The reimbursement ratio, the starting line and related formalities are unified regulations. The program is as follows:
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On the unification of the province's new rural cooperative medical compensation program
Guidance
For the establishment of the province's new rural cooperative medical care (hereinafter referred to as the new rural cooperative medicine) relatively unified compensation model, standardize the operation and management of the new rural cooperative medicine, the development of this guidance.
I, the basic principles
The new rural cooperative medical counties (districts) the development of the compensation model, adhere to the income to determine expenditure, to ensure that the appropriate level of savings; hospitalization compensation, taking into account the beneficiary surface; to maintain a relatively stable, and constantly improve; fully embodies the mutual assistance **** relief to the basic principles of the major disease co-ordination.
Second, strict use of hospitalization fund
Hospitalization fund can only be used to participate in the farmers hospitalization medical costs, outpatient medical costs of major diseases (chronic diseases) and compensation for maternity hospital delivery, shall not be used for the farmers' health checkups, immunization, preventive health care, health education, and other public **** health services and medical assistance.
Three, fund-raising
The central financial, provincial financial, municipal financial and county (district) level financial subsidies for each participating farmer annual subsidies for 20 yuan, 14 yuan (17 yuan in poor counties), 3 yuan (0 yuan in poor counties), and 3 yuan, respectively, and the farmers to pay no less than 10 yuan of funds for their own participation.
Fourth, fund distribution
The fund of the New Farmers' Cooperative is divided into three parts, namely, the risk fund, the hospitalization co-ordination fund and the outpatient family account fund (hereinafter referred to as the family account).
(I) Risk Fund. The risk fund is a special reserve fund drawn from the NAC fund and transferred from the balance of the NAC fund to make up for the abnormal overspending of the NAC fund. The risk fund shall be withdrawn by each county (district) from the total amount of the NAC Fund raised each year at the rate of 3%, and counties (districts) with larger fund balances may also transfer 50% of the balance to the risk fund. The size of the risk fund should be maintained at 10% of the total annual fundraising, and will not continue to be withdrawn after reaching the prescribed size. Risk fund management in accordance with the "new rural cooperative medical care pilot counties in Jiangxi Province risk fund management measures" (Gan Cai She [2004] No. 124).
(ii) Hospitalization Coordination Fund. The central and local financial subsidies to participating farmers are all included in the hospitalization fund, and no less than 20% of the farmers' contribution to the fund is included in the hospitalization fund. The hospitalization fund is used to compensate participating farmers for hospitalization expenses up to the starting line, and to compensate for outpatient illnesses (chronic diseases) as well as for hospital deliveries as specified by the counties (districts).
(3) Family accounts. The remaining portion of a farmer's contribution to the integrated fund is the participant's own family account, and the funds subsidized by the central and local governments for the participant shall not be included in the family account. The family account is used by family members*** together, and the amount in the family account can be used up in one go. The balance of the current year's account may be carried over to the next year. Reimbursement of outpatient expenses may not exceed the total amount of funds in the family account. The accumulated funds in the family account shall not be used to offset the contribution of farmers to the cooperative in the following year.
V. Compensation Mode
The province has adopted the mode of "outpatient family account compensation, hospitalization reimbursement of reimbursable expenses in proportion to the outpatient compensation for major illnesses (chronic diseases)".
VI. Compensation Settings
(1) Starting Line for Hospitalization
There are four levels of starting lines, 100 yuan for designated medical institutions at the township level, 300 yuan for designated medical institutions at the county level, 600 yuan for designated medical institutions outside of counties (districts), and 800 yuan for non-designated medical institutions outside of counties (districts), and the starting line shall not be less than 100 yuan. The starting payment line shall not be less than 100 yuan, and the part below the starting payment line shall be the individual's out-of-pocket payment. The starting line is calculated only once for multiple hospitalizations for the same disease during the year, and for consecutive transfers for the same disease, the starting line is calculated only once for one of the hospitals of the highest level.
(2) Hospitalization Compensation Ratio
Only one compensation ratio is established for the same level of medical institutions. 60% for designated medical institutions at the township level, 50% for designated medical institutions at the county level, 40% for designated medical institutions outside the county (district), and 30% for non-designated medical institutions outside the county (district). Counties (districts) may vary up and down by 5% for county-level designated medical institutions and hospitals outside the county on this basis. The hospitalization compensation ratio, in principle, is higher for township-level fixed-point medical institutions than for county-level fixed-point medical institutions, and higher for county-level fixed-point medical institutions than for out-of-county medical institutions, with the difference in the hospitalization compensation ratio at each level to be controlled within 10%. When calculating the actual amount of compensation for participating farmers, the reimbursable expenses should be subtracted from the amount of the starting line, and then compensated in accordance with the prescribed compensation ratio.
