The implementation of the program will be the first step in the implementation of the program.
The implementation of the program will provide a number of reform "dividends" for the participants Employee health insurance outpatient **** protection policy ten questions and ten answers take a look! 1 QWhat are the national and provincial requirements for the establishment of a sound outpatient **** protection mechanism for basic employee medical insurance? In December 2021, the General Office of the Provincial Government issued the Implementing Opinions on Establishing and Improving the Outpatient ****ji Guarantee Mechanism of Employee Basic Medical Insurance (Su Zhengban Fa [2021] No. 108, hereinafter referred to as the Implementing Opinions). The main spirit is to use about three years, by adjusting the structure of the integrated fund and individual accounts, the increase in the integrated fund is mainly used for outpatient ****ji protection, improve the outpatient treatment of insured persons, to promote the outpatient protection of workers' medical insurance from the individual accumulation of the protection mode to the social solidarity ****ji protection mode, to alleviate the burden of the masses, especially retirees of the burden of the cost of outpatient medical expenses.
2 QWuxi City, "the implementation of the program" to implement the requirements of the national and provincial deployment of what time schedule?
A In accordance with the national "Guidelines" and the provincial "Implementation Opinions" requirements, the city has issued the "Implementation Program", the implementation of the outpatient co-ordination **** financial policy has been improved. The city's "implementation program" will be implemented on January 1, 2023, when the level of outpatient co-ordination treatment will be increased, and the adjustment of the personal accounts of active employees, retiree personal account adjustment policy according to the provincial provisions of the end of the reform in place at the end of 2023, and January 1, 2024 onwards. 3 QWhat kind of outpatient treatment can the employee health insurance participants enjoy after the reform?
A The outpatient coordination covers all participants of the employee health insurance, and the general outpatient expenses incurred by the participants in the designated medical institutions in line with the scope of the basic medical insurance policy, exceeding the starting standard, will be included in the scope of payment of the outpatient coordination fund. Firstly, the starting standard (starting line) is adjusted; starting from January 1, 2023, the annual starting standard for working and retired persons is adjusted to 500 yuan and 300 yuan respectively (the starting line can be paid by individual account). The second is to set up different levels of medical institutions medical insurance payment ratio. From the original first appointment in the community medical institutions, in-service and retiree fund payment ratio of 70%, 85%, adjusted to the community health service institutions, in-service and retiree outpatient coordinated fund payment ratio of 80%, 90%; in the first and second level of medical institutions, in-service and retiree outpatient coordinated fund payment ratio of 75%, 85%; in the third level of medical institutions, in-service and retiree outpatient coordinated fund payment ratio of 75%, 85%; in the third level of medical institutions, outpatient coordinated fund payment ratio of 75%, 85%; in the third level of medical institutions, the outpatient coordinated fund payment ratio of 75%, 85%. For outpatient treatment in first- and second-tier medical institutions, the payment ratio of the outpatient coordinating fund is 75% and 85% for active and retired persons respectively; for outpatient treatment in third-tier medical institutions, the payment ratio of the outpatient coordinating fund is 60% and 70% for active and retired persons respectively. For the medical expenses within the scope of policy incurred at designated retail pharmacies and designated outpatient clinics (excluding prescriptions dispensed from prescription transfer platforms), the payment ratio of the co-ordination fund will be based on that of the tertiary medical institutions. Thirdly, the maximum payment limit (ceiling line) is raised. Within a year, the payment limit of the fund for both active and retired persons has been raised from 5,000 yuan and 6,000 yuan to a maximum of 12,000 yuan for medical expenses within the scope of the policy (of which the limit for all types of funds paid by designated retail pharmacies and designated outpatient clinics (clinics) within a year has been set at 2,000 yuan for compliance with the medical expense limit). Fourth, optimize the order of payment of medical insurance fund. From the original individual account funds must be used up first, and then enter the outpatient coordination of protection, adjusted to: reach the "starting line", you can use the coordinated fund. The use of the fund has changed from a three-stage system of individual account, starting line and coordinated fund to a two-stage system of starting line and coordinated fund. At the same time, with the gradual adjustment of individual account credits and the overall fund to enhance the capacity, outpatient treatment will be gradually improved. 4 QHow to improve the individual account crediting method?
