In order to further improve the medical security system for urban residents in our province and improve the level of serious and serious diseases, this implementation plan is formulated according to the Notice of the General Office of the People's Government of Henan Province on Forwarding the Implementation Opinions of Serious Illness Insurance for Urban and Rural Residents (for Trial Implementation) (Yu Zheng Ban [2065438+03] No.22) and combining with the actual situation in our province.
I. Guiding ideology
Guided by the spirit of the 18th National Congress of the Communist Party of China and the Third Plenary Session of the 18th Central Committee, we will deepen the reform of the medical and health system, explore the establishment of a serious illness insurance system for urban residents (hereinafter referred to as serious illness insurance), build and improve a multi-level medical security system, focus on solving the problem of "difficult and expensive medical treatment", effectively reduce the burden of serious illness medical expenses for urban residents, and promote the standardized operation and sustainable development of medical insurance for urban residents in our province.
Second, the basic principles
(a) government-led, market operation. The government is responsible for policy formulation, organization and coordination, fund raising management and strengthening supervision and guidance. Support commercial insurance institutions to undertake serious illness insurance, give play to the role of market mechanism, and continuously improve operational efficiency, service level and quality.
(2) Responsibility and sustainable development. The level of serious illness insurance should be compatible with the level of economic and social development, the level of medical consumption and the affordability of the basic medical insurance fund. Strengthen social mutual assistance, and gradually form a risk-sharing mechanism among the government, individuals and commercial insurance institutions to achieve sustainable development.
(three) overall planning, focusing on convergence. Under the principles and institutional framework determined by the state, formulate a unified serious illness insurance policy for the whole province and promote it as a whole. Give full play to the synergy and complementarity of basic medical insurance, serious illness insurance, social medical assistance, disease emergency assistance and other systems, strengthen the convergence and balance between systems, and form a joint force of protection.
(four) balance of payments, guaranteed profit. Scientific calculation, steady start, standardized operation, strengthen the management of serious illness insurance fund, and ensure the balance of the fund. Improve the performance of serious illness insurance, reasonably control the profit rate of commercial insurance institutions, and strive to achieve low-profit operation of commercial insurance institutions.
Three. Financing mechanism
(1) Financing channels. The serious illness insurance fund is raised from the basic medical insurance fund for urban residents in the cities under the jurisdiction of the province and the counties (cities) directly under the jurisdiction of the province, and is no longer charged to urban residents.
(2) Funding criteria. The fund-raising standard of serious illness insurance was determined with reference to about 6% of the total fund-raising of basic medical insurance for urban residents in the province in that year. Considering the factors such as the per capita disposable income of urban residents, the level of medical consumption, and the fairness of serious illness insurance benefits in provincial cities and counties (cities) directly under the provincial government, we will implement differentiated financing for provincial cities and counties (cities) directly under the provincial government. Funding criteria are divided into three grades: 26 yuan, 24 yuan and 22 yuan (see Annex). Establish a dynamic adjustment mechanism for financing standards, and the Provincial Department of Human Resources and Social Security shall, jointly with the Provincial Department of Finance, determine the annual financing standards for major illness insurance in cities under the provincial jurisdiction and counties (cities) directly under the provincial government according to the benefit of major illness insurance in the previous year, the financing level of basic medical insurance for urban residents and the income level of urban residents.
(3) Overall planning level. Serious illness insurance shall be coordinated at the provincial level, and the serious illness insurance fund shall be raised, managed and used in a unified way throughout the province.
Luoyang, Anyang and hua county can continue to carry out pilot projects according to the current serious illness insurance policy, which will be included in the provincial overall planning scope before the end of the year.
Fourth, the content of protection.
(1). The object of serious illness insurance is the insured of basic medical insurance for urban residents in our province. Newborns enjoy serious illness insurance benefits from the date of enjoying the basic medical insurance benefits for urban residents.
(2) scope of protection. The insured residents' hospitalization medical expenses (including the prescribed outpatient chronic disease expenses, the same below) within an insurance year shall be paid by the urban residents' basic medical insurance fund in accordance with the regulations, and the individual's accumulated compliance medical expenses exceeding the deductible line of serious illness insurance shall be paid by the serious illness insurance fund in accordance with the regulations. The specific scope of self-paid medical expenses for serious illness insurance compliance is determined by the Provincial Department of Human Resources and Social Security in accordance with relevant regulations.
