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Hello! Five cities are not exactly the same as the settlement policy of different medical insurance, single similar. Now Jinan City, Shandong Province, for example, is described below for your reference.
"Jinan City employees basic medical insurance measures" (hereinafter referred to as "measures") in March 22, 2014, the municipal government of the 47th executive meeting to discuss and adopt, since April 1 officially promulgated and implemented. The implementation details of the Measures, general outpatient coordination measures and several other supporting documents were formulated and issued simultaneously.
What changes will the implementation of these new policies bring to the city's 1.83 million insured workers? In order to facilitate a better understanding of the relevant provisions of the majority of insured workers, the Municipal Human Resources and Social Security Bureau of the relevant issues have been interpreted one by one.
Change 1: general outpatient visits can be reimbursed, pay 14 yuan more per month outpatient visits throughout the year can be reimbursed up to 2,400 yuan
In the original policy provisions, the insured general outpatient (except for outpatient diseases) medical costs are borne by the individual, from the principle of correspondence between the rights and obligations, there is no fairness, and also lead to the emergence of the insured people "crowded outpatient regulations "This is unfair from the point of view of the principle of correspondence between rights and obligations. With the implementation of the outpatient co-ordination, medical expenses incurred by participants in general outpatient clinics will be included in the scope of co-ordinated reimbursement. General outpatient co-ordination, hospitalization and outpatient treatment of prescribed diseases to form a more complete basic medical insurance treatment payment system, medical insurance treatment expanded to all participants, all diseases are also included in the co-ordination of the scope of payment, in the city to improve the level of medical care at the same time, to promote social equity.
At present, the normal enjoyment of health insurance treatment of the insured, in accordance with the principle of "the month of enrollment the next month to enjoy", April began to pay the general outpatient co-ordination funds, in mid- to late-April began to choose the fixed-point health care institutions, May 1 onwards to enjoy the relevant treatment. The time for choosing the designated medical institutions will be announced later.
Change 2: outpatient disease reduction, the abolition of the 12 types of disease implementation of the "old man old ways"
The implementation of outpatient co-ordination, the city's employee health insurance outpatient treatment on the "outpatient" and "outpatient co-ordination". "outpatient co-ordination" two forms of protection, from the future function of the division, the main direction is through the outpatient co-ordination to solve common diseases, multiple diseases, such as "minor" outpatient reimbursement, through the outpatient regulations to solve some special diseases, "serious" outpatient reimbursement problem, and to solve some special diseases, "serious" outpatient reimbursement. The main direction is to solve the problem of outpatient reimbursement for "minor diseases" such as common diseases and multiple diseases through outpatient coordination, and to solve the problem of outpatient reimbursement for some special diseases and "serious diseases" through outpatient regulation.
To this end, the relatively low cost, can be cured and through the outpatient coordination can basically meet the needs of outpatient regulation of the original Ⅳ type of disease (including: chorea, chronic bronchitis, hyperthyroidism, gout, osteoarthritis (hands, hips, knees, osteoarthritis), cerebral atrophy, hypothyroidism (primary), stone disease (urological, digestive), digestive system diseases (urea, gastroenteritis, atrophic gastritis, gastroenteritis, gastroenteritis, gastroenteritis, gastroenteritis, gastric diseases). Twelve outpatient diseases (superficial gastritis, atrophic gastritis, gastric ulcer, duodenal ulcer), herniated intervertebral disc, necrosis of the femoral head) and ophthalmologic diseases will be abolished, while the remaining 23 diseases will be retained. For the abolition of these 12 diseases, the implementation of the "old man old ways", the new "methods" before the implementation of the participants have been identified, the treatment of the temporary unchanged; April 1 will no longer accept the 12 types of new applications for identification, the participants can be in accordance with the policy of general outpatient co-ordination to enjoy the treatment.
Change 3: retiree personal account gold has a "bottom", has exceeded the "ceiling line" to keep the original amount of unchanged
In the "united account combination Before the implementation of outpatient co-ordination, a large part of the function of the individual account is used to protect outpatient visits; after the implementation of outpatient co-ordination, the pressure of reimbursement for outpatient visits has been alleviated, the burden on the individual has been reduced, and the pressure on the co-ordination fund to pay has been increased. In accordance with the requirement of "exploring the gradual establishment of outpatient co-ordination of employees' medical insurance through the adjustment of individual accounts" put forward by the State, the new Measures, in accordance with the principle of fairness, make appropriate adjustments to the provisions of the individual accounts of retirees, and, in accordance with the principle of "deducting the amount of money first and then guaranteeing the bottom", favor the disadvantaged groups and raise the income of low-income earners. In accordance with the principle of "first deduction, then the bottom", tilted to the disadvantaged groups, to improve the low-income groups of the transfer level.
