There is no starting line for outpatient expenses at first-class medical institutions and primary medical institutions
Active employees and retirees are reimbursed up to 1500 yuan and 2000 yuan, respectively
The general outpatient coordination system covers all the participants of the employee health insurance. Not only will participants in the integrated account model be able to enjoy the general outpatient reimbursement policy, but also those who are in difficulty in the single-account integrated system will also be able to enjoy the general outpatient reimbursement policy.
The outpatient medical expenses within the scope of the policy of the province's employee health insurance participants in the first-level medical institutions and primary medical and health care institutions, there is no starting standard, 70% of the proportion of the payment; in the second-level medical institutions, the starting standard of outpatient medical expenses within the scope of the policy of 200 yuan, 60% of the proportion of the payment; in the third-level medical institutions, the outpatient medical expenses within the scope of the policy of 300 yuan, 60% of the proportion of the payment. 300 yuan, paid at 60%.
In a natural year, the starting standard shall not exceed 300 yuan in total, and the maximum payment limit of the integrated fund shall be 1,500 yuan for active employees and 2,000 yuan for retirees. The maximum payment limit of the integrated fund refers to the maximum amount that the integrated fund can actually reimburse to the insured.
"The current payment limit determined by the general outpatient co-ordination policy, together with the amount transferred from individual accounts, can, on the whole, basically meet the outpatient medical needs of the insured." Provincial medical security bureau party group members, deputy director Wu Guoyu said, the province's employees health insurance general outpatient co-ordination policy design reflects the treatment payment appropriately tilted to the elderly, but also conducive to promote the implementation of hierarchical diagnosis and treatment system, guiding the insured personnel at the grass-roots level close to the medical treatment.
The slow special disease outpatient protection
Enjoy the special outpatient treatment can also enjoy the general outpatient reimbursement
The same cost does not repeat the treatment, the reimbursement amount of separate cumulative settlement reimbursement
High blood pressure, diabetes and other masses of people burdened by the outpatient chronic diseases, special diseases (hereinafter referred to as outpatient slow special disease) health care protection, has always been a great deal of attention.
Hunan is gradually expanding the scope of outpatient chronic and special diseases to be paid for by the integrated fund, and incorporating some of the outpatient costs of diseases with a long treatment cycle, great damage to health, and a heavy burden of outpatient costs into the ****ancial protection.
The province studied and formulated the employee health insurance slow special disease outpatient treatment guarantee management methods, unified the province's outpatient slow special disease diagnosis and inclusion of standards, clear outpatient slow special disease into the health insurance fund to pay for the evaluation process, the implementation of outpatient slow special disease medicine single column payment management.
At present, clinical experts have been organized to formulate outpatient slow special disease diagnosis and treatment norms, medication guidelines. The existing 43 types of diseases into the outpatient slow special disease reimbursement scope, and determine the reimbursement rate and amount of each type of disease, but also will establish the outpatient slow special disease types of dynamic adjustment mechanism. The outpatient medical expenses within the policy scope of slow special diseases for active employees will be paid at 80%, and the outpatient medical expenses within the policy scope of slow special diseases for retirees will be paid at 85%.
It is worth mentioning that after the implementation of the employee health insurance outpatient co-ordination *** relief system, the participants who have enjoyed the special outpatient treatment can enjoy the general outpatient reimbursement at the same time. After the implementation of the employee health insurance outpatient co-ordination *** relief system, the participants who have enjoyed the special outpatient treatment can also enjoy the general outpatient reimbursement treatment, but the same amount of money will not be repeated to enjoy the treatment. The special outpatient amount and the general outpatient reimbursement amount are accumulated and reimbursed separately.
For example, if a participant is entitled to a special outpatient treatment for hypertension, the monthly treatment rate is 260 RMB, and if the participant goes to the hospital for outpatient treatment due to illness in addition to the normal monthly treatment for the special outpatient treatment, the relevant medical expenses can be reimbursed in accordance with the policy of outpatient co-ordination and there is no contradiction with the expenses of the special outpatient treatment. The same expenses reimbursed by the outpatient clinic (including personal out-of-pocket expenses) are no longer included in the special clinic for reimbursement, and similarly, the expenses (including personal out-of-pocket expenses) that have already been entitled to special outpatient treatment are no longer included in the outpatient clinic for reimbursement.
