which is included in the personal accounts on a monthly basis. Before the average level of basic pension in Chengdu is determined in 222, it will be implemented according to the average level of basic pension in Chengdu in 221, and the difference will be made up after the average level of basic pension in Chengdu in 222 is determined. Personnel who participate in the insurance in the form of single construction and overall planning do not establish personal accounts. Article 5 Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions and designated retail pharmacies. Personal accounts can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies, and the personal contributions to social insurance related to medical security carried out by the government, such as basic medical insurance for urban and rural residents, supplementary medical insurance and long-term care insurance. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance. Strengthen the use and management of personal accounts, and incorporate the income and expenditure information of personal accounts into the monitoring and management of the medical security information management system. Sixth personal account funds (including personal account balances over the years before the reform) can be carried forward in accordance with the provisions and inherited according to law. When the insured workers transfer the medical insurance relationship across the overall planning area, the personal account funds will be transferred with them. Except for special reasons such as the death of the insured, going abroad to settle down, personal account funds shall not be withdrawn in principle. Chapter III Strengthening outpatient medical insurance Article 7 After adjusting the structure of employee medical insurance pooling fund and individual account, the increased pooling fund is mainly used to strengthen outpatient medical insurance and improve the level of outpatient medical insurance for insured persons. The general outpatient expenses and drug purchase expenses of the insured within the policy scope of designated medical institutions and qualified designated retail pharmacies are included in the payment scope of the employee medical insurance pooling fund according to regulations. Constantly improve the outpatient service economic security mechanism, and gradually realize the transition from disease protection to cost protection. Eighth outpatient * * * economic security mainly includes general outpatient expenses as a whole, "two diseases" (hypertension, diabetes) outpatient medication security, outpatient special disease security, etc. Ninth insured persons shall enjoy the outpatient economic security treatment in accordance with the provisions, and shall not enjoy it repeatedly. Tenth outpatient * * * economic security fund payment scope and standards should strictly implement the basic medical insurance payment scope and standards. Eleventh to participate in the medical insurance for employees in our city and enjoy the benefits during the period, according to the provisions, enjoy the general outpatient expenses of medical insurance for employees as a whole. Article 12 Employees' medical insurance general outpatient expenses shall be guaranteed as a whole, and the deductible line and annual payment limit shall be set according to the natural year, which shall be calculated cumulatively within a natural year, and the deductible line for on-the-job employees shall be 2 yuan and the retirees shall be 15 yuan; The payment ratio is 5% for the three-level designated medical institutions and qualified designated retail pharmacies, and 6% for the two-level and below designated medical institutions, and the retirees will increase by 1 percentage points on the basis of the above corresponding payment ratio; The annual payment limit for employees who participate in the insurance payment in the form of unified account is 2 yuan, and the annual payment limit for retirees is 25 yuan; The annual payment limit for employees who are insured in the form of single construction and overall planning is 88 yuan, and the annual payment limit for retirees is 1,1 yuan. Thirteenth people who participate in the insurance in the form of single construction and overall planning may apply for change to the insurance in the form of unified account, and may not change it again after changing the insurance mode. If the employees who are insured in the form of single construction and overall planning apply for changing the insurance mode, they will pay the fee according to the unified account and establish a personal account from the second month after the change, and enjoy the corresponding medical insurance benefits according to the regulations. The insured persons who have reached the statutory retirement age but do not meet the requirements of enjoying retirement medical insurance benefits by combining unified accounts with single accounts may voluntarily make up the payment difference between unified accounts and single accounts in a lump sum in accordance with the relevant provisions of the current basic medical insurance for urban workers in Chengdu, and enjoy the corresponding medical insurance benefits as required from the next month after the one-time supplement; Those who have not made up for it enjoy the treatment in the way of single construction as a whole until they make up the difference according to the regulations. After the implementation of these detailed rules, no new