(3) Hospitalization Compensation Capping Line
The hospitalization compensation capping line is 15,000 yuan, calculated cumulatively from the actual amount of compensation received during the year.
(4) Implementation of minimum compensation for hospitalization
After a participating farmer's hospitalization medical expenses reach the starting line, the farmer's minimum compensation will be no less than 30 yuan, and a participating farmer who has been hospitalized multiple times in a year will only be entitled to the minimum compensation once.
(E) Others
1. The agricultural population is insisted to participate in the New Rural Cooperative Program on a household basis, and farmers who request to participate in the program are no longer admitted after the deadline for the collection of fees.
2, the counties (districts) should be part of the outpatient treatment of major diseases (chronic diseases) into the scope of compensation of the integrated fund, the specific choice of diseases, compensation procedures and compensation standards, etc. with reference to my office "on the adjustment of the pilot counties of the implementation of the new rural cooperative medical care program of the guiding opinions" (Gan He Medical Office word [2004] No. 8) and "on the inclusion of outpatient diseases (chronic diseases) into the New Rural Cooperative integrated Compensation Provisions on Including Outpatient Major Diseases (Chronic Diseases) in the Compensation Scope of the New Rural Cooperative Medical Care Coordination Fund
3. Participating farmers are not required to go through the transfer procedures for medical treatment in designated medical institutions in counties (districts) and hospitalization in designated medical institutions in neighboring counties; moreover, they are required to go through the transfer procedures in the County Agricultural Medical Bureau for medical treatment outside the counties (districts); and for emergency medical treatment and hospitalization in local hospitalization of participants who are out-of-town workers, they are required to notify the County Agricultural Medical Bureau of their illnesses within seven working days, or else they will not be compensated.
4. Participating farmers will receive a fixed amount of compensation of 150 yuan for hospital delivery in designated medical institutions, and surgical delivery, obstetric complications and complications will be compensated in accordance with the hospitalization compensation standards.
5. The compensation ratio for the use of traditional Chinese medicine and traditional Chinese medicine techniques in treating diseases at designated medical institutions is 10% higher than that for Western medicine treatment at medical institutions of the same level.
6. For farmers who have participated in commercial insurance, if they need both commercial insurance and New Farmers' Cooperative Compensation after being discharged from the hospital, they can submit the original hospitalization invoices to the commercial insurance company to fulfill the procedures of compensation, and the Bureau of Farmers' Cooperative Medical Care will use the copy of the invoices and compensation list which are marked by the commercial insurance company as "consistent with the original" and stamped by the company to pay the original invoices. The Farmers' Medical Bureau shall use the copy of the invoice and the original payment list of the commercial insurance company stating that the invoice is "the same as the original" and sealed by the commercial insurance company to compensate the participating farmers. The Farmers' Medical Bureau should sign a cooperation agreement with each commercial insurance company in the county (district), establish a good information exchange mechanism, and regularly check the copies of invoices with the originals to ensure the authenticity of the copies.
7. If a participating farmer is hospitalized immediately after an outpatient examination in case of emergency, the cost of outpatient examination and treatment on the same day can be included in the scope of compensation of the coordinated fund. During the period of hospitalization, when the condition of the participant requires that he or she be examined in a hospital of a higher level, the cost of the examination incurred will be calculated in accordance with the compensation ratio corresponding to the level of the hospital where the examination is conducted, and will be included in the scope of compensation.
8, the coordinated fund does not pay and pay part of the cost of diagnostic and treatment items, according to the "Jiangxi Province, the new rural cooperative medical fund does not pay and pay part of the cost of diagnostic and treatment items and medical services and facilities range" implementation.
VII. Materials to be carried for compensation
(a) After hospitalization, participating farmers should carry the New Rural Cooperative Medical Card, hospitalization invoice, discharge summary, household registration, cost list, transfer certificate and other information required by the local regulations to the designated place for compensation procedures.
