Suqian City 2012 new rural cooperative medical management methods
In order to further improve the level of basic medical protection for rural residents, according to the "Jiangsu Province, the new rural cooperative medical regulations", "Jiangsu Province, the new rural cooperative medical fund management methods" and the Provincial Department of Health, "on the standardization and
Improvement of the compensation program of the new rural cooperative medical notice," the requirements, combined with the The city's actuality, the development of Suqian City, 2012 new rural cooperative medical care management measures (hereinafter referred to as "measures").
I, basic principles and work objectives
(a) basic principles: fund-raising implementation of individual contributions, social financing, government support; fund management implementation of the urban area (including Suyu District, Su Cheng District) and the county co-ordination; the use of funds to implement the implementation of the income to determine expenditures, balance of payments, a slight surplus; the operation process adhere to the open, fair and just.
(2) Work objectives: new rural cooperative medical care (hereinafter referred to as the new rural cooperative medical care) of the population coverage rate of more than 98% in 2012, of which 100% of the population coverage of the target population; outpatient co-ordination fund accounted for
the year 20% of the total amount of fund-raising, inpatient co-ordination fund accounted for 70% of the total amount of fund-raising in the same year; the fund's annual savings rate of control at 10% (including the risk fund) or less, the accumulated balance of The annual balance rate of the fund is controlled within 10% (including the risk fund), and the cumulative balance rate is controlled within 20% (including the risk fund)
. The reimbursement rate of hospitalization expenses within the policy scope at the county and township levels has reached about 75%.
Second, the object of participation
Rural residents (including rural primary and secondary school students) to participate in the household registration of the coordinating area of the new rural cooperative.
Infants and retired soldiers who were born between the last payment period of the New Farmers' Cooperative Program and the next payment period can participate in the New Farmers' Cooperative Program for the current year in accordance with the normal procedures for enrollment. If the parents apply for enrollment of the infant within fifteen working days from the date of birth, the medical expenses incurred from the date of birth will be included in the reimbursement scope of the New Farmers' Cooperative Fund.
Three, financing standards
The financing level of the New Rural Cooperative is about 300 yuan per person per year. Counties (districts) in the fight for the provincial financial subsidies given to participants on the basis of the county (district) finances according to the participants not less than 240 yuan per person per year to make up. Rural minimum subsistence guarantee recipients, the five guarantees of subsistence objects, key beneficiaries and other medical assistance by the people's government of the co-ordination area are all included in the new rural co-operation, and their individual contributions by the medical assistance fund to give the full amount of subsidies.
Four, medical care and referral
(a) All the city's first-class and above medical institutions, abide by the management of the New Rural Cooperative Medical Scheme, approved by the health administrative department and signed a service agreement with the Office of the co-management of the New Rural Cooperative Medical Scheme can be used as the designated medical institutions. Village health centers that carry out integrated management of rural
health institutions can carry out outpatient compensation for the New Rural Cooperative Medical Care. Urban participants can choose their own doctors from all designated medical institutions in the city; county participants can choose their own doctors from all designated medical institutions in their counties, and if they need to be referred out of their counties, the county hospitals will put forward their opinions on referral applications, which will be reviewed and agreed to by the county co-management office, and then priority will be given to the Suqian Municipal People's Hospital of Nanjing Gulou Hospital Group, the Suqian Branch of Shanghai Oriental Hospital (especially
referring to the hospital for cardiovascular and orthopedic diseases), the city infectious diseases hospital, and the Suqian branch of Nanjing Gulou Hospital Group (especially for cardiovascular and orthopedic diseases). and orthopedic diseases), the city infectious disease hospital referral.
If a participant in the urban area proposes to be referred to a hospital outside the city for treatment, he or she must obtain a written certificate from the Suqian People's Hospital of Nanjing Gulou Hospital Group, the Suqian Branch of Shanghai Oriental Hospital (specifically referring to cardiovascular and orthopedic diseases), or the city's hospital for infectious diseases, and the city's Office for the Administration of Comprehensive Social Security Assistance (OCSSA) must review and agree to the referral before the referral can be made.
(2) Critical, emergency and serious patients can be referred first, and the procedures will be made up within 15 working days; the referral procedures are valid once, and re-referrals need to be re-applied.
V. Compensation Scope and Standards
(1) The New Rural Cooperative Medical Expenses Compensation is divided into fixed compensation and segmented proportional compensation.
(2) In the first-class and above medical institutions, the scope of medication is based on the "Jiangsu Province New Rural Cooperative Medical Fundamental Drugs Catalog (2009 Revision)"; in the village health office, the scope of medication is based on the National Basic Drugs Catalog.