personnel will be insured in the form of single construction and overall planning. Article 14 The identification standard, scope of drug use, level of drug protection and management services of the "two diseases" outpatients who participate in medical insurance for employees are consistent with those of urban and rural residents. Patients with "two diseases" meet the standards of outpatient special diseases, and are included in the scope of outpatient special disease management, and the outpatient special disease policy is implemented. Article 15 The Municipal Medical Insurance Bureau can dynamically adjust the level of outpatient special disease treatment according to the affordability of the medical insurance fund, gradually expand the scope of outpatient special diseases paid by the overall fund, and include some outpatient expenses of diseases with long treatment cycle, great harm to health and heavy cost burden into the scope of outpatient special disease protection; Some special treatments suitable for outpatient service and more economical and convenient than hospitalization can be managed with reference to hospitalization treatment. Article 16 The medical expenses paid by the insured participating in Medicaid for civil servants within the scope of the general outpatient expenses and the "two diseases" outpatient drug security policy in designated medical institutions shall be included in the scope of Medicaid payment for civil servants, and shall be implemented according to the reimbursement policy for medical expenses for civil servants. Seventeenth workers' medical insurance outpatient * * * economic security benefits are limited to the insured himself, and the annual payment limit is not carried forward. Eighteenth insured persons from on-the-job to retirement, from the month to enjoy medical insurance retirement benefits for their personal account included in the way to change. Chapter IV Service and Settlement Management Article 19 Relying on the unified medical security information platform of the whole province, we will continue to promote the direct settlement management services for medical treatment in different places, such as general outpatient service, "two diseases" outpatient service and outpatient special diseases, and effectively protect the rights and interests of insured persons in different places. Article 2 Expand the scope of general outpatient co-ordination services, and include the drug support services provided by designated retail pharmacies with qualified compliance, standardized management, good reputation, reasonable layout, docking of the purchase, sale and storage management system with the medical insurance system, supporting electronic medical records and electronic prescriptions, and meeting the conditions of electronic traceability of drugs sold. Support the settlement and dispensing of external prescriptions in qualified designated retail pharmacies. When the outpatient drug demand of designated medical institutions cannot be met, the insured can dispense prescriptions in qualified designated retail pharmacies, and enjoy corresponding treatment according to the payment ratio of designated retail pharmacies. Explore the inclusion of qualified "internet plus" medical services in the scope of protection. Article 21 The insured who purchases medicines at the designated medical institutions with direct settlement conditions shall be directly settled with the social security card or medical insurance electronic certificate, and the medical expenses that should be borne by the individual shall be paid by the insured, and the medical expenses that should be paid by the medical insurance fund shall be settled regularly by the medical insurance agency and the designated medical institutions; Due to special circumstances, the designated medical institutions cannot directly settle accounts, and the designated medical institutions shall inform the insured of the reasons, disposal methods and supplementary settlement procedures. Outpatient medical expenses incurred by non-designated medical institutions (except emergency and rescue) will not be paid by the medical insurance fund. Chapter V Supervision and Management Article 22 Establish and improve the supervision and management mechanism that is compatible with the economic security mechanism of the basic medical insurance outpatient service for employees, improve the management service measures, innovate the system operation mechanism, guide the insured to make rational use of medical resources, ensure the smooth operation of the medical insurance fund, and give full play to the security function. Strictly implement the budget management system of medical insurance fund and strengthen the construction of fund audit system and internal control system. (1) Establish and improve the safety prevention and control mechanism of medical insurance funds, strictly implement the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds (Decree No.735 of the State Council), comprehensively strengthen the supervision and management of medical services, the purchase, sale and storage of drugs and medical consumables in designated medical institutions, and realize the supervision of medical insurance funds in all fields, processes and directions. (II) Strengthen the intelligent monitoring of outpatient medical expenses and medical insurance big data, and severely crack down on illegal activities such as excessive diagnosis and treatment, irrational drug