Individual account crediting methods
All individual contributions are credited to individual accounts, allowing family members to use them for each other
After the implementation of the "outpatient ****ji" in the employee health insurance, the method of crediting individual accounts will be improved. The basic medical insurance premiums paid by individual workers are all credited to their personal accounts, and the crediting standard is 2% of their contribution base. Retirees' personal accounts are credited by the integrated fund on a monthly basis at a fixed amount of 75 yuan per month. from January 1, 2023 onwards, the standard will be implemented in accordance with the unified standards of the province.
After adjusting the structure of the co-ordinated fund and individual accounts, the increased co-ordinated fund will be mainly used for outpatient ****ancial protection to improve the outpatient treatment of the insured.
Wu Guoyu said it is estimated that after improving the way individual accounts are credited, about 9 billion yuan of the fund will be used to strengthen outpatient protection that year. This money can then be turned into real fund inputs in the current period, which can really be used on the sick, especially the elderly, and really be used to pay for medical services, thus supporting the development of primary health care service providers and the utilization of medical resources. So in terms of the efficiency of the utilization of the fund, it is a great activation and enhancement. There are no new contributions from insured units or individuals, and the system switch has been implemented under the existing conditions to enhance the effectiveness of the system.
After the reform, family members will be allowed to use their personal accounts for mutual **** relief, but they will not be allowed to use their personal accounts for public **** health expenses, sports and fitness or health care consumption and other expenditures that do not fall within the scope of the basic medical insurance coverage.
It is understood that the health insurance department is expanding the scope of outpatient coverage of employee health insurance, and exploring the inclusion of outpatient medical services in line with the provisions of the "Internet +" into the scope of coverage. Do a good job of connecting outpatient costs with hospitalization payment policies.
Implementation Progress and Guarantees
By the end of the year, the province will establish a general outpatient co-ordination system for employees' health insurance
The province has recognized the first batch of 149 designated medical institutions, and outpatient co-ordination costs will be directly settled through the Internet
At present, Hunan's employees' health insurance outpatient***consolidation policy has been formally implemented in the province, Changsha, Zhuzhou, Xiangtan, Shaoyang, and Chenzhou by the end of the year, and other municipalities and states will also start up in succession by the end of the year. Other cities and states will also be launched one after another.
In the next two months, Huaihua, Yueyang, Zhangjiajie, Yiyang, Yongzhou, Loudi, Xiangxi Tujia and Miao Autonomous Prefecture, Changde and Hengyang will also launch the policy, and by the end of the year, the province will have fully established the general outpatient co-ordination system of the employees' health insurance.
The new policy will benefit the province's 10.4 million employees insured. In order to facilitate the outpatient treatment and reimbursement of the insured people, the health insurance department has been simplifying and optimizing the business process and launching convenient service measures.
As long as the opening of the basic medical insurance hospitalization designated services of medical institutions and eligible retail pharmacies, in principle, can be directly recognized as outpatient coordinated designated medical institutions. At present, the provincial level has directly recognized the first batch of 149 fixed-point medical institutions, covering primary health care institutions and first-, second- and third-level hospitals.
Participants in the medical insurance registration and reimbursement procedures to simplify the purchase of medicines, the implementation of outpatient outpatient costs network direct settlement. Participants need to pay only part of the individual out-of-pocket expenses, belonging to the outpatient outpatient fund part of the payment by the designated medical institutions and agencies in accordance with the provisions of the agreement to pay for outpatient outpatient outpatient reimbursement of integrated costs of medical insurance do not need to "advance funds, errands".
The outpatient medical insurance registration procedure has been canceled in the province across the integrated area, the insured persons across the integrated area of the designated medical institutions for medical consultation, without the need to apply for the record of registration of medical treatment, only need to take the initiative to indicate the place of participation and the type of medical treatment, with the electronic voucher of the medical insurance, resident identification card or social security card can be directly settled for the purchase of medicines and reimbursement.
In order to implement the outpatient co-ordination policy "the last kilometer" of the important link, the designated medical institutions to actively open up the hospital internal blockage, the opening and expansion of outpatient co-ordination settlement window, the development of the hospital internal settlement process system, to speed up the hospital information system transformation, real-time settlement of outpatient costs, to facilitate the insured people to see a doctor.
