May 12, 2006, the Shenzhen Municipal Government of the fourth 29th executive meeting successfully passed the "Interim Measures for Medical Insurance of Laborers in Shenzhen", which marks the birth of the first medical insurance of laborers in the country, and the medical insurance system of laborers will be comprehensively promoted in the city. Recently, the Shenzhen Municipal Bureau of Labor and Social Security related to the detailed interpretation of the approach.
I. The Necessity of Comprehensively Implementing Medical Insurance for Laborers
(1) The State Council's Opinions on Solving the Problems of Migrant Workers (hereinafter referred to as the Opinions) issued by the State Council in March this year pointed out that the problem of migrant workers is related to China's economic and social development in general, and that safeguarding the rights and interests of migrant workers is an outstanding problem that needs to be solved, and that the solution of the problem of migrant workers is a strategic task for building socialism with Chinese characteristics. Solving the problem of rural migrant workers is a strategic task in building socialism with Chinese characteristics. Solving the problem of social security for rural migrant workers, including medical care, is one of the main elements of safeguarding the rights and interests of rural migrant workers.
(2) In recent years, "difficult and expensive to see a doctor" has become a widespread social concern. Our city laborers to medical problems are caused by a variety of reasons, such as high medical costs, legal clinics and the layout of the unreasonable, low income of laborers and poor ability to pay, enterprises do not follow the provisions of the laborers for medical insurance, medical leave or deductions from wages and bonuses, etc., in addition, there are also laborers in the health care system, such as the existence of the standard of payment is still too high, coverage is not broad, only inpatient not outpatient insurance There are also reasons for the laborers' medical insurance system, such as the fact that the contribution standard is still high, the coverage is not extensive, and only inpatient but not outpatient care is covered. To solve the problem of labor workers to medical problems, is the city in the past two years, one of the largest number of proposals of the National People's Congress.
(3) In August 2005, the Shenzhen Municipal Party Committee and the Shenzhen Municipal People's Government formulated the "Shenzhen Economic and Social Control Indicator System for the Implementation of the Scientific Outlook on Development (for Trial Implementation)" (hereinafter referred to as the "Control Indicator System"), stating that, "The formulation and implementation of the Control Indicator System is an exploratory and innovative work in the city's implementation of the Scientific Outlook on Development, and a fundamental change in the city's economic and social development model. An important symbol of the fundamental transformation of the city's economic and social development model, for the guidance and promotion of the creation of a harmonious Shenzhen, the efficiency of Shenzhen has a realistic guiding significance and far-reaching historical significance of the work." The "Proposal of Shenzhen Municipal Party Committee on Formulating the Eleventh Five-Year Plan for National Economic and Social Development of Shenzhen" adopted by the Fourth Plenary Session of the Fourth Session of the Shenzhen Committee of the C*** Producers' Party on December 30, 2005, included the establishment of a multi-level medical insurance system, the comprehensive promotion of medical insurance for laborers, and the solution to the problem of laborers having difficulties in obtaining medical treatment and the high cost of medical treatment in the Eleventh Five-Year Plan for National Economic and Social Development of Shenzhen City. The full implementation of medical insurance for laborers is one of the key tasks of the government in 2006.
Therefore, the full implementation of medical insurance for laborers throughout the city, and strive to reach 3 million participants in medical insurance for laborers by the end of this year, reaching nearly 40-50% of the number of participants in work-related injury insurance has become the recent work goal.
Second, the feasibility of the full implementation of medical insurance for laborers
(a) medical insurance for laborers is generally welcomed by the community
Laborers medical insurance contribution level is low, easy access to medical treatment, reimbursement ratio moderate by the enterprise, the staff of the general welcome. 2005, November, we are in the pilot area of the insured, participating enterprises to do the questionnaire survey anonymous *** retrieve the insured, participating enterprises to do the questionnaire survey, **** the insured, participating enterprises to do the questionnaire survey, **** the insured, participating enterprises to do the questionnaire survey. **The number of questionnaires collected from participants and participating enterprises was 14,438 and 1,487 respectively. 72.84% and 81.84% of the participants and participating enterprises were satisfied with the pilot laborers' medical insurance scheme; 87.04% of the participants considered it necessary to set up a medical insurance scheme for laborers, and 64.56% of the enterprises chose the most popular form of medical insurance. medical insurance.