use, and cashing in personal accounts. Designated retail pharmacies included in the scope of outpatient economic security services should regularly report the circulation of prescriptions, drug purchase, sale and storage ledgers and financial accounting accounts to medical insurance agencies, so as to realize the transformation of medical insurance fund supervision to "managing services, technologies and prices" and ensure the safe, efficient and rational use of medical insurance funds. Twenty-third establish a dynamic management mechanism for the whole process of personal accounts, further improve the personal account management methods, strictly implement the budget management of medical insurance funds, and strengthen the audit of the use, settlement and payment of personal accounts. Realize the dynamic management of the whole process of personal accounts and ensure the smooth operation of medical insurance funds. Establish and improve the internal control system of medical insurance fund management, improve the mutual restraint mechanism of incompatible positions such as handling and auditing, accounting and cashier, business and finance, and prevent and resolve internal regulatory risks. Twenty-fourth to promote the construction of primary medical service system, improve the graded diagnosis and treatment and family doctor contract service, standardize the long-term prescription management, and guide the insured to seek medical treatment at the primary level. Combined with the improvement of outpatient chronic and special disease management measures, standardize the diagnosis, treatment and referral of primary medical institutions. Strengthen the agreement management of designated medical institutions. Improve the service agreement of designated medical institutions, and timely bring the economic security of the general outpatient service of employee medical insurance into the scope of agreement management. Implement the consultation and negotiation mechanism, and strictly evaluate the designated medical institutions according to the principle of "good technology, excellent service, low price and reasonable layout"; According to the principle of step-by-step classification and dynamic adjustment, improve the management mechanism of designated medical institutions. The requirements of giving priority to the use of drugs in the medical insurance catalogue (diagnosis and treatment items), controlling the proportion of self-expense, strictly prohibiting inducing drugs to be purchased outside the hospital, not issuing "big prescriptions" in violation of regulations, the drug price of designated retail pharmacies being not higher than the online price of the same product on the platform of centralized procurement of medical equipment and medical price supervision in Sichuan Province, and meeting the standards of outpatient information construction are included in the agreement management, and the terms and indicators of the agreement are strengthened. Improve the monitoring, early warning, reminding, analysis and assessment mechanism of medical service behavior, regularly monitor the growth of medical expenses, the average cost, the use of off-catalogue items and other indicators, and guide designated medical institutions to standardize the provision of medical treatment and drug security services. Incorporate the use of medical insurance funds by designated medical institutions into medical insurance credit management, strengthen the daily management and regular assessment of designated medical institutions, link the assessment results with medical insurance expense settlement and agreement renewal, encourage designated medical institutions to strengthen self-management, standardize diagnosis and treatment behavior, and give play to the regulatory incentive and restraint role of medical insurance funds. Twenty-fifth improve the payment mechanism to adapt to the outpatient economic security, and strengthen the data collection, analysis and application of outpatient medical expenses. Pay per head for primary medical services, and actively explore the combination of pay per head and chronic disease management; Pay by disease for special diseases in daytime surgery and eligible outpatient clinics. We can explore the reform of outpatient co-ordination payment mode in combination with the actual work of paying by groups related to disease diagnosis and paying by disease scores. For outpatient expenses that are not suitable for package payment, they can be paid according to the project. Scientifically and reasonably determine the payment standard of medical insurance drugs, and guide medical institutions and patients to take the initiative to use drugs with definite curative effect and reasonable price. Chapter VI Supplementary Provisions Article 26 The Municipal Medical Insurance Bureau and the Municipal Finance Bureau may, according to the deployment of higher authorities, the payment ability of medical insurance funds and the development of medical technology, make timely adjustments to the policies related to outpatient economic security and personal accounts. Twenty-seventh the detailed rules for the implementation by the Municipal Medical Insurance Bureau is responsible for the specific interpretation. Article 28 These Measures shall come into force as of January 1, 223 and shall be valid until January 31, 227. Where the previous provisions are inconsistent with these Detailed Rules, these Detailed Rules shall prevail.