Attached: "on further improving the medical assistance system to comprehensively carry out the opinions of the work of medical assistance for serious illnesses" State Office of the People's Republic of China [2015] No. 30
People's governments of provinces, autonomous regions and municipalities directly under the central government, the State Council ministries and commissions and all directly subordinate institutions:
Ministry of Civil Affairs, Ministry of Finance, Ministry of Human Resources and Social Security, Ministry of Health The Ministry of Civil Affairs, the Ministry of Finance, the Ministry of Human Resources and Social Security, the Ministry of Health, the Health and Family Planning Commission and the China Insurance Regulatory Commission have agreed to the Opinions on Further Improving the Medical Aid System and Comprehensively Carrying Out the Work of Medical Aid for Serious Diseases.
General Office of the State Council
April 21, 2015
In order to fully implement the "Interim Measures for Social Assistance" relevant provisions, weave a tightly woven safety net to protect the basic livelihood of the people, according to the State Council's decision-making and deployment of the relevant work arrangements, is now on the further improvement of the medical assistance system, to comprehensively carry out the work of the medical assistance for serious illnesses to put forward the following views:
One, the overall requirements
(a) Guiding ideology
In-depth implementation of the spirit of the 18th CPC National Congress and the 18th Session of the Second, Third and Fourth Plenary Sessions of the 18th CPC Central Committee, in order to improve the social assistance system, to protect the basic medical rights and interests of the needy people for the goal, to further improve the working mechanism, improve the policy and measures, strengthen the standardization of management, strengthen the coordination and convergence, and continue to improve the medical assistance management and service level, and maximize the effectiveness of the medical assistance. Improve the level of medical assistance management services, and minimize the burden of medical expenses on the needy.
(2) Basic principles
To support the bottom line. In accordance with the medical expenses of the aid recipients, the degree of family difficulties and affordability and other factors, scientific and rational development of the aid program to ensure that they have access to the necessary basic medical and health services; the level of aid and the level of economic and social development in line with.
Integration. Promote the integrated development of the medical assistance system in urban and rural areas, and strengthen the effective convergence with the basic medical insurance, urban and rural residents' major illness insurance, emergency relief for illnesses, and various types of supplemental medical insurance, commercial insurance and other systems, to form a synergy of the system. Strengthening the orderly connection with charitable undertakings, and realizing the efficient linkage and benign interaction between government assistance and the participation of social forces.
Openness and fairness. Publicize the relief policy, work procedures, relief targets and implementation, actively accept the public and social supervision, to ensure that the process is open and transparent, and the results are fair and just.
Efficient and convenient. Optimize the relief process, simplify the settlement procedure, speed up the construction of information technology, enhance the time of relief, and give full play to the function of emergency relief, so that the people in need of timely and effective relief.
(3) Objectives and Tasks
The urban medical assistance system and the rural medical assistance system were combined and implemented by the end of 2015, and medical assistance for serious illnesses was comprehensively carried out, with further refinement and actualization of policies and measures to achieve a scientific and standardized medical assistance system that operates effectively and is complementary to the relevant social assistance and medical insurance policies, and to safeguard the basic medical rights and interests of urban and rural residents.
Second, improve the medical assistance system
(a) Integration of urban and rural medical assistance system. All regions shall, by the end of 2015, integrate the urban medical aid system and the rural medical aid system into an urban and rural medical aid system. In accordance with the requirements of the Measures for the Administration of Urban and Rural Medical Aid Funds (Caixa [2013] No. 217), the "special account for urban medical aid funds" and the "special account for rural medical aid funds" that were originally set up in the special account of the Social Security Fund should be merged, and the policy objectives, fund-raising, target scope of medical aid should be determined in accordance with the requirements of the Measures. Policy objectives, fund-raising, the scope of the target group, the standard of assistance, assistance procedures, etc. to speed up the promotion of urban and rural integration, to ensure that the urban and rural people in need of medical assistance to obtain the right to fairness, fairness of opportunity, fairness of the rules, fairness of treatment.
(2) Rationally defining the objects of medical assistance. Minimum subsistence guarantee family members and special hardship dependents are the key target of medical assistance. To gradually low-income families of the elderly, minors, severely disabled and seriously ill people in need (hereinafter collectively referred to as low-income recipients), as well as the people's governments at or above the county level, other special difficulties into the scope of assistance. Appropriately expanding the range of recipients of medical assistance for serious and serious illnesses, and actively exploring the implementation of assistance for seriously ill persons in families that incur high medical expenses that exceed the family's ability to bear them, and that experience serious difficulties in their basic livelihoods (hereinafter referred to as seriously ill persons in families that are impoverished as a result of illnesses). Among the various types of medical aid recipients, emphasis should be placed on increasing the assistance for seriously ill and disabled children.