(3) Protection level. The deductible line of serious illness insurance is determined with reference to the per capita disposable income of urban residents in our province last year. The deductible is 6.5438+0.8 million yuan. In an insurance year, the medical expenses for compliance out-of-pocket expenses accumulated over the deductible line shall be paid by the serious illness insurance fund in proportion: 50% for the part of 6.5438+0.8 million yuan-50,000 yuan (including 50,000 yuan), and 60% for the part of 50,000 yuan-6.5438 million yuan (including 6.5438 million yuan), exceeding 6.5438 million yuan. The annual maximum payment limit is 300,000 yuan. Insured residents who are hospitalized within an insurance year (including multiple hospitalizations) only bear the deductible line of serious illness insurance once. After participating in the reimbursement of serious illness insurance, the remaining expenses will not be calculated repeatedly.
Establish a mechanism for adjusting the deductible line, payment ratio and maximum payment limit of serious illness insurance, and the Provincial Department of Human Resources and Social Security shall, jointly with the Provincial Department of Finance, make timely adjustments according to the income and expenditure of serious illness insurance funds in cities under the jurisdiction of the province and counties (cities) directly under the jurisdiction of the province, the financing level of basic medical insurance for urban residents, the annual per capita disposable income of urban residents and other factors.
(4) Insurance year. Serious illness insurance is consistent with the basic medical insurance for urban residents, and the natural year is the insurance year, that is, from June 65438+ 10/to February 3 1.
(5) expense settlement. If the medical expenses paid by the insured residents in the designated medical institutions of medical insurance exceed the deductible line of serious illness insurance, they shall be settled immediately in the designated medical institutions. According to the regulations, the medical expenses that should be borne by individuals shall be settled by themselves and designated medical institutions; Medical expenses that should be paid by the serious illness insurance fund shall be settled by commercial insurance institutions and designated medical institutions.
For those who do not have immediate settlement conditions for the time being, but the hospitalization compliance self-paid medical expenses exceed the specified deductible line, the insured urban residents can go through the reimbursement procedures for serious illness insurance at the service outlets designated by the commercial insurance institutions in the insured areas with valid identity documents, copies of the proof of referral or medical treatment in different places (referred or treated in different places) and settlement bills for hospitalization reimbursement expenses of urban residents.
Verb (abbreviation of verb) handling management
(a) the way of undertaking. The Provincial Department of Human Resources and Social Security adheres to the principles of openness, fairness and impartiality, and selects commercial insurance institutions that undertake serious illness insurance in the province through government bidding. Commercial insurance institutions undertaking serious illness insurance should not only meet the basic conditions stipulated in document No.22 of Yu Zhengban [2065438+03], but also have the business qualification of serious illness insurance publicized by Henan Insurance Regulatory Bureau, and have branches in the urban residents' basic medical insurance co-ordination area in our province (they can enjoy the service outlets and service team resources of other subsidiaries in the same commercial insurance group company).
(2) Contract management. The Provincial Department of Human Resources and Social Security signed a contract with the selected commercial insurance institutions to undertake serious illness insurance, clarifying the responsibilities, rights and obligations of both parties. The term of the contract is 3 years. In the contract, the fund-raising standard, guarantee scope, expense settlement and payment standard, profit and loss and risk control and treatment, information exchange and guarantee, assessment methods, supervision and management, liability for breach of contract, etc. are stipulated. Have a clear definition. Following the principle of balance of payments and guaranteed profit, the annual profit (including operating costs) of commercial insurance institutions should be controlled within 3% of the amount raised by the serious illness insurance fund in that year. At the end of the year, after deducting profits according to the prescribed profit rate, the balance shall be deducted from the serious illness insurance fund to be allocated in the next year.
(3) Handling service. Commercial insurance institutions should set up service windows or service outlets in the basic medical insurance agencies of cities and counties (cities, districts) under the provincial jurisdiction to provide "one-stop" services for the insured; Construction of serious illness insurance payment and settlement management information system, and the basic medical insurance management information system of urban residents around the country to achieve effective docking, to ensure that the medical expenses of serious illness insurance are settled immediately in designated medical institutions; Reasonable distribution of medical insurance management information system operation and maintenance service fees; Do a good job in medical expenses audit, payment and settlement, supervision of designated medical institutions and business consulting, strengthen medical behavior supervision and medical expenses monitoring, and promote the standardization of medical behavior; Improve the service process, improve the service efficiency, and pay the medical expenses of serious illness insurance to the designated medical institutions in time. Provincial social medical insurance agencies should establish an assessment mechanism to monitor and assess the number of medical visits and referral rates in different places, clarify rewards and punishments, and strengthen the sense of local responsibility.
