*** relief protection mechanism implementation rules
Chapter I General Principles
Article I in order to further improve the basic employee medical insurance (hereinafter referred to as employee medical insurance) system, optimize the structure of the use of medical insurance funds, the use of medical insurance funds, the use of medical insurance funds, the use of medical insurance funds. further improve the employees' basic medical insurance (hereinafter referred to as employees' medical insurance) system, optimize the structure of the use of medical insurance fund, enhance the effectiveness of the use of medical insurance fund, better solve the problem of outpatient protection of the insured, according to the "General Office of the State Council on the establishment of a sound employees' basic medical insurance outpatient **** financial protection mechanism of the guiding opinions" (State Office of the State Council [2021] No. 14), the "General Office of the People's Government of Shandong Province On the issuance of Shandong Province to establish and improve the implementation of basic medical insurance outpatient ****ji protection mechanism notice "(Lu Zhengban Fa [2021] No. 22) requirements, combined with the city's actual, the development of the implementation of the rules.
Second adhere to the protection of basic, mutual ****ji, responsibility ****take, and effectively safeguard the rights and interests of insured workers; adhere to a smooth transition, properly handle the reform before and after the policy convergence; adhere to the synergistic linkage, the establishment of the workers' health insurance general outpatient protection system, synchronized with the reform of the individual account, optimize the internal structure of the fund; adhere to local conditions, from the actual start, and actively explore the feasibility of the implementation of the mechanism, the implementation of the rules. From a practical point of view, actively explore effective ways to enhance the outpatient protection of employees' medical insurance, scientifically set up the payment policy for employees' general outpatient treatment, steadily raise the level of outpatient medical protection, and promote a fairer and more sustainable medical protection system.
Article 3 medical insurance department to take the lead in the establishment of a sound outpatient medical insurance **** financial protection mechanism; financial sector to do a good job of supervision and management of the medical insurance fund; the tax department to do a good job of medical insurance premiums collection; health sector to strengthen the supervision of the medical institutions assessment, to promote the standardization of diagnostic and treatment behavior of the designated medical institutions; the market Supervision departments to strengthen the circulation of drugs, the use of link supervision, crack down on illegal channels to purchase drugs and other illegal behavior.
Chapter 2: Employee Health Insurance General Outpatient Treatment Guarantee
Article 4 establishes a mechanism to guarantee general outpatient treatment for employees, and from December 2022 onwards, fully establishes a system of general outpatient treatment guarantee for employee health insurance, improves and perfects the policy, standardizes the management measures, and guarantees the fairness and universality of general outpatient medical needs. medical needs. In conjunction with the implementation of the province's unified medical insurance treatment list system, we will ensure that the general outpatient protection system within the municipal area will be unified in terms of the content of protection and payment of treatment, and will do a good job of converging with the payment policy for outpatient chronic and special diseases and hospitalization treatment.
Article 5 determines the general outpatient treatment and payment policy of employee health insurance. Scientific set the city's unified outpatient fund annual starting standard, payment ratio and maximum payment limit, different levels of designated medical institutions set differentiated starting standard and payment ratio, appropriate tilt to the primary health care institutions, and promote hierarchical diagnosis and treatment.
(a) Starting standard. In a natural year, the employee health insurance general outpatient coverage starting standard implementation of the year cumulative calculation. First-class and below (including integrated management of village health clinics, community health service stations, etc., the same below), second-class, third-class designated medical institutions starting standard for 200 yuan, 400 yuan, 800 yuan. Participants in the first and the following, second and third level designated medical institutions for outpatient medical care, employee health insurance general outpatient clinic coordinated starting standard implementation of the cumulative difference in the calculation. (ii) Payment ratio. Participants in the general outpatient medical expenses incurred within the scope of the policy, the part of the starting standard above, in-service workers in the first level and below, second, third-point medical institutions, the proportion of the co-ordination fund for 70%, 60%, 50%; retired workers in the first level and below, second, third-point medical institutions, the proportion of the co-ordination fund for 75%, 65%, 55% respectively. (C) the maximum payment limit. Within a natural year, the insured workers incurred within the policy scope of the general outpatient medical expenses, health insurance co-ordination fund of the maximum payment limit of 1500 yuan. The payment limit will not be carried forward or accumulated to the following year.Article 6 general outpatient coverage policy covers all participants in the city's employees' health insurance and the normal enjoyment of the benefits of all personnel (including retirees and flexibly employed persons). Participants in all designated medical institutions in the city outpatient medical expenses incurred within the scope of the policy, can be paid in accordance with the provisions of this regulation. The insured persons who seek medical treatment in other places will be included in the scope of general outpatient protection, and the treatment standards for long-term residents in other places will be implemented in accordance with these rules; for the temporary out-of-town medical personnel, the costs that meet the scope of payment of medical insurance will be paid by the individual firstly by paying 10% out-of-pocket, and then in accordance with the prescribed proportion.
