On December 27, 2022, the Nanjing Municipal Government issued the Measures for the Implementation of Nanjing Employee Basic Medical Insurance Outpatient **** Relief Guarantee Mechanism (hereinafter referred to as the Measures), which will be implemented on January 1, 2023 onwards. After the implementation of the Measures, it will improve the outpatient treatment of insured persons and reduce the burden of outpatient medical expenses on the public, especially retirees, by establishing and perfecting the outpatient co-ordination of employee health insurance, standardizing the outpatient special disease protection of employee health insurance, adjusting the policy of individual account crediting, standardizing the scope of use of the individual account, and establishing a health incentive mechanism for the individual account, among other five aspects.
In terms of establishing and improving the outpatient co-ordination of employee health insurance, Nanjing will establish a new outpatient co-ordination policy starting from January 1, 2023, optimize and integrate the original outpatient co-ordination and outpatient chronic disease policy of employee health insurance, and merge it into a new outpatient co-ordination policy, realize the transformation of basic health insurance disease protection to expense protection, and improve the fairness and accessibility of outpatient protection treatment. After the implementation of the Measures, the level of outpatient treatment will be increased. Firstly, the starting standard will be abolished, the original starting standard for outpatient co-ordination and outpatient chronic diseases (ranging from 600-2200 yuan) of the employee health insurance will be abolished, and the new outpatient co-ordination policy will not set a starting standard. The new outpatient coordination policy does not set a starting payment standard. The new outpatient co-ordination cost payment limit covers the original outpatient co-ordination and the original outpatient chronic disease fund payment limit, and is raised overall, with the annual outpatient cost limit raised from the original 3,333 yuan-12,000 yuan to 15,000 yuan. Third, the implementation of cost segmentation protection. The higher the outpatient medical expenses, the higher the payment ratio of the integrated fund; and appropriately tilted to the primary health care institutions and retirees, 1,000 yuan (including) the following costs, the fund to pay the proportion of 40%-60%; 1,000 yuan (excluding) - 5,000 yuan (including) costs, the fund to pay the proportion of 60%-85%; 5,000 yuan (excluding) - 15,000 yuan (including) costs, the fund to pay the proportion of 65%-90%. In addition, Nanjing will expand the forms of outpatient coverage. It will support the settlement and dispensing of outpatient prescriptions at designated retail pharmacies, and include the medication protection services provided by qualified designated retail pharmacies in the scope of outpatient protection, with the proportion of the co-ordination fund paying for the costs of medicines within the scope of the policy being the same as that of the designated healthcare institutions for outpatient dispensing, so as to give full play to the role of the designated retail pharmacies as being convenient and accessible to the public.
After the implementation of the Measures, on the basis of the original four categories of outpatient specialties such as malignant tumors, dialysis treatment for chronic renal failure, anti-rejection treatment after organ transplantation (including hematopoietic stem cells), hemophilia, and so on, there will be a new 9 categories of diseases, *** counting 13 kinds. The new 9 categories of special diseases are: aplastic anemia, systemic lupus erythematosus, benign intracranial tumors, myelofibrosis, motor neuron disease, chronic renal failure non-dialysis treatment, tuberculosis, severe mental disorders, AIDS. from January 1, will also cancel the payment limit and the course of the disease linked. Adjustment of the annual fund payment ceiling for each type of disease, the fund payment ceiling is no longer linked to the duration of the disease, in accordance with the original maximum payment ceiling set. Such as outpatient treatment of malignant tumors, the original policy for the diagnosis of outpatient auxiliary examination and medication in the 1st -3rd year of the fund payment ceiling of 20,000 yuan / year, the 4th -5th year of the fund payment ceiling of 10,000 yuan / year, the 6th year onwards for 4,000 yuan / year; adjusted outpatient auxiliary examination of malignant tumors after the diagnosis of outpatient medication payment ceiling of a unified fund for 20,000 yuan / year. After the implementation of the Measures, the payment ratio of the medical insurance fund will be increased. For example, for outpatient treatment of malignant tumors, the original policy is that the payment ratio of radiotherapy fund is 92%-96%, and the payment ratio of auxiliary medication examination fund is 90%-95%; the new policy is uniformly raised to 92%-96%. Newly included in the outpatient special disease category of systemic lupus erythematosus, the original implementation of outpatient chronic disease policy, the fund to pay the proportion of the population and the nature of the medical institutions from 60% -95%; the new policy uniformly increased to 92% -96%.
After the implementation of the Measures, the individual account crediting policy will also be adjusted. Including, from January 2023, the personal account of active employees monthly by the basic medical insurance premiums paid by the individual credited, credited to the standard of 2% of the base amount of my participation in the premiums. from January 2023, retirees (retired) personal account in accordance with the amount of the transfer of their own personal account in December 2022 by a fixed amount of the monthly transfer; 2023 the year of the new retirees according to the month of retirement pension of 5.4% The approved transfer amount is transferred in a fixed amount on a monthly basis. If the employee health insurance participant is transferred to retirement, after completing the relevant procedures, the next month onwards, according to the employee health insurance retiree individual account crediting methods. 2024 January onwards, the retiree individual account transfer policy is adjusted according to the relevant provisions of the state and the province. After the implementation of the Measures, the individual account funds are mainly used to pay for the out-of-pocket expenses within the scope of the policy incurred by the person himself in the designated medical institutions on the basis of the realization of family members **** relief. The scope of payment mainly has ten categories.
In addition, from January 1, Nanjing will also establish a personal account health incentive mechanism. Participate in the Nanjing Municipal Employee Health Insurance a natural year did not occur in the integrated fund payment (including sporadic reimbursement of medical expenses, excluding outpatient consultation fees, general consultation fees and nucleic acid testing integrated fund payment), the following year, individual account additions to the transfer of 200 yuan for two consecutive years did not occur in the integrated fund payment of another 100 yuan, the cumulative total increase of 300 yuan. And so on, up to a maximum of 500 yuan.