Fund management of intransitive verbs
The serious illness insurance fund shall be managed by two lines of revenue and expenditure, with special account accounting and special fund. Provincial social medical insurance agencies shall, in accordance with the relevant provisions, set up zero-balance income accounts to collect serious illness insurance funds, and remit the income household deposits to the financial accounts on schedule. In addition to the income transferred to the finance department, no other payment business may occur, and the income households have no balance at the end of the month. According to the application of the provincial social medical insurance agency, the provincial finance department will allocate the serious illness insurance fund to commercial insurance institutions on schedule. Commercial insurance institutions set up serious illness insurance fund accounts.
Before the end of April each year, the medical insurance agencies of cities and counties (cities) under the jurisdiction of the province will solve the serious illness insurance fund, and settle the accounts according to the facts in the following year.
The Provincial Department of Finance reserves 5% from the serious illness insurance fund as the policy loss risk adjustment fund. If the adjustment of the basic medical insurance policy for urban residents leads to the loss of the serious illness insurance fund in the current year, the commercial insurance institution shall bear the loss within the scope of winning the bid, and the rest shall be solved by means of risk adjustment fund or raising the financing level for the next year; Non-policy losses shall be borne by commercial insurance institutions.
Seven. Division of responsibilities
After the implementation of the serious illness insurance system, cities and counties (cities) under the jurisdiction of each province shall not reduce the level of basic medical insurance benefits. According to the relevant regulations and requirements, the basic unified urban residents' basic medical insurance policy will be implemented from 1, and the online settlement application software of urban residents' basic medical insurance will be used before 12+3 1, which will provide a good support for the development of serious illness insurance.
The provincial development and reform department coordinated economic and social development and strengthened the guidance on the province's major illness insurance. Provincial human resources and social security departments take the lead in formulating basic policies for serious illness insurance; Select commercial insurance institutions through public bidding and sign contracts with the determined commercial insurance institutions; Strengthen the audit supervision of the use and management of funds. The provincial finance department provides financial support for the construction of medical insurance information system in this province according to the actual needs. The audit department strengthens the audit of the use of the serious illness insurance fund. Provincial insurance supervision departments participate in the bidding work of commercial insurance institutions, and strengthen the daily business supervision and investigation of violations of commercial insurance institutions. All relevant departments should cooperate with each other, strengthen communication and cooperation, form a joint effort to promote the work of serious illness insurance in our province.
Eight. job requirement
(1) Raise awareness and strengthen leadership. Carrying out serious illness insurance is an important content to establish and improve the security mechanism for serious and serious diseases of urban residents, an important measure to deepen the reform of medical and health system and establish a multi-level medical security system, and is of great significance to further embody mutual assistance and promote social fairness and justice. Governments at all levels and relevant departments should attach great importance to it, conscientiously implement the overall arrangements of the state and our province on the work of serious illness insurance, effectively regard the work of serious illness insurance as an important task, put it on an important agenda, strengthen leadership and actively coordinate to ensure the smooth start and steady progress of the work of serious illness insurance.
(2) Strengthen supervision and standardize management. It is necessary to strengthen supervision and inspection to ensure the smooth progress of serious illness insurance. The establishment of commercial insurance institutions assessment and reward and punishment mechanism, timely investigate and deal with violations. Strengthen the supervision of the service behavior of designated medical institutions, standardize the medical service behavior, ensure the quality of medical services, and control the unreasonable increase of medical expenses.
(three) extensive publicity, strengthen guidance. Intensify publicity, and widely publicize the policies and reimbursement methods related to serious illness insurance to the insured. It is necessary to strengthen the publicity and training of serious illness insurance policies for medical personnel in designated medical institutions, announce supervision and consultation telephone numbers, unblock complaint channels and accept social supervision. Starting from June 65438+1 October1,the critical illness insurance will be fully launched according to this plan. This plan is a pilot project. During the trial period, the Provincial Department of Human Resources and Social Security will improve relevant supporting policies and management systems in a timely manner, and adjust relevant policies in a timely manner in conjunction with the Provincial Department of Finance and other departments according to the financing level of urban residents' basic medical insurance and the operation of the serious illness insurance fund.
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Degree of provincial cities and counties (cities)
Financing standard of serious illness insurance for urban residents
First, the financing standard is 26 yuan, a city or county (city) under the jurisdiction of the province.
Zhengzhou, Pingdingshan, Jiyuan and gongyi city.
Two, the financing standard is the provincial city and county (city) directly under the jurisdiction of 24 yuan.
Kaifeng, Hebi, Xinxiang, Jiaozuo, Puyang, Xuchang, Luohe, Sanmenxia, Nanyang, Shangqiu, Xinyang, Zhumadian, Ruzhou, dengzhou city and yongcheng city.
Three, the financing standard for the provincial city and county (city) directly under the jurisdiction of 22 yuan.
Zhoukou City, lankao county, Changyuan County, Gushi County, Luyi County and Xincai County.