Reimbursement and compensation program in 2010
Municipal health bureaus, civil affairs bureaus, finance bureaus, agriculture bureaus in all counties, social development bureaus and finance bureaus of the management committees of Jining Hi-Tech Zone, and the offices and finance bureaus of the management committees of the Jining Beihu Resort Area:
In order to comprehensively implement the "Implementing Opinions of the Municipal Party Committee and the Municipal Government on Further Deepening the Medical and Health System Reform Implementation Opinions" (Jifa [2009] No. 17), the municipal government "on the issuance of medical and health system reform in the near future focus on the implementation of the program (2009-2011) of the notice" (Jizhengfa [2009] No. 30) spirit, according to the Provincial Department of Health, Provincial Department of Civil Affairs, Provincial Department of Finance, the Provincial Department of Agriculture, "on the consolidation and development of a new type of rural cooperative medical care system of opinions" ( Lu Wei agricultural health hair [2009] No. 5) requirements, combined with the city's actual, is now unified in 2010 the city's new rural cooperative reimbursement compensation program and other related matters are notified as follows.
I, financing standards
In 2010, the new rural cooperative financing level increased to no less than 120 yuan per person per year, of which, financial subsidies at all levels increased to no less than 100 yuan per person per year, the farmers' personal contribution of 20 yuan per person per year. In the provincial financial (including central subsidies) to the city of participating farmers per person per year subsidy of 45 yuan on the basis of municipal finance to Yanzhou City, Zoucheng City, Jining High-tech Zone participating farmers per person per year subsidy of 6 yuan, on the city of Central District, Rencheng District, Qufu City, Weishan County, Beihu Resort farmers per person per year subsidy of 10 yuan, on the Sishui County, Yutai County, Jinxiang County, Jiaxiang County, Wenshang County, Liangshan County, farmers per year subsidy of 24 yuan. Subsidies of 24 yuan per person per year, the balance by the county (city, district) level of finance to make up for the 2011, the new rural cooperative financing level increased to no less than 150 yuan per person per year, of which the subsidies at all levels of government of no less than 120 yuan per person per year, the individual farmer contributions of no less than 30 yuan per person per year. Localities in a position to do so are encouraged to appropriately raise the standards for local financial subsidies and farmers' contributions in accordance with their financial situation and the affordability of farmers.
II. Compensation model
In 2010, the city continued to uniformly implement inpatient co-ordination plus outpatient co-ordination model. Outpatient co-ordination fund (including health check-up costs, etc.) accounted for the year the proportion of the total amount of fund-raising is generally not higher than 35%, inpatient co-ordination fund and the current year's withdrawal of risk funds accounted for the total amount of fund-raising in the current year is generally not less than 65%, of which the withdrawal of risk funds in accordance with the Provincial Department of Finance, the Provincial Department of Health, Lu CaiShe 〔2008〕 No. 18 document implementation.
Three, hospitalization compensation
1, hospitalization starting line
The establishment of a four-tier starting line, first-class designated medical institutions for 100 yuan, the second and third-class designated medical institutions for 500 yuan, designated medical institutions outside of the city for 600 yuan. The starting line for hospitalization compensation is deducted from the expenses within the scope of compensation and is not compensated. Participating farmers who are hospitalized in the same hospital will only have the starting line deducted once in a year.
2. Hospitalization compensation ratio
The reimbursement and compensation ratio of the first-level designated medical institutions is 65%, the reimbursement and compensation ratio of the second-level designated medical institutions is 55%, the reimbursement and compensation ratio of the third-level designated medical institutions is 45%, and the reimbursement and compensation ratio of the provincial-level designated medical institutions is 35%. Counties (cities and districts) may fluctuate on this basis, but not more than 5%. When calculating the actual amount of compensation for participating farmers, the reimbursable expenses minus the amount of the starting line should be applied and then compensated according to the prescribed compensation ratio. The guaranteed compensation is implemented, and the actual compensation ratio for hospitalization in county-level and above medical institutions shall not be less than 25%.
For non-referral record, in the province outside the city of the new rural cooperative designated medical institutions hospitalization can be compensated according to the stipulated compensation ratio of 60%; non-referral record of out-of-province medical treatment and non-designated medical institutions in the province (except for the participating migrant workers in the field of medical treatment and emergency) will not be compensated.
3. The hospitalization of participating pregnant women for normal delivery will be compensated at a fixed amount of 200 yuan. Cesarean section is still in accordance with the requirements of the "four unified, four fixed" management approach. For medical expenses incurred by newborns born between the previous and the next payment period of the New Farmers' Cooperative, their mothers can enjoy the New Farmers' Cooperative compensation policy.