(2) During the pilot period, the laborers' medical insurance fund had balanced income and expenditure with savings
From March 2005 to April 2006, there were 762,800 outpatient visits, with a rate of 69.8 per thousand, and the average outpatient cost was 59.92 yuan, and the reimbursement rate was 75.18 per cent; and there were 2,397 hospitalizations, with a rate of 2 per thousand, and the average hospitalization cost was 3490.01 yuan, with a reimbursement rate of 3,490.01 yuan, and the reimbursement rate of 3,397 yuan. 3490.01 yuan, the reimbursement rate is 35.07%. Outpatient fund, hospitalization fund expenditure rate of 52.36%, 5.43%.
(3) Increase in primary medical care outlets
Last May, the Municipal Health Bureau issued the Notice on Standardizing the Setting of Community Medical Service Stations, which standardized and accelerated the examination and approval of community medical service stations, and laid out the laborers' medical outlets in a more expeditious and reasonable manner, providing convenience for them to seek medical treatment. By April this year, the number of laborers' medical insurance designated medical institutions had reached 145.
(4) the pilot of medical insurance for laborers has accumulated experience for the full-scale promotion
For example, through propaganda and exchanges, the first to mobilize large enterprises to participate in the medical insurance for laborers, and through the large enterprises to influence the small enterprises, driving them to participate in the insurance, and improve efficiency; for enterprises that have participated in the work-related injury insurance, but have not participated in the medical insurance, to take the bundling of the payment of work-related injury insurance to pay for the payment of cooperative medical care. Simplifying procedures, improving efficiency, etc. Laborers medical insurance designated medical institutions in the pilot also accumulated a lot of experience, for example, self-printed and distributed to factories with hospital contact phone number, address leaflets, to the patient first, improve the quality of service, etc., are the implementation of the new approach is worth learning from the experience.
Three, modify and improve the principles of the pilot scheme of medical insurance for laborers
The general principle is to "take the essence, remove the dross". Laborers cooperative medical pilot one year, to protect the basic medical needs of laborers, curbed the growth and spread of black clinics, purified the health care market, and promote the construction of community medical and health service outlets, basically solved the insured laborers difficult to get medical care, expensive medical problems, and achieve a balance of income and expenditure of the fund, and accumulation, and achieved the desired purpose. However, some deficiencies have been revealed in the pilot program, mainly: (1) the industries participating in the pilot program are narrow and limited to the manufacturing industry; (2) the reimbursement rate for hospitalization expenses is too low; (3) it is inconvenient to access to medical care; (4) the rate of medicines in the catalog of the designated medical institutions is low; and (5) the construction of grass-roots medical outlets needs to be strengthened, and so on. In response to these shortcomings, the newly formulated provisional measures have been amended.
Fourth, the newly formulated provisional measures will be "cooperative medical care for laborers" to "medical insurance for laborers"
Theoretically, the cooperative medical care is voluntary, while the social medical insurance is mandatory; the Shenzhen Laborers' Cooperative Medical Care is actually in accordance with the medical insurance. Cooperative medical care is actually established in accordance with the principles of medical insurance, including the determination of contribution standards, the establishment of cost control mechanisms, fund-raising, treatment payment, fund management, etc.: "Laborers cooperative medical care" is mainly for rural medical care, the level of lower; there are a number of leaders and professionals recommended that the A number of leaders and professionals have suggested that the "cooperative medical care for laborers" be renamed "medical insurance for laborers".
V. Expanding the scope of coverage
The provisional measures expand the scope of coverage to all enterprises in the city and the laborers who have established labor relations with them.