Chapter III of the individual account management
Article 7 Improvement of the workers' health insurance individual account crediting methods. The adjustment of the individual account crediting method is synchronized with the establishment of the outpatient protection mechanism. Individual accounts continue to be retained, the historical balance of the individual account still belongs to the insured.
(a) adjust the basic medical insurance for working employees individual account crediting methods. 2022 December, the unit of the basic medical insurance premiums paid into the individual account of working employees partially reduced to 50% of the current standard, that is, according to the individual contribution base of 2.25% of the individual account. 2024 January, the unit of the basic medical insurance premiums paid by the working employees will no longer be transferred to individual accounts, all credited to the integrated fund, the individual account will be transferred to the individual account of the individual. All into the integrated fund, the basic medical insurance premiums paid by individual employees are all transferred to their personal accounts, the standard is 2% of the contribution base for their own participation. (B) adjust the retiree basic medical insurance personal account crediting method 1. unit of normal participation in the retiree. 2024 January, the retiree personal account by the Coordinated Fund at a fixed amount of money, the age of 70 years old retirees in accordance with the average level of the city's basic pension in 2023 2% into the age of 70 years old and retirees in accordance with the average level of the city's basic pension in 2023 2.2% of the average level of the city's basic pension. The city's average basic pension level of 2.5%. 2. Retirees insured under flexible employment. 2023 January onwards, eligible to enjoy the health insurance retirement benefits of flexible employment retirees (including other retirees enjoying health insurance retirement benefits without the establishment of health insurance individual account), the establishment of employee health insurance individual account and the integrated fund by the amount of the fixed amount of the retirees under 70 years of age in accordance with the average level of the city's basic pension in 2022, 2% of the average level of the basic pension in the city, 2% of the average level of the city's basic pension in 2022, 2% of the average level of the city's basic pension in the age of 70 years of age and above, 2.5% of the basic pension in the city. Retirees under the age of 70 will receive 2% of the city's average basic pension for the year 2022, while those aged 70 and above will receive 2.5% of the city's average basic pension for the year 2022. From January 2024, the transfer standard is consistent with the unit of normal participation in the retiree. 3. In-service to retired employees, from the month of enjoying the retirement health insurance treatment of personal accounts in accordance with the standard of retirees. (C) adjust the civil service medical subsidy individual account crediting method. 2023 January onwards, in-service, retired civil service medical subsidy credited to the individual account portion of the fixed amount, the standard for the December 2022 individual contribution base (pension) of 2.5%. For newly recruited staff, the flat rate of 2.5% of the first month's trainee salary before regularization and 2.5% of the first month's salary after regularization; for newly retired staff, the flat rate of 2.5% of the first month's pension after retirement. Adjustments will be made in due course in accordance with the income and expenditure of the Civil Service Medical Benefits Fund.Article 8 standardize the use of personal accounts. Individual account funds are mainly used to pay for out-of-pocket expenses within the scope of the policy incurred by participants in designated medical institutions. It can be used to pay for the medical expenses incurred by the insured person, his/her spouse, parents and children in the designated medical institutions, the expenses incurred in the designated retail pharmacies for the purchase of medicines, medical equipments and medical consumables, as well as the individual contributions for the participation in the urban and rural residents' basic medical insurance, long term care insurance, and government-guided universal commercial medical insurance, etc. The individual account shall not be used for public ******************. Individual accounts may not be used for public **** health expenses, sports and fitness or health care consumption and other expenditures that are not covered by basic medical insurance.
Article 9 Individual account funds can be carried forward for use and inheritance, and employees' basic medical insurance individual accounts cannot be withdrawn or disguised as withdrawals except for the transfer of relations across the integrated regions, relocation, settlement abroad, and death.
Chapter IV: Connections between related systems
Article 10 standardizes and improves the policy of employees' basic medical insurance contributions. Employers shall pay 7% of the contribution base (excluding maternity insurance), and individuals shall pay 2% of their own contribution base; from January 2023, individual industrial and commercial households without employees, part-time workers who do not participate in the employee health insurance in the employing organization, and other flexibly employed persons shall pay 7% of the contribution base (excluding maternity insurance), and shall not set up a personal account for the health insurance during the period of employment.