4. The hospitalization compensation ceiling is 50,000 yuan, and the hospitalization compensation ceiling is calculated cumulatively with the actual amount of compensation received during the year.
5. Participating migrant workers at their workplaces and participating farmers who are out of town with sudden illnesses can first seek medical treatment, and within a week or before discharge, they can inform the coordinating region's New Rural Cooperative Medical Institutions by phone, and the medical expenses incurred in hospitalization will be reimbursed in accordance with the reimbursement ratio of the local fixed-point medical institutions of the same level on the basis of the relevant certificates.
6, a substantial increase in the proportion of compensation for basic national drugs, the proportion of compensation for drugs in the basic drug list increased by 10%. Appropriately increase the proportion of compensation for traditional Chinese medicine services, the proportion of compensation for traditional Chinese medicine costs (excluding proprietary Chinese medicines) was increased by 10%, and the proportion of compensation for hospitalized patients' treatment costs for acupuncture and moxibustion and other appropriate Chinese medicine techniques was 90%.
7. Strengthening departmental cooperation, and doing a good job in the effective convergence of the New Rural Cooperative and the rural medical assistance system in terms of policy, technology, service management and cost settlement. At the county level, a unified service platform for the New Farmers' Cooperative and rural medical assistance was established to realize the information***sharing of the two systems, and the implementation of the "one-stop" service of settling the New Farmers' Cooperative compensation and medical assistance subsidies on the spot at the healthcare institutions for the convenience of the poor farmers after their visits to the healthcare institutions.
Four, non-hospitalization compensation
1, outpatient compensation
Outpatient coordination is generally in the New Farmers' Cooperative first-level and village-level designated medical institutions compensation (not included in the integration of rural health services management of the village medical institutions shall not be designated as the New Farmers' Cooperative medical institutions), there is no starting line, outpatient costs at a rate of 20% of the compensation, per person per year, the outpatient outpatient reimbursement of the compensation cost of the ceiling line of 50 yuan. The cap line is 50 yuan per person per year, calculated cumulatively with the actual amount of compensation received during the year.
2. Compensation for chronic diseases
The following diseases shall be included: hypertension (stage II), heart disease with cardiac insufficiency, cerebral hemorrhage and cerebral infarction recovery, rheumatoid arthritis, chronic active hepatitis, chronic obstructive pulmonary emphysema and pulmonary heart disease, epilepsy, hepatomegaly, decompensated cirrhosis of the liver, diabetes mellitus with ineffective dietary control, chronic nephritis, Parkinson's disease, systemic lupus erythematosus, intervertebral discs, and other diseases. lupus erythematosus, herniated intervertebral disc, chronic pelvic inflammatory disease and adnexitis, tuberculosis, schizophrenia.
Chronic diseases should be identified by the county-level new rural cooperative agencies organized by expert appraisal or prior verification of medical records. Chronic disease patients voluntarily choose a county-level designated medical institutions for treatment of chronic diseases and are compensated at their chosen county-level designated medical institutions or county-level New Farmers' Cooperative agencies, with a starting line of 200 yuan, expenses below the starting line are compensated in accordance with the outpatient compensation ratio, and the compensation ratio above the starting line is 40% (nominal compensation ratio), with a cumulative annual cap line (compensation earned) of 1,000 yuan. Funds are paid out of the Outpatient Coordination Fund.
Major outpatient treatment costs for special diseases such as malignant tumor radiotherapy, aplastic anemia, hemophilia, and organ transplantation anti-discharge treatment are implemented in accordance with the inpatient compensation for hospitalization at the same level. Patients with special diseases voluntarily choose a county-level designated medical institution for treatment and are compensated at the county-level designated medical institution of their choice or at the county-level new rural cooperative agency, with a starting line of RMB 400 yuan; expenses below the starting line are compensated in accordance with the proportion of outpatient compensation, and expenses above the starting line are compensated in accordance with the compensation for inpatient treatment at the same level of hospitals. The annual cumulative cap line (compensation income) is 5,000 yuan. Dialysis treatment for chronic renal insufficiency and large outpatient treatment costs for leukemia are compensated in accordance with the inpatient compensation of the same level of hospitals, with a starting line of RMB 400 yuan, and an annual cumulative ceiling (compensation gain) of RMB 50,000 yuan. The above funds are expended from the Hospitalization Coordination Fund.