The new policy stipulates that the retiree's personal account will be credited at 4% of the monthly basic pension (pension), with a guaranteed minimum and maximum. Among them, under 60 years of age, the monthly delineation amount is less than 50 yuan according to 50 yuan, up to a maximum of 170 yuan; 60 years of age and above 70 years of age and below the monthly delineation amount is less than 60 yuan according to 60 yuan, up to a maximum of 190 yuan; 70 years of age and above 80 years of age and below the monthly delineation amount is less than 70 yuan according to 70 yuan, up to a maximum of 220 yuan; more than 80 years of age and below 90 weeks of age Monthly transfer amount below $80 will be credited at $80 up to $220; monthly transfer amount above 90 weeks of age below $90 will be credited at $90 up to $220.
The "guaranteed ceiling" amount refers to the standard after deducting the 10 yuan outpatient co-ordination funds and 8 yuan large medical subsidies payable by individuals. Participants who have enjoyed the basic medical insurance benefits for retirees before the implementation of the Measures, and whose individual account monthly transfer amount is higher than the capped amount for the corresponding age group, the transfer amount will remain at the standard at the time of the implementation of the Measures.
Change 4: the maximum payment limit has been increased, a medical year participants incurred within the scope of the integrated payment of medical expenses up to 440,000 yuan
The Measures on the hospitalization and outpatient specified types of illnesses of the maximum payment limit standard by the city's previous year the average salary of on-the-job workers four times increased to six times. To this end, the Municipal Human Resources and Social Security Bureau simultaneously issued the Notice on the Announcement of the Maximum Payment Limit of the Employee Basic Medical Insurance Fund, determining that since April 1, 2014, the maximum payment limit of the Employee Basic Medical Insurance Fund for inpatient and outpatient prescribed illnesses will be increased from 90,000 yuan to 240,000 yuan, together with the coverage of 200,000 yuan of large-scale aid, the maximum payment limit of the Jinan Employee's Medical Insurance has reached 440,000 yuan, which is a better guarantee for the The maximum payment limit for employee health insurance in Jinan has reached 440,000 yuan, which better guarantees the medical needs of patients with serious illnesses.
Change 5: The health insurance year has been changed to be consistent with the natural year
The original policy stipulates that the health insurance year is from April 1 to March 31 of the following year. In the new Measures, the health insurance year is adjusted to January 1 to December 31 each year, consistent with the natural year and accounting year. This adjustment means that there are only 9 months left in the 2014 health insurance year (the outpatient co-ordination benefit entitlement period is only 8 months), in order to ensure the medical treatment of the participants, the outpatient prescribed diseases, outpatient co-ordination of the year's starting standard, the maximum payment limit will be adjusted on a temporary and proportional basis, and the full standard will be restored in the next year. (See the table below)
Outpatient prescribed diseases, outpatient co-ordination year starting standard, the maximum payment limit will be temporarily adjusted proportionally
Changes 6: The process of settlement in other places has been adjusted, and the participant's selected medical institutions are included in the province's networked settlement platform in other places to realize instant settlement
In order to adapt to the requirements of the province's networked settlement in other places, the Measures for the referral of personnel, long-stay staff, staff in foreign places, and staff in other places to achieve immediate settlement of the settlement.
In order to adapt to the requirements of the provincial networking settlement, the Measures have adjusted the cost settlement process for personnel transferred to hospitals from other places, staff permanently stationed in other places, retirees resettled in other places, and personnel hospitalized for sudden and acute illnesses in other places. There are three specific cases:
Participants who need to be referred to hospitals for treatment in other places should be diagnosed by experts from designated medical institutions of Grade 3A or designated specialized medical institutions at or above the municipal level and recommendations should be made, and the medical insurance management departments of the designated medical institutions should fill in the form of filing for the referral and transfer of hospitals.