Article 11 unified medical insurance payment scope. The basic medical insurance general outpatient coverage to implement a unified medical insurance drug list, diagnosis and treatment catalog, medical supplies catalog and medical service facilities scope of the catalog. The general outpatient medical expenses incurred during the hospitalization of the insured employees and during the period of enjoying the long-term care insurance medical care treatment are not included in the scope of payment of the general outpatient coordinated fund; the general outpatient medical expenses incurred during the period of enjoying the long-term care insurance institutional care and home care treatment are included in the scope of payment of the general outpatient coordinated fund. Employees' general outpatient medical insurance benefits and outpatient chronic and special disease medical insurance benefits can be enjoyed at the same time.
Article 12 standardizes the types of outpatient chronic diseases and health insurance policy. According to the relevant provisions of the province to unify the city's basic disease names and identification standards. Part of the transfer out of slow special disease types, according to the fund's ability to bear and general outpatient protection level, through the outpatient protection mechanism to realize the transition from disease protection to cost protection.
Article 13 broaden the outpatient drug coverage channels. Support for outpatient prescriptions dispensed at designated retail pharmacies, gradually incorporate the medication protection services provided by qualified designated retail pharmacies into the scope of outpatient protection, implement a unified outpatient payment policy with designated medical institutions, and combine the annual starting payment standard and annual maximum payment limit with designated medical institutions.
Article 14 encourages "Internet +" medical services. Explore the eligible "Internet +" medical services into the scope of medical insurance payment, with health insurance electronic vouchers as a medium to open up the slow special disease follow-up medical insurance online payment channels, online registration, online follow-up, online prescription renewal, prescription flow, medical insurance payment, drug delivery and other service functions.
Article 15 Improvement of medical insurance information management. The establishment of the city's unified outpatient information system, the realization of health insurance agencies and designated medical institutions interconnectivity, resources **** enjoy. The fixed-point medical institutions to establish a prescription and other information upload system to strengthen the daily audit and supervision of outpatient costs. The outpatient expenses incurred by the insured in the designated medical institutions will be settled instantly through the network, and the insured will only pay the part of their personal burden, while the rest will be settled between the medical insurance management organization and the designated medical institutions.
Article 16 Improvement of the settlement of medical expenses and payment methods. Outpatient medical services will be included in the medical insurance designated medical institutions agreement management content, the establishment of outpatient cost statistical analysis system. Promote outpatient payment reform, general outpatient and outpatient slow special disease services, can be implemented by headcount payment, according to the type of payment and other composite payment methods.
Article 17 The family doctor contracting service and general outpatient services, outpatient chronic special disease management measures, guiding the insured to primary care at the grass-roots level, and promoting the soundness and perfection of the grass-roots medical and health service system.
Article 18 clarifies the payment policy for outpatient and emergency expenses before hospitalization. The outpatient emergency expenses within the scope of the policy incurred by the insured before hospitalization shall be paid in accordance with the general outpatient co-ordination policy; in the event of death of the outpatient emergency rescue, the medical expenses within the scope of the policy shall be reimbursed in accordance with the one-time hospitalization.
Chapter V Supervision and Management
Article 19 sound supervision and management mechanism. The establishment of a sound and outpatient **** financial security fund management system and audit inspection mechanism, the implementation of the main responsibility of the designated medical institutions. The designated medical institutions should strictly abide by the basic medical insurance and health care laws, regulations and policies, the implementation of the real name system, strictly grasp the indications, so that the treatment of disease, reasonable diagnosis and treatment, and actively publicize the medical insurance policy. Seriously investigating and dealing with outpatient over-diagnosis and treatment, irrational use of medication, and the use of employee health insurance personal accounts, general outpatient reimbursement amount to obtain fraudulent health insurance funds and other illegal and irregular behavior and problems, to ensure the safe, efficient and reasonable use of funds. It also improves the monitoring and analysis mechanism for outpatient medical services, and guides designated medical institutions to standardize the provision of diagnostic and treatment services.
Article 20 strictly enforcing the management of medical insurance fund income and expenditure, strengthen the use of individual accounts, settlement and other aspects of the audit, do a good job of income and expenditure information statistics. Improve the personal account settlement in the province and across the province intelligent monitoring platform, "one card line" designated medical institutions dynamic maintenance mechanism, regular inspection mechanism, emergency disposal mechanism. Improve the monitoring and analysis mechanism of outpatient medical services, and guide the designated medical institutions to standardize the provision of diagnosis and treatment services.
Chapter VI Supplementary Provisions
Article 21 Municipal Health Insurance Bureau, the Municipal Bureau of Finance can be deployed according to the higher level, the ability of the health insurance fund to pay for the situation, the outpatient outpatient integrated security treatment standards for adjustment.
Article 22 The implementation of the rules by the Municipal Health Insurance Bureau is responsible for interpretation.