(2) Participating farmers should bring their New Farmer's Cooperative Card with them when they visit outpatient medical institutions within the county, and the outpatient medical consultation fees will be reduced or waived directly by the designated medical institutions.
(3) Participating farmers suffering from outpatient major illnesses (chronic diseases) should bring their New Farmers' Cooperative cards, household registration books, certificates of outpatient major illnesses (chronic diseases) issued by the Agricultural Medical Bureau, outpatient medical records, outpatient invoices and lists to the designated places to go through the reimbursement formalities in the specified period of time (usually in December).
VIII. Compensation Procedures
Participating farmers are hospitalized at county (district) level designated medical institutions, and after being discharged from the hospital, they go through the compensation procedures at the New Farmers' Cooperative Compensation Window, where the designated medical institutions audit the medical expenses incurred by them, and advance the compensable amount according to the standards stipulated in the implementation plan. For hospitalization in a designated medical institution in a township (town) or in a hospital outside the county (district) with hospitalization costs of less than 2,000 yuan, the Farmers' Medical Office of the participant's hukou is responsible for auditing the medical costs incurred by the participant and paying the compensable amount to the farmer in accordance with the standards stipulated in the implementation plan; hospitalization costs of more than 2,000 yuan (inclusive of 2,000 yuan) or doubtful hospitalization information is reported by the Farmers' Medical Office to the The Farmers' Medical Bureau will audit and the Farmers' Medical Institute will pay the amount to be subsidized to the farmers within 20 working days according to the standards stipulated in the implementation plan.
Nine, the compensation program approval process
The compensation program of the new rural cooperative counties (districts), need to be reported to the municipal cooperative medical office of the initial review, and then by the municipal cooperative medical office uniformly reported to the Provincial Cooperative Medical Office for review, and ultimately finalized by the county (district) government. Once the program is determined, it is generally not appropriate to make new adjustments within the year, the program does need to be adjusted, should seek prior consent of the municipal and provincial cooperative medical office before implementation.
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The following expenses are not reimbursed by Jiangxi Province Cooperative Medical Care:
I. Diagnostic and treatment items that are not paid for
(1) Service items
1, registration fee, consultation fee, outpatient consultation fee, remote diagnosis and treatment fee, and home hospital bed fee.
2. Fees for special medical services such as self-requested special nursing care, door-to-door service, and high-quality priority fees, as well as expedited fees for examinations and treatments, and surcharges for named surgeries.
3. Fees for medical records, certificates of illness, microcomputer inquiries and management fees, various billing fees, and magnetic card fees.
(2) Non-disease treatment items
1, various beauty treatments such as freckles, pimples, warts, acne, blemishes, pigmentation and alopecia (including baldness), white hair, moles, piercing of the ears, saddle-nose, breast augmentation, single eyelid to double eyelid, massage and other beauty items.
2, a variety of cosmetic, orthopedic (except for the sequelae of polio) and physiological defects in the treatment of such surgical procedures as cutting bad breath, stuttering, correction of squinting, "o" shaped legs, "x" shaped legs, refractive error, vision correction, and other surgical projects.
3, diabetes decision support system, sleep respiratory monitoring system, trace element testing, bone densitometry, human body information diagnosis, computerized selection of the optimal gestation period, fetal gender and fetal development checkups and other diagnostic and treatment programs.
4, a variety of weight loss, fat gain, height, bodybuilding, smoking cessation treatment programs.
5, a variety of prevention, health care treatment (except perinatal care) and other programs.
6, a variety of medical consultation (including psychological counseling, health counseling, dietary counseling, disease counseling), a variety of predictions (including stroke prediction, health prediction, disease prediction), a variety of appraisal (forensic appraisal, work-related injury appraisal, medical appraisal, paternity appraisal), health guidance and other projects.
(C) diagnostic and therapeutic equipment and medical materials
1, the application of positron emission tomography device pet, electron beam ct, ophthalmology excimer laser therapy instrument and other large-scale medical equipment for the inspection and treatment program.
2, eyeglasses, prosthetic eyes, prosthetic teeth, prosthetic limbs, hearing aids, brain fitness, leather (steel) undershirt, steel girth, steel head and neck, stomach tray, kidney tray, scrotum tray, uterus tray, crutches, wheelchairs, deformed insoles, pillows, pill pads, hot packs, pressure pulse belt, infusion network, testicular band, hernia belt, knee belt, artificial anal bags and other appliances.
