First, promote the transformation of medical insurance outpatient security for employees from personal security to social economy;
The second is to improve the allocation and service capacity of primary medical resources and reduce the cost of medical treatment for the masses;
Third, take measures to improve the security system and improve the health security level of the elderly.
In addition, there are three requirements for improving the security system and improving the health security level of the elderly:
The first is to improve outpatient security. The second is the special treatment for the special needs of the elderly. The third is to propose a new mechanism to expand the scope of personal accounts and help families.
Then, in 2023, what will happen to the medical insurance reform of employees in Jiangsu Province, and will the reimbursement ratio increase?
According to public reports, on February 27th, 20021,the General Office of Jiangsu Provincial Government issued the "Implementation Opinions on Establishing and Perfecting the Outpatient Security Mechanism for Employees' Basic Medical Insurance". According to the document of Su Zhengban 108, the reform of the outpatient security system for employees mainly includes four items.
First, establish and improve the overall guarantee mechanism for general outpatient expenses of employee medical insurance, and enhance the economic guarantee function of outpatient services.
Among them, the implementation opinions stipulate that the general outpatient expenses that meet the scope of the basic medical insurance policy and exceed the Qifubiaozhun shall be included in the payment scope of the outpatient pooling fund.
Taking Suzhou as an example, according to the "Implementation Measures on Improving the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients" issued by Suzhou in September 2022, it is adjusted and optimized in three aspects:
The first is to increase the maximum payment limit for general outpatient clinics. The maximum annual payment limit for general outpatient service of insured employees is raised from the current 4,000 yuan for working and 4,800 yuan for retirement to13,000 yuan. Qifubiaozhun remains at the current level, with 600 yuan as an on-the-job employee and 400 yuan as a retired employee. At the same time, establish and improve the dynamic adjustment mechanism of qifubiaozhun and maximum payment limit.
The second is to adjust the payment scope of the basic medical insurance pooling fund. From June 5438+1 October1day, 2023, the general outpatient expenses incurred by the insured employees that meet the requirements of the medical insurance policy shall be paid by the basic medical insurance pooling fund according to the specified proportion. Among them, on-the-job employees (including flexible employees) who seek medical treatment in eligible first-class and first-class medical institutions, second-class medical institutions and third-class medical institutions are paid by the overall fund for 80%, 75% and 60% respectively. On the basis of retired employees and on-the-job employees, it will increase by 10 percentage point respectively.
Third, after the reform, the insured workers can enjoy the corresponding outpatient security treatment in the designated medical institutions of medical insurance according to the corresponding regulations. Through the unified prescription circulation platform of the whole province, when the insured workers purchase medicines in qualified designated retail pharmacies, they can be paid by the basic medical insurance pooling fund according to the regulations, and the proportion of the pooling fund payment can be consistent with the designated medical institutions with prescriptions. Designated pharmacies do not yet support prescription circulation, and the payment ratio is implemented according to the proportion of tertiary medical institutions.
Second, standardize the protection of chronic diseases and special diseases in medical insurance clinics for employees.
These include establishing a unified outpatient chronic disease and special disease system in the province, and gradually unifying the scope of chronic disease and special disease in the province.
Taking Suzhou as an example, according to the Implementation Measures on Improving the Outpatient Security Mechanism of Employees' Basic Medical Insurance issued by Suzhou in September 2022, the outpatient security policy for special diseases and chronic diseases was adjusted and optimized on the premise of ensuring the overall comprehensive security level of the insured employees. Among them, outpatient special diseases shall be implemented in accordance with the Notice of Jiangsu Provincial Medical Security Bureau on unifying the outpatient special diseases policy of basic medical insurance; Outpatient chronic diseases are unified into the outpatient economic security mechanism, and under the overall planning of municipal basic medical insurance, the fair, standardized and unified treatment of employees' medical insurance outpatient service within the city is realized.
Third, improve the method of personal account calculation and payment.
Among them, starting from June 5438+ 10/day, 2023, the basic medical insurance premiums paid by individuals in the personal accounts of on-the-job employees will be included, and the inclusion standard is 2% of the base of their own insurance contributions, and all the basic medical insurance premiums paid by the unit will be included in the overall fund; From June 5438+1 October 1, retirees' personal accounts will be transferred according to their monthly personal account quota in 2022, and from June 65438+1October1,the retirees' personal account amount will be uniformly adjusted to the overall planning area according to the Opinions.
Taking Suzhou as an example, according to the Implementation Measures on Improving the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients issued by Suzhou in September 2022, the monthly basic medical insurance premium paid by employees' individual accounts will be included in the overall fund from June 5438+ 10/day, 2023, and the inclusion standard will be 2% of their participation payment base. From June 65438+1 October1day in 2023, the personal accounts of retirees will be transferred according to the personal account allocation amount in 2022. From June 5438+1 October1in 2024, the amount of personal accounts of retirees was uniformly adjusted to 2.5% of the average basic pension level in the year when the reform was implemented in accordance with the Opinions. The specific inclusion methods and standards shall be determined separately by the municipal medical insurance department according to the provincial regulations.
Fourth, standardize the scope of use of personal accounts.
Personal account funds are mainly used to pay the out-of-pocket expenses of the insured within the policy scope of designated medical institutions, and can be used to pay the medical expenses incurred by the insured himself and his spouse, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies.
Taking Suzhou City as an example, according to the provisions of the Implementation Measures on Improving the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients issued by Suzhou City in September, 2022, from June 5438+1 October1day, 2023, the personal account funds are mainly used to pay the out-of-pocket expenses of the insured within the policy scope of designated medical institutions. After the reform, the economic mechanism of individual account family will be established according to provincial regulations to help family members in three aspects:
First, it can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions;
Second, it can be used to pay the expenses borne by the insured himself, his spouse, parents and children in purchasing drugs, medical devices and medical consumables at designated retail pharmacies;
Third, it can be used for the insured to participate in large medical expenses subsidies (or serious illness insurance), long-term care insurance and other personal contributions, and explore personal accounts for spouses, parents and children to participate in the basic medical insurance for urban and rural residents.
At the same time, the "Implementation Measures" stipulates that personal accounts shall not be used for public health expenses, physical fitness or health care consumption not covered by basic medical insurance.
According to the above situation, in 2023, the medical insurance reform of employees in Jiangsu Province and the treatment of employees participating in medical insurance will change in the following four aspects, including:
The first is to increase the maximum payment limit for the annual general outpatient service of insured employees.
Second, the proportion of general outpatient expenses and overall fund payment for employee medical insurance will increase.
Third, insured employees can enjoy reimbursement when purchasing medicines at qualified designated retail pharmacies.
The fourth is to unify the methods and standards of employee medical insurance personal accounts.
Fifth, the scope of use of employee medical insurance personal accounts will be further expanded.
Based on the above situation, the medical insurance reform for employees in Jiangsu Province in 2023 will adjust the above five medical insurance benefits for employees, including the annual maximum payment limit for employees' general outpatient service and the reimbursement ratio for employees' medical insurance general outpatient service.