3, secondary compensation
Secondary compensation does not belong to the normal compensation methods, do not advocate secondary compensation, but the fund balance or the cumulative balance of the fund of the previous years more places, can be the year to obtain compensation for serious illnesses of farmers in general for the second compensation, can not be compensated only for a small number of farmers, and at the same time, we must do a good job in the organization of the second compensation of propaganda and publicity work, to avoid causing the enrolled The second compensation should be well organized, publicized and announced to avoid unnecessary comparison of treatment among farmers.
4, for participating farmers at the same time to participate in commercial medical insurance or other policy provisions of the cost of preferential, should be the first implementation of the commercial insurance payout or preferential policies, and then the total cost of medical care for participating farmers in accordance with the provisions of the New Rural Cooperative Compensation to be compensated.
Fifth, continue to implement the "city a pass" system
In order to further facilitate the participating farmers to the city at all levels of the New Rural Cooperative designated medical institutions for medical reimbursement, to continue to implement the "city a pass" system, the municipal Bureau of Public Health announced that the city, the county (City and district) and township-level New Rural Cooperative Medical Care designated medical institutions in the city recognize each other, and all participating farmers who go to the New Rural Cooperative Medical Care designated medical institutions at all levels in Jining City for medical treatment will no longer have to go through the referral procedures. If a participating farmer is hospitalized in a mutually recognized New Rural Cooperative Medical Institution, he will be entitled to the same reimbursement rate of the New Rural Cooperative Medical Institution at the same level as that of the participating farmer's location.
Sixth, clear scope of participation
In accordance with the Provincial Government General Office "on the comprehensive promotion of new rural cooperative medical care pilot notice" (Lu Zhengban Fa [2007] No. 1), a clear definition of the scope of coverage of the New Rural Cooperative Medical Insurance and urban residents, to avoid duplication of participation (insurance). The principle of participation in the New Rural Cooperative Health Insurance on a household basis is strictly enforced, and participants should be registered as residents with agricultural household registration; where reform of the household registration system has been implemented, they can be defined as rural residents on the basis of the family planning policies, veterans' resettlement policies and urban low income insurance policies enjoyed by their families. Primary and secondary school students and pre-school children with rural household registration should join the new rural cooperative program with their parents.
Seven, strengthen supervision and management to ensure standardized operation
Strict implementation of the new rural cooperative medical care basic drug list, diagnostic and treatment catalog and antibiotic use guidelines and other relevant provisions, reasonable examination, reasonable treatment, gradient medication, reasonable dispensing, and shall not be abusive use of medicines, prescribing large prescriptions. Discharged patients should be discharged from hospitals with medicines in accordance with the prescription regulations, and the amount of medicines discharged from hospitals for general acute diseases should not exceed 7 days' dosage, and that for chronic diseases should not exceed 15 days' dosage. The implementation of a system of mutual recognition of examination results by medical institutions; if a higher-level hospital has already conducted an examination and issued a report on the results, the lower-level hospital should recognize it, and the reports on the results issued by hospitals at the same level should be mutually recognized to avoid duplication of examinations. An out-of-catalog medication and diagnosis and treatment notification system has been implemented, and the proportion of out-of-catalog medication costs to total medication costs in villages and first-, second-, and third-level designated medical institutions is no higher than 5%, 10%, 15%, and 20%, respectively. Supervisory departments of the New Rural Cooperative at all levels shall implement a system of notification of average hospitalized medical costs and warning and admonition, and regularly publicize the medical costs of New Rural Cooperative designated medical institutions in an appropriate manner. County (city, district) new rural cooperative management department, the new rural cooperative designated medical institutions at all levels to develop specific measures to strengthen the audit management of the cost of consultation, to put an end to the new rural cooperative fund irregularities in expenditure, violation of the new rural cooperative management regulations, cancel the new rural cooperative designated medical institutions qualification and in accordance with the relevant provisions of the relevant responsible person seriously dealt with.
Eight, the instructions
1, the city's unified reimbursement compensation program since January 1, 2010 onwards.
2, in the city to continue to implement the new rural cooperative medical care "four unified, four fixed" and "four one" management approach.
3, the counties and municipalities to organize at least once every six months with the participation of members of the New Rural Cooperative Supervisory Committee supervisory inspections to ensure the safety of funds.
4, this notice of outstanding matters, should be in accordance with the Provincial Department of Health, Provincial Civil Affairs Department, Provincial Department of Finance, Provincial Department of Agriculture, "on the consolidation and development of the new rural cooperative medical system of views" (Lu Wei Nongwei Fa [2009] No. 5) the provisions of the implementation.
December 3, 2009