The establishment of a cooperative medical system for laborers is a major initiative of the municipal government to solve the problem of "difficult and expensive medical treatment" for laborers. The number of non-manufacturing laborers in our city accounted for a low percentage, especially in the tertiary industry, the laborers cooperative medical insurance to expand the scope of non-manufacturing laborers, is conducive to expanding the coverage of the city's health insurance system.
According to estimates, the scope of cooperative medical insurance for laborers from enterprises engaged in the manufacturing industry and their labor relations with the laborers, expanding to all enterprises and their labor relations with the laborers, the expenditure on medical costs is still within the affordable range of the fund, expanding the scope of coverage is feasible. After expanding the coverage, the average two-week outpatient consultation rate of the cooperative medical care for the laborers will increase from 36.1 per thousand to about 52 per thousand (according to the results of the National Health Service Survey), and the outpatient fund's expenditure rate will increase from 47.98 per cent to 68.85 per cent under the condition that the standard of contribution and reimbursement rate will remain unchanged; the average monthly inpatient hospitalization rate of the cooperative medical care for the laborers will increase from 0.23 per thousand to 1.5 per thousand (in the year of 2005). The average monthly hospitalization rate of the city's inpatient medical insurance for non-resident workers will increase from 0.23 per thousand to 1.5 per thousand (the monthly hospitalization rate of the city's inpatient medical insurance for non-resident workers in the year 2005), and the expenditure rate of the fund will increase from 5.2% to 34.24% under the condition that the standard of contribution and reimbursement rate remain the same.
Sixth, an appropriate increase in outpatient treatment
Pilot period, the laborers medical insurance outpatient cost reimbursement rate of about 75%, after the following adjustments, can be increased to 79% (Table 1):
One is to expand the list of medicines, from 900 to 1,200 species; the second is the diagnosis and treatment of more than 90 yuan of medical treatment items from non-payment to the fund to pay 90 yuan.
In addition, the following adjustments have been made to the outpatient treatment:
One, the reimbursement rate for outpatient dialysis costs for chronic renal failure has been increased by 30 percentage points compared with the pilot scheme;
Two, the reimbursement rate for outpatient costs for anti-rejection medication used after organ transplantation and chemotherapy, interventional therapy, radiotherapy, or nuclide therapy for malignant tumors, has been changed from nonpayment under the pilot scheme to reimbursement of 50% of the costs in accordance with the regulations. The outpatient expenses of the participants will be reimbursed at 50% instead of no payment under the pilot scheme. In addition, the reimbursement rate for outpatient medical expenses incurred by participants who are referred to non-settlement hospitals with the approval of the settlement hospitals due to the need of their condition has been increased by 40 percentage points; the reimbursement ratio for emergency medical expenses incurred in non-settlement hospitals and their subordinate medical institutions has been clarified, i.e., 70% of the expenses that should be paid by the fund as stipulated in Article 14 of the provisional measures.
VII. Substantial Improvement of Hospitalization Treatment (Table 2)
1. Expansion of the hospitalization drug list from 900 items to 2,077 items (implementation of the National Basic Medical Insurance Drug List).
2. Increasing the percentage of drug accounts, from 80% to 100% for Class A drugs and from 60% to 80% for Class B drugs.
3. Increase the proportion of diagnosis and treatment items, the unit price of less than 90 yuan, from the original 80% to 90%; unit price of more than 90 yuan, from the original 40% to 80%.
4, improve the general medical materials accounting ratio, unit price of less than 90 yuan, from the original 80% to 90%; more than 90 yuan, from the original 30%-50% to 60%-80%.
5. The hospitalization starting line will be lowered by 100 yuan on top of the original standard.
6. Reducing the hospital-level out-of-pocket payment ratio by 5 percentage points for first-level hospitals and 10 percentage points for hospitals of other levels.
7. The reimbursement rate for blood transfusion expenses is clarified to be 50 percent.
8. The reimbursement rate for hospitalization expenses incurred by participants who are out on business or on a business trip for emergency rescue in medical institutions outside the jurisdiction of the street office is increased from 50% to 90% of the expenses payable by the original fund.