A January 1, 2023 onwards, the individual account of active employees monthly by the individual to pay the basic medical insurance premiums into the standard in accordance with their own participation in the contribution base of 2%, the unit to pay the basic medical insurance premiums are all accounted for in the integrated fund; from January 1, 2023 onwards, the retiree's personal account in accordance with the size of the transfer of their personal accounts in 2022, the amount of the transfer. 2024 onwards, the retiree's personal account in accordance with the size of their personal accounts, the amount of the transfer. Fixed amount of transfer. 2024 January 1, retiree personal account transfer amount uniformly adjusted to 2023 Wuxi City, the average level of basic pensions, the specific mode of credit and standards by the municipal health care sector in accordance with the provincial regulations to be determined separately. Important reminder: the incumbent and flexibly employed personnel health insurance personal account is no longer January 1, 2023 unified injection. The employees and the freelance participants who choose to pay on behalf of the withholding will be automatically funded monthly after the monthly payment of health insurance premiums, usually after the 15th of the month, and up to the 6th of the next month at the latest, and it is normal for the account to be funded within this time frame; the freelance participants who choose to make monthly payments manually will be paid within seven working days after the payment is made successfully.Let's see
An example
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Through the two case studies, we can see that in 2023, the individual account and the personal account of the person will be paid by the person who has made the payment. Individual account and outpatient coordination what changes: Case 1: active employee Zhao, 35 years old, monthly contribution base 5000 yuan (assuming that the base for 3 years are unchanged); annual outpatient medical expenses of about 3,000 yuan, drugs for the A (ie, medical insurance catalog within the full coverage of the costs, excluding out-of-pocket expenses, self-care costs); in December 2021 the balance of the individual account of 0 yuan.2022:January 1, 2022 personal account injection 5000 * 12 * 3% = 1800 yuan.
Medical expenses for the year were $3,000. Had an outpatient co-ordination appointment at the community health center. The first half of the year cost $1,000, all from the individual account. In the second half of the year, the community hospital spent 2,000 yuan, of which 800 yuan was spent from the individual account, and the remaining 1,200 yuan was reimbursed by the outpatient coordination of 1,200* yuan, so that the individual spent 1,200-840=360 yuan.3,000 yuan of individual account payment of 1,800 yuan, the individual cash payment of 360 yuan, the individual **** total responsibility for 2,160 yuan.
2023:2023 monthly injection of 5000 * 2% = 100 yuan; annual total of 1200 yuan.
Medical expenses for the year are $3,000, again at a community hospital. The first half of the year cost 1000 RMB, of which 500 RMB start line personal responsibility (can use personal account payment), the remaining 500 RMB outpatient reimbursement of 500 * RMB, personal expenditure 500-400 = 100 RMB.The second half of the year cost 2,000 yuan, outpatient reimbursement of 2,000 * yuan, personal expenses 2000-1600 = 400 yuan.
3000 yuan of the individual **** counted to bear 1000 yuan, the cost of the individual account balance in the case of personal account can be paid by the individual account, can also be paid by the individual cash.
Case 2: retired employee Liu, 61 years old, 22 years of retirement salary of 4,000 yuan (assuming that 3 years of retirement salary remains unchanged), annual outpatient medical expenses of about 10,000 yuan, drugs for the Category A (i.e., health insurance directory of the full coverage of the costs, excluding out-of-pocket expenses, self-care costs); in December 2021 the balance of the individual account is 0 yuan.2022:January 1, 2022 personal account injection 4000 * 12 * 7% = 3360 yuan.
$10,000 in medical expenses for the year. Outpatient co-ordination appointments have been made at community health centers. In the first half of the year, it cost 4000 RMB, 3360 RMB from the individual account, 640* RMB from the outpatient coordination, and 640-544=96 RMB from the individual. In the second half of the year, it cost 6000 RMB in the community hospital, of which 6000* RMB was reimbursed by the outpatient system and 6000-5100=900 RMB was spent by the individual.10,000 yuan of individual account payment of 3360 yuan, personal cash payment of 996 yuan, personal **** total responsibility for 4356 yuan.
2023:January 1, 2023, a one-time injection of 4000 * 12 * 7% = 3360 yuan.
Medical expenses for the year were $10,000, all at community hospitals. The first half of the year cost 4,000 RMB, of which 300 RMB was paid by the individual (personal account can be used), and the remaining 3,700 RMB was reimbursed by the outpatient clinic coordinator for 3,700*RMB, and the individual expenditure was 3,700-3,330 = 370 RMB.The second half of the year cost 6000 yuan, outpatient reimbursement of 6000 * yuan, personal expenditure of 6000-5400 = 600 yuan.
10,000 yuan of the individual **** counted 1270 yuan, the cost can be paid by the personal account. After the payment, the individual account has a balance of $2090.
It can be seen that through the synergistic reform of the individual account and outpatient co-ordination policy, the level of general outpatient medical insurance treatment for the insured has been significantly improved. 5 QAfter the reform of outpatient chronic diseases, how to adjust the treatment of special diseases?
A Our city will be in accordance with the province's unified outpatient chronic disease, special disease (hereinafter referred to as outpatient chronic special disease) system, and gradually standardize the city's outpatient chronic special disease disease scope of illnesses and protection treatment. Continuously improve the outpatient **** financial protection mechanism, through the improvement of employee health insurance general outpatient integrated protection treatment, to guide the outpatient chronic disease protection gradually transition to outpatient integrated protection. In order to further improve the efficiency of the use of health insurance funds, we synchronize to promote the improvement of other health insurance treatment in the city. First, to improve the employee hospitalization reimbursement ratio; second, to improve the medical material health insurance payment policy; third, to establish a sound employee subsidies for large medical expenses. The relevant program will be implemented simultaneously from 2023 onwards, the specific policy will be pushed later, please continue to pay attention to the "Wuxi medical insurance" WeChat public number. 6 QWhat does it mean for family members of individual accounts to be ****ed?