(3) Outpatient compensation standards. The outpatient medicine fees of fixed-point medical institutions in townships (towns) are compensated at a rate of 40%, and the outpatient medicine fees of village health offices approved by the health administration department are compensated at a rate of 45%. The outpatient prescription drug fee limit for each person at the designated medical institutions in townships (towns) is 100 yuan per day; the outpatient prescription drug fee limit for each person at the village health office is 30 yuan per day, and the maximum compensation for each person is 60 yuan per year. Village health center after the implementation of the basic drug system,
In accordance with the provisions of the general diagnosis and treatment fee charged patients 6 yuan, of which the patient pays 1 yuan, the remaining 5 yuan from the New Agriculture Cooperative Fund, not included in the compensation per person per year cumulative maximum limit. The general diagnosis and treatment fee is controlled by the village as a unit according to the participating population and
service volume.
Other outpatient medical fees for medical institutions inside and outside the city will not be compensated.
(4) Hospitalization compensation standards.
First-class hospitals can report medical expenses in two sections of compensation, 40% of the compensation ratio of less than 400 yuan, more than 400 yuan compensation ratio of 85%;
Second-class hospitals can report medical expenses in two sections of compensation, 40% of the compensation ratio of less than 400 yuan, more than 400 yuan compensation ratio of 70%;
Third-class hospitals in the city, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan, the starting line of 400 yuan.
The starting line for tertiary hospitals in the city is 400 yuan, and the reimbursement of reimbursable medical expenses is divided into two sections, with the reimbursement rate for 401-20,000 yuan being 50%, and that for more than 20,000 yuan being 60%.
The starting line for out-of-town hospitals is 600 yuan, and the reimbursement of reimbursement of reimbursable medical expenses is divided into two sections: 45% for reimbursement of 601-20,000 yuan, and 55% for reimbursement of more than 20,000 yuan.
Participants who are hospitalized more than twice in a year will have the starting line set only once.
Hospitalization medical expenses are subject to guaranteed compensation. The minimum compensation rate for patients with malignant tumors is 40%, and the minimum compensation rate for other diseases is 35%. For participants who have gone through the referral procedures to go abroad for medical treatment, the guaranteed compensation is adopted. For participants who do not fulfill the referral procedures, the normal referral compensation rate of 90% of the implementation.
(E) Outpatient special disease compensation standards. Outpatient medical expenses for radiotherapy for malignant tumors, dialysis treatment for end-stage renal disease, anti-rejection treatment for organ transplantation, aplastic anemia, hemophilia, etc., will be compensated at a rate of 75%, with a maximum of 40,000 yuan per person per year; outpatient medical and treatment expenses for chronic hepatitis B combined with cirrhosis, nephrotic syndrome, systemic lupus erythematosus and Parkinson's disease will be compensated at a rate of 75%, with a maximum of 40,000 yuan per person per year. The maximum limit is 20,000 yuan per person per year
. The outpatient special disease costs of the participants are compensated based on the patient's medical records and actual costs incurred by the second-level or higher medical institutions.
Insulin-dependent diabetes mellitus, stage III hypertension, post-stroke sequelae, severe mental illness and other outpatient treatment costs will be compensated at a rate of 75%, with a limit of 2,000 yuan per person per year. Outpatient special disease costs are compensated on the basis of the patient's medical records and actual costs incurred issued by the first-level and above medical institutions.
If the above outpatient special diseases are treated in outpatient medical institutions of the corresponding level outside of the city, they will be reimbursed at 90% of the above reimbursement rate.
(F) the medical institutions of maternal hospital delivery costs limit management. That is: 800 yuan for normal delivery in first-level hospitals and 900 yuan in second-level hospitals; 1,250 yuan for vaginal surgery to assist delivery in first-level hospitals and 1,500 yuan in second-level hospitals; and 2,000 yuan for cesarean section in first-level hospitals and 2,450 yuan in second-level hospitals. The part that exceeds the price limit will be borne by the designated medical institutions.
Participating rural pregnant women who are in line with the family planning policy and are hospitalized for delivery are compensated in segments in accordance with the New Rural Cooperative Hospitalization Compensation Standard, and those who have less than 400 yuan are compensated at the rate of 400 yuan. The total cost of the New Rural Cooperative Reimbursement and the financial subsidy for hospitalized delivery will not exceed the actual costs incurred. Prenatal screening is compensated at 40 yuan per case.
(7) Compensation for infectious diseases. Infectious diseases are centrally admitted and hospitalization is encouraged. Infectious disease patients in urban areas are admitted and treated centrally by the Municipal Infectious Disease Prevention and Control Center, while infectious disease patients in Shuyang, Siyang and Sihong counties are admitted and treated centrally by 1-2 medical institutions designated by county health
health administrations, with outpatient reimbursable expenses compensated at a rate of 50% and inpatient reimbursable expenses compensated at a rate of 80%. Infectious disease hospitalization expenses incurred in other medical institutions
will not be compensated.