After the above adjustments, the reimbursement rate for hospitalization expenses will be increased from the current 35% to about 62%.
VIII. Increasing the range of choices of medical treatment points
The new measures stipulate that the insured units should choose a fixed-point medical institution as their medical treatment point (i.e., the selected fixed-point medical institution, which is referred to as the bound community health center) in accordance with the street in which the insured person's actual workplace is located. The participant shall seek medical treatment at the bound community health center; under special circumstances, he/she may seek medical treatment at other designated community health centers or medical stations under the same billing hospital as his/her bound community health center, and shall go through the referral procedure if he/she seeks medical treatment at the headquarters of the billing hospital or outside of the billing hospital (except for emergency medical treatment and rescue).
Under the pilot scheme, medical treatment can only be sought at one of the bound community health centers. Since most of the laborers' workplaces are at a certain distance from their lodgings, no matter whether a community health center is selected near the workplace or around the lodgings, it will be inconvenient to seek medical treatment for an illness at another place, which is one of the opinions reflected more during the pilot period of the cooperative medical treatment for laborers. Therefore, it is necessary to expand access to other designated community health centers or community medical service stations under the same hospital as the bounded community health. Expanding the choice of access points are all community health centers under the same hospital, which will not put pressure on the outpatient fund, and at the same time, there is not too much of a problem in terms of operation.
Nine, the laborers medical insurance and the basic medical insurance of employees link
According to the regulations, the participant's maximum payment limit of the laborers medical insurance fund each year (i.e., the ceiling line) and continuous participation in the time of the laborers medical insurance is linked. And the city has established a multi-level medical insurance, participants can choose different levels of medical insurance, there is the possibility of transferring from one type of insurance to another, in order to reflect the fairness of allowing participation in the previous type of continuous participation in the time as the current type of continuous participation in the time, however, due to the level of different types of contributions, treatment level has a large difference, therefore, the new method provides:
Participants from participating in the city's social health insurance to participate in the laborers' health insurance, its continuous participation in social health insurance time can be regarded as continuous participation in the laborers' health insurance time.
If a participant switches from participating in the city's social health insurance to participating in the city's social health insurance, his/her continuous participation in the city's social health insurance can be partially regarded as continuous participation in the city's social health insurance, which is calculated as follows:
If a participant switches from participating in the city's social health insurance to participating in the city's in-patient health insurance, his/her continuous participation in the city's social health insurance can be partially regarded as continuous participation in the city's in-patient health insurance. The period of continuous participation in the laborers' medical insurance is divided by two and is regarded as the period of continuous participation in the hospitalization medical insurance.
If you switch from the Laborers' Health Insurance to the Comprehensive Health Insurance, the period of continuous participation in the Laborers' Health Insurance divided by 12 shall be deemed to be the period of continuous participation in the Comprehensive Health Insurance.
Tenth, the use of outpatient fund balance
On how to use the balance of the outpatient fund, the new approach has not been modified, the provisions of the outpatient costs of the year the balance of the medical institutions, transferred to the next year to use.
The designated medical institutions should gain revenue through the provision of medical services, and it is not appropriate to gain too much revenue through the balance. If medical organizations can withdraw bonuses or buy medical equipment etc. from the balance, it will harm the interests of the insured. As to how the balance of funds can be used, whether it can be used for health education of the participants, disease prevention, etc., what percentage is appropriate to use, how to operate, etc., we are exploring.
Xi, laborers medical insurance also has exclusions
and other medical insurance, laborers medical insurance is not possible to "full coverage", especially laborers medical insurance contribution level is low, but also provides for the corresponding exclusions, specifically:
One of the following situations
The laborers' medical insurance fund will not reimburse the laborers in any of the following cases:
(1) treatment in Hong Kong, Macao, Taiwan and abroad;
(2) treatment in a non-settlement hospital without referral, except for those who need to be rescued nearby if there is a danger to vital signs;
(3) purchase of medicines by oneself;
(4) injuries caused by traffic accidents, medical accidents, other liability accidents, or various accidents;
(v) injuries caused by suicide, self-injury, self-inflicted injury, alcoholism, brawling, etc.;
(vi) injuries caused by others' aggression;
(vii) other cases stipulated by the national, provincial and municipal medical insurance.