AThe funds in the individual account are mainly used to pay for the out-of-pocket expenses within the policy scope incurred by the insured in the designated medical institutions. After the reform, the individual account is mainly used to realize the family members in three aspects **** relief: First, it can be used to pay for the participants themselves, their spouses, parents and children in the designated medical institutions medical expenses borne by the individual; Second, it can be used to pay for the participants themselves, their spouses, parents and children in the designated retail pharmacy to buy drugs, medical equipment, medical supplies incurred by the individual's expenses, medical equipment and medical supplies, and medical equipment. The scope of medical equipment and medical consumables is uniformly formulated by the province; thirdly, it can be used for the individual contributions of the insured to participate in the employee's large medical expense subsidy (or major disease insurance), long-term care insurance, etc., and to explore the use of individual accounts for the individual contributions of the spouses, parents and children to participate in the basic urban and rural residents' medical insurance. It is expected that from February 1, 2023, the implementation of individual account family **** relief use of specific measures.
7 QWhat are the benefits of the reform for the insured, and what are the special guarantees for the elderly retirees?
A The reform of the outpatient *** relief protection mechanism takes into account the implementation of strategies to cope with the aging of the population, and adopts three measures to enhance the level of protection for retirees. First, it is clear that outpatient treatment can be appropriately tilted in favor of retirees, mainly reflected in the starting line is lower than the active workers 200 yuan, the payment ratio is higher than the active workers 10 percentage points. Secondly, the individual account can be used for family **** relief, when the individual account of an elderly retiree is not enough, the individual account of his/her children who have participated in the employee medical insurance can be used for family **** relief to reduce the burden of medical expenses on the elderly. Third, improve the outpatient special disease policy, according to the provincial health insurance bureau on the unification of basic health insurance outpatient special disease protection policy requirements, the city's outpatient special disease protection policy has been unified. 8 QWhat measures are there to strengthen the use of personal accounts and outpatient management?
A On the one hand, the Implementation Plan makes it clear that the individual account shall not be used for public **** health costs, sports and fitness or health care consumption and other expenditures that do not fall within the scope of the basic medical insurance coverage; on the other hand, the Implementation Plan makes it clear that the supervision of the medical insurance fund is strengthened, and that outpatient medical expenses will be included in the province's unified scope of intelligent monitoring of the medical insurance fund, and that the "Regulations on the Supervision and Management of the Use of the Medical Insurance Fund" will be strictly implemented. The implementation of the program is clear, strengthen the supervision of medical insurance fund, the outpatient medical expenses into the province's unified medical insurance fund intelligent monitoring scope, strict implementation of the "medical insurance fund use supervision and management regulations" and other laws and regulations, and strictly prevent the personal account cash, over the scope of the use of violations. 9 QWhat are the measures to improve the accessibility of medical services for the insured?
A First, it supports the settlement and dispensing of outpatient prescriptions at designated retail pharmacies, incorporates the medication protection services provided by qualified designated retail pharmacies into the scope of outpatient protection, and establishes a prescription flow platform, with the proportion of the integrated fund payment for medication costs within the scope of the policy being the same as that of the designated healthcare institutions for which the outpatient prescriptions are dispensed, so as to give full play to the role of the designated retail pharmacy as a convenient and accessible place to live. Before the deployment of the prescription flow platform is completed and the conditions for its implementation are in place, the payment ratio of the integrated fund for qualified designated retail pharmacies will be implemented in accordance with the ratio of tertiary medical institutions. Secondly, a sound "dual-channel" medication protection mechanism for nationally negotiated medicines has been established to actively promote the landing of negotiated medicines, do a good job of linking the separate payment of medicines with outpatient coordination policies, and explore the inclusion of eligible "Internet+" medical services in the scope of protection. Third, through the concerted promotion of the construction of primary medical service system, improve the family doctor contracting service, standardize the long-term prescription management, etc., to guide the non-emergency insured persons in primary medical and health care institutions in the first visit. 10 QHow does the reform of outpatient payment methods meet the requirements of the reform of the outpatient ****ancial protection mechanism?
Answer The Implementation Program makes it clear that improving the total budget management of the outpatient integrated fund and deepening the reform of the outpatient medical insurance payment method in line with the outpatient ****ancial protection mechanism. For the characteristics of outpatient medical services, innovative health insurance payment policy and management. Outpatient services for primary care institutions, to explore the capitation-based payment method; outpatient slow special diseases, and actively explore the combination of capitation and chronic disease management; day surgery and eligible outpatient special diseases, the implementation of the disease or diagnosis of diseases related to the group payment; not suitable for outpatient packaged payment of fees, can be paid by the project.