(3) Subsidizing participation in the insurance program. The key aid recipients to participate in the basic medical insurance for urban residents or the new rural cooperative medical care individual contribution part of the subsidy, the special hardship support staff to give full funding, the minimum subsistence guarantee family members to give a fixed amount of subsidies to ensure that they have access to basic medical insurance services. Specific funding methods are studied and formulated by local people's governments at and above the county level, based on factors such as the level of local economic and social development and the mobilization of funds for medical assistance.
(d) Standardizing outpatient assistance. Outpatient assistance focuses on chronic diseases requiring long-term medication or serious diseases requiring long-term outpatient treatment, resulting in higher out-of-pocket expenses for medical assistance recipients. The health and family planning department has already defined the path of diagnosis and treatment, and the types of diseases that can be treated through outpatient treatment can be carried out in the form of outpatient assistance by means of single-patient payment. The outpatient assistance of the maximum limit of assistance by the local people's governments at or above the county level in accordance with the needs of the local aid recipients and medical assistance fund-raising and other research to determine.
(E) improve hospitalization assistance. Key aid recipients in the policy scope of hospitalization costs incurred in designated medical institutions, the basic medical insurance, urban and rural residents of major disease insurance and various types of supplemental medical insurance, commercial insurance reimbursement of the personal burden of the cost of the annual aid limit within the proportion of not less than 70% to give aid. The annual maximum limit for hospitalization assistance shall be determined by the local people's governments at or above the county level in accordance with the needs of local assistance recipients and the mobilization of medical assistance funds. The designated medical institutions shall reduce or waive the hospitalization deposit of the aid recipients, and provide timely treatment; the medical aid agencies shall confirm the aid recipients in time, and may provide a certain amount of prepaid funds to the designated medical institutions, so as to facilitate the aid recipients to seek medical treatment.
Three, comprehensive medical assistance for serious illnesses
(a) scientifically formulate the implementation program. Each region should be in the assessment, summarize the pilot experience based on further improvement of the implementation of the program, expand the policy coverage area, comprehensive medical assistance for serious illnesses. The key aid recipients and low-income aid recipients by the basic medical insurance, urban and rural residents of major medical insurance and all kinds of supplementary medical insurance, commercial insurance and other reimbursement of the individual burden of compliance with the medical costs, directly to aid; due to the illness of the poor families with serious illnesses and other aid recipients of the burden of compliance with the medical costs, the first by the individual to pay for, to the part of more than the family affordability to aid. Compliance with medical expenses is determined primarily by reference to the relevant provisions of local basic medical insurance, and in areas where urban and rural residents' major disease insurance has been carried out, it may also be determined by reference to the relevant provisions of urban and rural residents' major disease insurance.
(2) Reasonable determination of the standard of assistance. Comprehensive consideration of the burden on the sick family, personal out-of-pocket expenses, local financing and other factors, categorized and segmented set the proportion of medical assistance for serious illnesses and the maximum limit of assistance. In principle, the proportion of key aid recipients is higher than that of low-income recipients, and the proportion of low-income recipients is higher than that of other recipients; for the same type of recipients, the greater the amount of out-of-pocket expenses, the higher the proportion of aid. The threshold of assistance should be completely abolished for key assistance recipients; a starting line can be set for seriously ill patients from families impoverished by illness, and assistance will be provided for out-of-pocket expenses above the starting line.
(3) Clearly define the scope of medical treatment and medication. In principle, the scope of medication and diagnostic and treatment programs for medical assistance for serious illnesses should be based on the relevant provisions of basic medical insurance and urban and rural residents' major disease insurance. For medical aid recipients who really need to go to higher-level medical institutions or cross-county hospitals, referral or filing procedures should be carried out in accordance with the regulations. For serious diseases that have a clear clinical diagnosis and treatment pathway, assistance can be provided by means of payment for each type of disease.
(D) to strengthen the connection with the relevant medical insurance system. Civil affairs, finance, human resources and social security, health planning, insurance supervision and other departments should strengthen collaboration and cooperation, *** with the effective convergence of medical assistance for serious illnesses with basic medical insurance, urban and rural residents' major illness insurance, emergency relief for illnesses, and commercial insurance, to ensure that the urban and rural residents' major illness insurance covers all impoverished patients with serious illnesses, and to help all eligible people in difficulty to obtain insurance compensation and medical assistance. (c) Ensuring that urban and rural residents' major disease insurance covers all impoverished patients with serious and serious diseases, and helping all eligible people in difficulty to receive insurance compensation and medical assistance. Strengthening the efficient linkage between medical assistance for serious and serious illnesses and the emergency disease relief system, moving the relief gate forward, and taking the initiative to provide assistance to eligible emergency disease relief recipients. Civil affairs departments, in conjunction with the relevant departments and urban and rural residents' major disease insurance contractors, should further improve the information ****sharing and business collaboration mechanism, ****with the basic work related to medical assistance for major diseases.