Experience: "***济" reimbursement, 1300 yuan of medical expenses only need to pay 778 yuan
Recently, the public Cao Qinghe (a pseudonym) due to abdominal discomfort, to Hunan Cancer Hospital outpatient clinic.
The doctor prescribed the appropriate examination, Cao Qinghe settlement found a *** for 1300 yuan cost, but they only need to pay 778 yuan. October 1, Hunan Cancer Hospital began to implement the health insurance outpatient *** relief protection policy, the general outpatient costs can be included in the health insurance reimbursement.
How exactly is the reimbursement? Within a natural year, the starting standard of outpatient coordination for employees does not exceed 300 yuan in total, and the maximum payment limit for active employees is 1,500 yuan, and the maximum payment limit for retirees is 2,000 yuan. Take a tertiary designated hospital as an example: the starting standard is 300 RMB, and the employee health insurance fund will reimburse 60% of the total cost. The total outpatient cost is 1,300 RMB, of which the out-of-pocket percentage is 10% (130 RMB). Then, the outpatient reimbursement amount = (1300-130-300) × 60% = 522 yuan (300 yuan is the starting line, and there is no need to deduct after the annual accumulation of 300 yuan).
The scope of payment for outpatient co-ordination for employees is the same as the scope of payment for basic medical insurance, i.e., the scope of the basic medical insurance drug catalog, medical service item catalog and medical consumables catalog as stipulated by the state and the province, and those outside the scope of payment for basic medical insurance will not be paid.
After the outpatient doctor's prescription, the insured person can settle the bill at the outpatient window with the electronic voucher of medical insurance, ID card or social security card, and the insured person only needs to pay the out-of-pocket expenses. During the hospitalization, the insured person is not entitled to the outpatient treatment for employees and the outpatient treatment for chronic and special diseases; the outpatient treatment for employees will not be paid for the medical expenses that have already been paid for by the treatment of "dual-channel" medicines and the outpatient treatment for chronic and special diseases; and the outpatient medical expenses for accidental injuries borne by a third party will not be included in the reimbursement of the medical insurance.
Extension
Accidentally injured insured employees in the outpatient medical treatment, can be included in the general outpatient reimbursement?
Outpatient medical expenses within the scope of the accidental injury policy can be included in the general outpatient reimbursement for employees, but there are a few special cases that are not included in the general outpatient reimbursement. The first one is the outpatient expenses of accidental injuries covered by a third party; the second one is the outpatient medical expenses incurred in the event of work-related injuries.
In practice, if a participant complains that there is no third-party liability, the designated medical institution should strengthen the identity verification of the traumatized person, and then fill in the "Commitment of No Third-Party Liability for Accidental Injuries" by the participant or his family members after combining the actual situation of the consultation and the condition of the participant, and then the outpatient medical expenses will be included in the general outpatient reimbursement.
Can health checkup expenses be included in the general outpatient reimbursement?
Health checkups cannot be included in the general outpatient reimbursement for the time being. The establishment of the general outpatient coordination of the employee health insurance is aimed at reducing the burden of expenses incurred by insured employees in outpatient consultations due to illnesses. In addition, the national and provincial medical insurance treatment list also clearly stipulates that "physical fitness, health care consumption, health checkups" are not part of the medical insurance fund payment scope.
Medical insurance can reimburse:
1, basic medical insurance drug reimbursement
There are two types of drugs in the reimbursement scope, one is class A, one is class B. The first one is class A, the second one is class B. Class A drugs are the most basic drugs that we can guarantee clinical treatment. And Class B drugs are those that each region adjusts to its own situation.
2, basic medical insurance treatment program reimbursement
Basic medical insurance treatment program to meet the three conditions: must be safe and effective, the cost is appropriate; the price department set the fee standard; designated medical institutions treatment.
3. Reimbursement of basic medical service facilities.
Legal basis;
Article 23 of the Social Insurance Law of the People's Republic of China*** and the State of China
Employees shall participate in the basic medical insurance for employees, and shall pay the basic medical insurance premiums by the employing unit and the employees in accordance with the state regulations*** together.
Individual industrial and commercial households without employees, part-time employees who do not participate in the basic medical insurance for employees in their employing units, and other flexibly employed persons may participate in the basic medical insurance for employees, and individuals shall pay the basic medical insurance premiums in accordance with the state regulations.