If the medical institution to which the medical institution is transferred belongs to the medical institution of the foreign network instant settlement, the insured person should hold the record form of referral and transfer to the social insurance agency for the record, and the medical expenses will be settled instantly when he is discharged from the hospital; if the medical institution does not belong to the medical institution of the foreign network instant settlement, the medical expenses will be advanced by the insured person, and then after the discharge from the hospital, the management unit will make the advance payment by presenting the record form of referral and transfer to the medical institution, the valid bill of expense, the first page of the medical record, and the copy of the medical prescription order. A copy of the medical record, a copy of the doctor's order, a summary of the cost details and other materials in a timely manner to reimburse the social insurance agency.
If a participant fails to go through the relevant procedures and refers to a hospital on his/her own, the integrated fund will not pay for his/her medical expenses.
The outpatient medical expenses of outpatient prescribed diseases and general outpatient coordinated medical expenses of long-stayed overseas staff and retired persons resettled in other places shall be reimbursed by the management unit to the social insurance administration organization with outpatient prescriptions, medical records, valid expense documents and expense lists.
If the staff stationed abroad and retirees resettled in other places are hospitalized in overseas medical institutions, and if the selected medical institutions belong to the medical institutions of other places with networked instant settlement, the insured shall file a record with the social insurance agency when he is hospitalized, and the medical expenses will be settled instantly when he is discharged from the hospital; if they do not belong to the medical institutions of other places with networked instant settlement, the medical expenses will be advanced by the insured and then be reimbursed by the management unit with valid expense receipts and copies of the first page of the medical record after discharge. Expense documents, copies of the first page of medical records, copies of medical orders, summarized cost details and other materials timely reimbursement to the social insurance agency.
If a participant is temporarily hospitalized for an emergency out of town, he/she can only be reimbursed for the medical expenses of one of the medical institutions; if there are medical bills from more than one medical institution, they must be accompanied by a certificate of corresponding referral. The participant must promptly inform the management unit of the hospitalization, and the management unit will inform the social insurance administration organization in writing within five working days after the participant is admitted to the hospital. Medical expenses are first paid in advance by the participant. After being discharged from the hospital, the management unit will reimburse the social insurance agency in a timely manner by presenting valid bills, a copy of the first page of the medical record, a copy of the medical order form, a summary of the cost details, a copy of the hospital entry and exit records, and a copy of the relevant examination and test orders.
Change 7: violation of the details of the clear, further increase in penalties
"Measures" of the employer, the insured, as well as medical institutions and retail pharmacies to make prohibitive norms, and provides for the corresponding legal responsibility. For the employer or individual fraudulent basic medical insurance treatment behavior, the measures require the social insurance administrative department to order the return of fraudulent basic medical insurance fund, and impose a fine of two times the amount of fraud more than five times.
Designated medical institutions and designated retail pharmacies and their staff should strictly implement the basic medical insurance drug list, diagnostic and treatment items, the scope of medical services and facilities and payment standards. When using drugs and materials outside the scope of the basic medical insurance catalog or providing services outside the scope of the basic medical insurance catalog for the insured, they shall obtain the consent of the insured in advance. In the event that the violation of this provision causes economic losses to the insured, the designated medical institutions and designated retail pharmacies shall bear the compensation responsibility.
The designated medical institutions and designated retail pharmacies of excessive medical treatment, the use of participants' personal accounts to cash and other eight kinds of behavior, the measures provide that the social insurance agency for its violations of the medical costs incurred will not be paid, has been paid to be recovered, and, as appropriate, with the suspension of the settlement or termination of the agreement; by the social insurance administrative department of the fraudulent amount of more than twice the five times the amount of the fine imposed on; If the circumstances are serious, the qualification of fixed-point shall be canceled.
Special note: in accordance with the 5.5% rate of payment of employee health insurance premiums for flexibly employed people in the bank card each month to deposit an additional 14 yuan
Since this month, to raise funds for general outpatient co-ordination in accordance with the standard of 10 yuan per month, the large amount of medical fee assistance from 4 yuan per month to 8 yuan per month, meaning that employee health insurance participants have to pay more than 14 yuan per month. According to the relevant provisions, the establishment of basic medical insurance individual account participants (including retirees), will be the social insurance agency from the employee basic medical insurance fund into the individual account gold part of the direct debit; not established basic medical insurance individual account participants, to pay in accordance with the above standards. The Municipal Social Security Bureau reminds participants who have not established individual accounts (mainly flexibly employed people who pay employee medical insurance premiums at the rate of 5.5%) to deposit sufficient funds in their personal bank cards so as to avoid the failure of deduction due to insufficient funds, which will bring unnecessary troubles such as retroactive payment or affecting the enjoyment of benefits.
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