Article 28: The Laborers' Medical Insurance Fund shall not reimburse participants for the use of the following diagnostic and therapeutic items and medical materials:
(1) outpatient consultation, registration, out-of-hospital consultation, special medical services and other services;
(2) cosmetic treatment, non-functional cosmetic surgery, health checkups, medical consultation, preventive health care and other non-disease treatment;
(3) Positron Emission Tomography (PET) scanning (PEP); (4) medical treatment; and (5) medical treatment. (C) positron emission tomography (PET), photon knife and other non-basic medical insurance items;
(D) special medical materials (including artificial pacemakers, artificial heart valves, artificial crystals, artificial joints, intravascular catheters, intravascular stents, intravascular balloons of the heart) and imported medical materials with a unit price of more than 90 yuan;
(E) eyeglasses, dentures, hearing aids
(vi) various types of organ or tissue transplantation;
(vii) qigong therapy, magnetic therapy and other complementary therapeutic programs;
(viii) various infertility (pregnancy), sexual dysfunction diagnostic and treatment programs;
(ix) a variety of scientific research, clinical validation of diagnostic and treatment programs;
(x) the relevant provisions of the state, provinces and municipalities are not reimbursed. (j) Other treatment programs that are not reimbursable under the relevant national, provincial and municipal regulations.
Twelve, the enterprise does not participate in the insurance will also have to bear the corresponding responsibility
The new approach provides that the employer does not pay the required medical insurance premiums for laborers shall not be compensated for the unpaid period of hospitalization costs incurred by the employer in accordance with the "Shenzhen municipal workers' social health insurance approach" provisions; outpatient costs paid by the employer in accordance with the provisions of this approach.
Laborers medical insurance old and new program outpatient treatment comparison table
Table 1:
Projects Pilot Approach Provisional Approach Drugs Catalog 900 kinds 1200 kinds 90 yuan or more diagnostic and therapeutic items do not pay to pay 90 yuan outpatient dialysis fees for chronic renal failure (directory of the cost of blood transfusion for salvage does not pay 50% outpatient after organ transplantation with anti- Rejection drugs, and outpatient chemotherapy, interventional therapy, radiotherapy or nuclide treatment of malignant tumors incurred medical expenses (costs in the catalog) will not be paid50% Outpatient medical expenses incurred by the participant due to medical condition and approved by the settling hospital for referral to a non-settlement hospital will be reimbursed according to the outpatient fund's payable expenses50%90% Emergency medical expenses incurred in non-settlement hospitals and their subordinate medical institutions will be reimbursed according to the outpatient fund's payable expenses. Payment of expenses reimbursement is not clear 70%
Table 2:
Projects Pilot Approach Provisional Approach Pharmaceutical Catalog 900 kinds of drugs in conjunction with the national directory Category A 80% 100% Category B 60% 80% Inpatient diagnostic and treatment items less than $90 80% 90% more than $90 40% 80% General domestic medical materials less than $90 80% less than $90 (including imported materials) 90%90-200 yuan50%90-500 yuan80%200-500 yuan40%500-1000 yuan70%more than 500 yuan30%more than 1,000 yuan60%Hospitalization starting lineFirst-level hospital300200Second-level hospital400300Third-level hospital500400Out-of-town hospital600500Hospital-level payment ratioFirst-level hospital90%95%Second-level hospital 80%90%Tertiary hospitals 70%80%Out-of-town hospitals 60%70%Transfusion fees for resuscitation are not paid 50%Participants who go out on official business or business trips outside the jurisdiction of the street office of the medical institutions due to emergency resuscitation of hospitalization costs incurred in accordance with the hospitalization fund should be paid to reimburse the costs.50%90%
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