(viii) Encouraging the use of traditional Chinese medicine. In case of using traditional Chinese medicine for treatment, after the outpatient and inpatient costs are compensated in accordance with the compensation standards of the Measures, the cost of traditional Chinese medicine tablets used by the patient will be compensated by another 30%. Traction, acupuncture and other treatment programs are compensated.
(ix) the provincial human resources and social security department, the provincial civil affairs department and other five departments "issued by jiangsu province on the part of the rehabilitation program into the scope of the implementation of the basic medical insurance notice" (su people's social security hair [2010] No. 479) part of the medical rehabilitation program, children with disabilities aged 0-6 years rescue rehabilitation and auxiliary aids are included in the hospitalization compensation.
(J) the full implementation of the reform of payment methods, such as payment by type of disease, the number of diseases paid for by type of disease in medical institutions at the second level and above should reach more than 20.
Comprehensively promoting the protection of eight categories of major diseases, including childhood leukemia, coronary heart disease, end-stage renal disease, women's breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, and opportunistic infections caused by AIDS, and continuously improving the level of protection. Hemophilia, chronic granulocytic leukemia, cleft lip and palate, lung cancer, esophageal cancer, stomach cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, rectal cancer, and other 12 categories of diseases into the pilot scope of protection for major diseases of rural residents.
(xi) Trauma patients are compensated at a rate of 70% of the compensation standard.
(xii) Compensation ceiling. The cumulative limit of compensation for New Rural Cooperative expenses is 140,000 yuan per person per year, including 100,000 yuan for inpatient expenses and 40,000 yuan for outpatient expenses.
(xiii) Compensation time. New rural cooperative compensation in principle in a natural year, special circumstances across the year compensation does not exceed six months.
VI. Scope of non-compensation
The following expenses are not covered by the New Agricultural Cooperative Fund:
(a) The expenses incurred by the participants for the use of drugs outside the catalog will not be compensated. The proportion of costs incurred by designated medical institutions for the use of out-of-catalog drugs by participants should be controlled. Village health clinics must use all drugs in the catalog
The cost of using out-of-catalog drugs in first-level medical institutions shall not exceed 5%, the cost of using out-of-catalog drugs in second-level medical institutions shall not exceed 10%, and the cost of using out-of-catalog drugs in third-level medical institutions shall not exceed 15%. The designated medical institutions
must inform and obtain the signatures of the participants or their immediate family members in advance of the use of off-list drugs.
(2) Expenses that should be paid by the Industrial Injury or Maternity Insurance Fund in accordance with the regulations; expenses that should be paid by urban workers' and residents' medical insurance; expenses that should be borne by a third party; expenses that should be borne by public **** health; and expenses incurred for medical treatment outside of China.
(3) Expenses incurred in medical institutions at all levels for non-basic medical treatment (mainly referring to higher wards, special wards, special nursing care, home hospital beds, etc.).
(4) Expenses incurred for medical services, examinations, and treatment items in medical institutions that have not been approved by the price and health departments, as well as expenses incurred for unauthorized fee increases.
(v) expenses incurred for fighting and assault, alcoholism, drug addiction, sexually transmitted diseases, traffic accidents, intentional self-inflicted injuries and self-mutilation, unproductive pesticide poisoning, medical malpractice (disputes), and family planning.
(6) Registration fee, cost of medical records, consultation fee, surcharge for surgery by name, Chinese medicine decoction fee, travel expenses for medical treatment, ambulance fee, companion bed fee, bed charter fee, consultation fee, food (nutrition) fee, living supplies fee, certificate fee, health care file bag fee, stretcher fee, air-conditioning (including heating) fee, TV fee, telephone fee, personal care fee, escort fee.
(7) Fees for weight loss, body building, treatment of freckles, pigmentation, gray hair and medical cosmetic surgery; nose job, breast augmentation, blepharoplasty, mole removal, ear piercing, wart flattening, dental insertion, teeth cleaning, correction of irregularities in the teeth, treatment of
pigmented teeth, eyeglasses, treatment of nearsightedness, as well as assembly of prosthetic eyes, wigs and prosthetic limbs; fees for the use of traction devices, crutches, leather and steel back nails, girdles and deformities; fees for shoe pads, medicinal pads and pillows; and fees for the use of a stretcher, air conditioning (including heating), television, telephone, personal care and nursing care. shoe insoles, medicinal pads, pillows, hot and cold packs; massage, magnetic therapy,
heat therapy (except for tumor patients).
(viii) Costs of various medical consultations, medical appraisals and health forecasts, commercial medical insurance premiums, physical therapy fees, examination and treatment fees for male and female infertility and sexual dysfunction.
(ix) Hospitalization costs for titular hospitalization or hospitalization that obviously does not meet the conditions for hospitalization; hospitalization in super-standard wards, whose costs exceed the standard of ordinary beds.