Four, sound working mechanism
(a) sound financing mechanism. Each region should be based on the number of aid recipients, the prevalence of disease, the standard of aid, the growth of medical costs, as well as basic medical insurance, urban and rural residents of major disease insurance, commercial insurance reimbursement level, etc., scientifically estimate the demand for medical aid funds, increase financial input, encourage and guide social donations, and improve the multi-channel financing mechanism. County-level finances shall reasonably arrange medical assistance funds at their own level and include them in their annual budgets, based on the measured financial needs and the financial subsidies from higher levels. Provincial and prefectural and municipal-level finances shall increase funding subsidies to economically difficult areas within their administrative regions. The central financial authorities will further increase the assessment of local financial financing at all levels when allocating medical assistance subsidies. Localities should adjust their assistance programs in a timely manner according to the annual financing situation, and improve the effectiveness of the use of funds.
(2) Improving the "one-stop" instant settlement mechanism. To do medical assistance and basic medical insurance, urban and rural residents of major disease insurance, disease emergency relief, commercial insurance and other information management platform interconnection, open and transparent, to realize the "one-stop" information exchange and instant settlement, the medical costs incurred by the relief object can be the first fixed-point medical institutions to pay the part of the medical assistance fund, the relief object only pay the part of the self-payment. The medical expenses incurred by the recipients can first be paid by the designated medical institution for the part paid by the medical aid fund, and the recipients will only pay for the self-paid part. In conjunction with the advancement of medical insurance for medical treatment in other places, it is actively exploring the management mechanism for medical assistance for serious illnesses in other places.
(3) Improve the supervision mechanism of relief services. Within the scope of the basic medical insurance designated medical institutions, in accordance with the principle of openness and equality, competition and selection of excellence to determine the medical assistance designated medical institutions. Civil affairs departments and medical aid designated medical institutions to sign a commissioning cooperation agreement, clear service content, quality of service, cost settlement and the responsibility and obligations of both parties, the development of service specifications, and in conjunction with finance, human resources and social security, health planning and other departments and commercial insurance institutions to do a good job in the supervision and management of the quality of health care services behavior, prevention and control of irrational medical behavior and costs. The medical aid fund will not settle the expenses incurred in the use of medicine, diagnosis and treatment and the provision of medical services not in accordance with the regulations. For violation of the cooperation agreement, do not provide medical assistance services in accordance with the provisions of the medical assistance fund loss or waste, to terminate the fixed-point cooperation agreement, cancel the qualification of medical assistance fixed-point medical institutions, and be held accountable according to law.
(D) improve the social forces involved in the convergence mechanism. Localities should strengthen the construction of medical assistance and social forces to participate in the articulation mechanism, the implementation of the relevant national fiscal and tax incentives, fee waivers and other policy provisions to support and guide the social forces to actively participate in the medical assistance, especially medical assistance for serious illnesses through the donation of funds and materials to form an effective complementary to the government's assistance. A platform for information ****sharing should be set up to provide timely information on assistance needs, create conditions and facilities for social forces to participate in medical assistance, and form a synergy of efforts. To start from the medical security needs of the needy, to help them seek charitable assistance. To focus on the professional advantages of social forces, to provide medical cost subsidies, psychological guidance, affectionate accompaniment and other forms of charitable medical services, to help people in need to reduce the financial burden of medical care, alleviate physical and mental pressure.
Fifth, strengthen the organization and leadership
Improve the medical assistance system, comprehensive medical assistance for serious illnesses, to alleviate the "unbearable weight" of the masses in trouble due to illness, is an important responsibility of the government. Local people's governments at the county level and above should strengthen organizational leadership, refine policies and measures, clarify progress arrangements, implement management responsibilities, increase funding, strengthen supervision and inspection, and strive to achieve results. To effectively strengthen the grass-roots agencies and capacity building, so that there is someone in charge, responsible for someone, and constantly improve the level of work.
Civil affairs departments at all levels should take the initiative to strengthen coordination and cooperation with finance, human resources and social security, health planning, insurance supervision and other departments, and do a good job in the design of medical assistance programs, policy adjustments, etc., so as to give better play to the role of medical assistance to save the urgent and difficult. For the medical assistance policy is difficult to solve the case problem, to make full use of the local social assistance coordination mechanism, thematic study of the solution measures, to avoid the impact of social morality and psychological bottom line of the incident occurred.