3, a variety of home inspection and testing instrument (device), therapeutic instrument (device), physical therapy instrument (device), massager and magnetic therapy supplies and other therapeutic instruments.
4, the provincial price department regulations can not be charged separately disposable medical materials.
(D) therapeutic items category
1, all types of organ or tissue transplantation of human organ source or tissue source and access to organ source, tissue source of the relevant surgery and so on.
2. Transplantation of organs or tissues other than kidney, cornea, skin, blood vessel, bone and bone marrow transplantation.
3, prostate hyperplasia microwave (radiofrequency) treatment, helium-neon laser intravascular irradiation (hemotherapy), new technology of analgesia after anesthesia surgery (pain bed), endoscopic retrograde appendicostomy and other diagnostic and treatment programs.
4, dental veneers, dental implants, dental cleaning, dental irregularities correction, yellow and black teeth, dental defects, stained teeth, grilled magnetic teeth and other diagnostic and therapeutic projects.
5, qigong therapy, music therapy, hypnotherapy, magnetic therapy, water bar therapy, oxygen bar therapy, positional therapy, psychotherapy and suggestive therapy (except for psychiatric patients), food therapy, nutritional therapy and other auxiliary treatment programs.
6, a variety of infertility (pregnancy), sexual dysfunction diagnosis and treatment program.
7, around the scientific research, teaching, clinical verification of the treatment program.
(E) other
1, due to fights, assaults, alcoholism, self-injury, self-injury, suicide, drug rehabilitation, sexually transmitted diseases, medical accidents, and other accidents caused by responsibility for the treatment program.
2. All medical expenses incurred during the period of going abroad and leaving the country.
3. Medical expenses incurred in the event of non-compliance with medical advice, refusal to be discharged from the hospital, and hospitalization in a hospital with a hospital bed.
4, not included in the price policy management of the treatment program.
Two, pay part of the cost of diagnostic and treatment items
(A) diagnostic and treatment equipment and medical materials
1, the application of γ-knife, χ-knife, χ-ray computed tomography (ct), cardiac and angiographic χ-ray machine (including digital subtraction equipment), magnetic **** vibration imaging device (mri), single-photon emission computer scanning device (spect), color Doppler. spect), color doppler instrument, medical linear gas pedal, color b ultrasound, brain topography and other large medical instruments for examination and treatment, project.
2, extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy program.
3, the provincial price department stipulates the disposable medical materials that can be charged separately.
(B) treatment program category
1, hemodialysis, peritoneal dialysis treatment program.
2, kidney, cornea, skin, blood vessels, bone, bone marrow transplantation program.
3, cardiac pacemaker, artificial valves, artificial joints, artificial crystals, a variety of stents, a variety of anastomoses, a variety of catheters, implanted drug delivery devices, such as the body replacement of artificial organs, the body of the material and installation or placement of surgical projects.
4, heart bypass, cardiac catheterization balloon dilatation, cardiac radiofrequency ablation and other surgical projects.
5, coronary angiography, cardiac laser perforation, tumor biotherapy in the t-lymphocyte reflux method, tumor thermotherapy and other diagnostic and therapeutic projects.
6, a variety of microwave, spectrum, far infrared and other auxiliary treatment programs.
Three, the scope of medical services and facilities that do not pay for the cost
(1) the transportation cost of consultation (referral).
(ii) air-conditioning, heating, television, telephone, electric stove, refrigerator, food warmer and compensation for damage to public property, as well as water, electricity, gas and other fees.
(iii) escort fees, escort fees, bathing fees, medicated baths, disinfection fees, hairdressing fees, washing fees, etc.
(4) Outpatient decoction fee, Chinese medicine processing fee.
(v) Recreational activities, newspapers and magazines, fitness activities.
(F) Meal expenses.
(vii) Flower and arrangement expenses.
(viii) Costs of disposable items such as sanitary tableware, washbasins, mouth cups, toilet paper, bed sheets, pillowcases, bed-sweeping towels, and diapers.
(ix) The cost of household items such as soap and water, garbage bags, and anti-mosquito dispensers.
(j) the cost of medical institutions to raise their own charges for medical service facilities or self-imposed charges.
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Problems to be noted
I. Go through the relevant procedures and collect the relevant bill information according to the regulations
II. Pay attention to the catalog of medicines used in cooperative medicine when you use medicines, and medicines outside of the catalog are an important factor affecting the reimbursement.