(j) the cost of transplantation of all kinds of organs or tissues, installation of artificial organs and placement of materials in the body in the course of medical consultation.
(xi) Other cases in which the state or province stipulates that no compensation shall be made.
VII. Compensation Methods
(1) Participants are required to provide their NHB cards for outpatient treatment at designated medical institutions in the city, and their NHB cards, original ID cards and photocopies for hospitalization, and outpatient medication and hospitalization fees are settled on-site.
(2) For hospitalization medical expenses incurred outside the city, the materials of participants from Shuyang County, Siyang County and Sihong County will be examined and processed by the county cooperative management office; the materials of participants from urban areas will be examined and processed by the city cooperative management office.
1. Participants are required to provide the following information when applying for compensation: New Farmers' Cooperative License (card); original and photocopy of ID card; approval form for referral from the municipal and county cooperative management offices; valid bills issued by the hospitals (originals), computer-printed hospitalization expense settlement list and discharge summary.
2. Participants who work outside the city or live outside the city for a long period of time are required to provide the following information when applying for compensation for medical treatment outside the city: the New Farmers' Cooperative Medical Card (card); the original ID card and a copy of the ID card; a certificate of the village (neighborhood) committee or the work unit in the place where the participant lives for a long period of time; a valid bill (original) issued by the hospital of the hospital visit; a computer-printed bill of hospitalization expenses and a summary of the discharged person's stay in the hospital.
(3) In Shuyang County, Siyang County and Sihong County, the township co-management offices shall publicize the medical fee reimbursement situation in the township health centers and village health offices on a monthly basis. The designated medical institutions in urban areas are responsible for publicizing the compensation for hospitalization of participants in urban areas on a monthly basis.
VIII. Fund Raising, Management and Supervision
(1) Shuyang County, Siyang County, Sihong County and downtown NAC funds are included in the financial management of the NAC fund account, which is earmarked for specific purposes, and the balance is carried over to the next year for further use.
(2) Township (township) people's governments are responsible for raising individual farmers' contributions, county (district) finance and health departments are responsible for securing provincial funds, and county (district) finance departments are responsible for implementing financial matching funds. County financial
Department is responsible for the new rural cooperative fund into the county new rural cooperative account, Suyu District, Su Cheng District, the city of Yanghe New City, the financial sector is responsible for the new rural cooperative fund into the city new rural cooperative account. Audit department is responsible for regular management and use of the new rural cooperative fund
Special audit.
(C) the agency shall, in accordance with state regulations in the new rural cooperative fund to withdraw risk fund, used to make up for the new rural cooperative fund abnormal overspending caused by the fund of temporary difficulties in the turnover, the withdrawal of the risk fund shall not be more than the total amount of funds raised in the year 10%.
(4) In the process of fund-raising, it is strictly prohibited to ride on fees, unauthorized changes in funding standards, advances for non-participants, account discrepancies, retention, squandering, misappropriation of funds.
(E) the fixed-point medical institutions should be located in the city and county co-management office to pay the service performance bond, the city and county co-management office of the fixed-point medical institutions in violation of the service agreement should be deducted in accordance with the security deposit, deducted for the city and county co-management office of the normal operation of the security deposit expenditure.
(F) the designated medical institutions and their staff should provide medical services in accordance with the requirements of the agreement, comply with laws and regulations, abide by professional ethics, the implementation of clinical technical specifications, to carry out business training, improve the quality and efficiency of services, to achieve reasonable examination and treatment, rational use of medication, control of medical costs.
(VII) designated medical institutions to forge certificates and other means of fraudulent new rural cooperative fund costs, the health administrative department shall order the return of fraudulent fund costs, and impose fraudulent amount of more than two times the amount of five times the fine
funds, the agency shall be terminated with its new rural cooperative medical designated service agreement; the directly responsible for the supervisor and other personnel directly responsible has the practicing license, the health administrative department shall revoke their practicing certificates according to law.
(h) fraudulent new rural cooperative medical fund fees by means of forged documents, use of other people's new rural cooperative medical documents, etc., the administrative department of health shall order them to return the fraudulent compensation fees, and impose a fine of more than two times and less than five times the amount of the fraud. Constitutes a crime, transferred to the judicial organs.
Nine, the bylaws
(a) The Measures shall be implemented from the date of issuance. Suqian City, 2010 new rural cooperative medical management measures" at the same time repealed. Previously, the new rural cooperative medicine related provisions inconsistent with these Measures, the Measures shall prevail.
(2) These Measures shall be interpreted by the Municipal Health Bureau.
Subject: health rural cooperative medical △ management methods notice
Copy: Municipal Committee Ministries and Commissions Office, the Municipal People's Congress Standing Committee Office, Municipal People's Consultative Conference Office,
Municipal Court, Municipal Procuratorate, Suqian military sub-district.
Suqian Municipal People's Government Office issued on July 19, 2012
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