In order to implement the "General Office of the People's Government of Zhejiang Province on accelerating the establishment and improvement of the major medical insurance system notice of the relevant issues" (Zhejingbanfa ﹝2014 ﹞ No. 122) spirit, to further improve our city's medical security system, the establishment of a multi-level health care insurance system, in the city and the urban and rural residents who have carried out the major medical insurance system On the basis of the municipal people's government agreed, is to further improve the city's major medical insurance system to put forward the following implementation views.
First, the work objective
In accordance with the requirements of the province's major medical insurance system construction, the goal of basic medical care for all, integrated planning, step-by-step implementation. On the basis of the current basic medical insurance system, further improve the city's major medical insurance system, and gradually implement the municipal co-ordination, improve the city's major medical insurance co-ordination level and level of medical insurance, and effectively reduce the burden of major medical expenses of the insured.
The implementation of the views referred to in the major medical insurance, including employees and urban and rural residents of major medical insurance. The city's major medical insurance system temporarily set up a two-year transition period (-), that is, in the current implementation of urban and rural residents on the basis of major medical insurance, the establishment of the employee's major medical insurance, the transition period of the employee and the urban and rural residents of the major medical insurance fund collects and collects, the contribution and treatment of the implementation of the differentiation of the settings. In accordance with the construction of basic medical insurance as the main body, major disease insurance as an extension, medical assistance as the bottom, social charity and commercial insurance as a supplement to the requirements of the medical security system, to strengthen the integration of the system, when conditions are ripe, to the city as a unit of a unified policy system, unified financing standards and treatment levels, the fund to implement the unity of collection and expenditure.
Second, the policy measures
(a) the scope of participation
Participating in the basic medical insurance employees (including flexible employment participants) and urban and rural residents of the basic medical insurance participants unified into the scope of the medical insurance system for major diseases.
(B) financing mechanism
In accordance with the principle of fairness and sustainability, the establishment of a multi-channel financing mechanism reasonably shared by the government, units, individuals, the funds required by the government or the unit of 70%, 30% of the proportion of the individual to bear the specific financing standards of the major medical insurance by the people's governments of the counties (cities) to determine. Employee medical insurance participants in the major disease insurance premiums on an annual basis, a one-time from the employee basic medical insurance fund, urban and rural residents from the urban and rural residents in the overall allocation of the basic medical insurance fund, of which the employee's individual contributions from the individual account transfer, no individual account by the individual participants to pay, the local tax department is responsible for the collection of the employee's major disease insurance premiums; the urban and rural residents funding standards in accordance with the original basis and the inclusion of the cost of special drugs within the scope of payment of major disease insurance uniformity. The financing standard for urban and rural residents is determined by the original basis and the unified measurement of the costs of special medicines included in the scope of payment of major disease insurance. According to the operation of the Fund, the financing standard will be adjusted in due course.
Wenzhou city workers in urban areas of major medical insurance units, the individual's total financing standards in principle for the annual per capita 40 yuan. There is no establishment of personal accounts of employee health insurance participants, the individual contribution part of the major medical insurance premiums paid by the insured individual (in the staff of the major medical insurance premiums collected by the local tax department on a yearly basis, retirees major medical insurance premiums by the salary & lt; pension & gt; issued by the unit withholding, annual lump sum payment). Wenzhou urban and rural residents of the principle of urban and rural residents of major medical insurance financing standards for the annual per capita 30 yuan.
The major medical insurance fund to implement the two lines of income and expenditure and financial account management, separate accounts, separate accounting, earmarked.
(C) the level of protection
1. treatment content. A medical insurance year, participate in major medical insurance personnel due to hospitalization and outpatient medical expenses incurred for special diseases, according to the local basic medical insurance reimbursement, the participant's personal burden of the cumulative compliance with the medical costs, in the designated medical institutions or with the dispensing prescription to the major medical insurance designated pharmacy to buy special drugs in Zhejiang Province included in the scope of payment of the major medical insurance, the cost of such medicines occurring in a different place in line with the provisions of the reimbursement, over the local major medical insurance starting standard. The portion of the local starting payment standard of the major disease insurance shall be included in the payment of the major disease insurance. For the special drugs included in the scope of payment of major disease insurance in Zhejiang Province, in accordance with the spirit of the Notice of the Human Resources and Social Security Department of Zhejiang Province on the Inclusion of Gleevec and Other 15 Drugs in the Scope of Payment of Major Disease Insurance (Zherenshefa [2015] No. 11), from January 1 onwards, it will be included in the scope of the settlement of degree medical insurance. Participants in the designated medical institutions and related pharmacies incurred in line with the scope of payment of major disease insurance expenses, by the participants and the designated medical institutions and related pharmacies directly card settlement; should be paid by the individual medical expenses, by the designated medical institutions and related pharmacies directly to the participants. Zhejiang Province, special drugs for major disease insurance are:
No.
Drug Name
Formulations
Manufacturer
Generic Name
Trade Name
1
Imatinib Mesylate
Gleevec
Tablet
NovartisPharmaSchweizAG
2
Pemetrexed disodium
Lipitor
Injectable
EliLilly&Company
3
Gefitinib
Erectin< /p>
Tablets<
AstraZenecaUKLimited
4
Liposomal doxorubicin hydrochloride
Ribotec
Injection
Shanghai Fudan-Zhangjiang Bio-pharmaceutical Co. Injection
MerckKGaA
6
Decitabine
Chingvaiko
Injection
Zhengda Tianqing Pharmaceutical Group Co.
7
Anti-human T-cell rabbit immunoglobulin
ATG- FreseniusS
Injection
FreseniusBiotechGmbH
8
Trastuzumab
Herceptin
Injection
GenentechInc.
9
Recombinant human coagulation factor VIIa
Nocicept
Injection
Novo Nordisk Denmark
10
Rituximab
Merovax
Injection
RocheDiagnosticsGmbH
11
infliximab
Classico
Injection
CilagAG
12
Lanthanum Carbonate
Foslino
Chewable Tablets
ShirePharmaceuticalContractsLimited
13
Nitolizumab
Teicosan
Injection
Biotec Pharmaceuticals Biologics Limited
14
Lanreotide Acetate
Somatulin
Injection
IPSENPHARMABIOTECH
15
Teriparatide<
Foteo
Injection
LillyFrance
In the future, the special medicines included in the city's payment for major disease insurance will be adjusted accordingly according to the adjustment of the catalog of special medicines for major disease insurance in Zhejiang Province. If the insured person uses or buys the special medicines for the major disease insurance outside Zhejiang Province, the price will be included in the calculation of the medical insurance cost according to the access negotiation price in Zhejiang Province. The applicable population, indications, usage and payment standards of special drugs for major disease insurance are strictly enforced according to the regulations.
2. Treatment standards. Wenzhou City, major medical insurance in accordance with the medical insurance year for settlement. A medical insurance year, Wenzhou City, major medical insurance set a starting standard, in principle, the starting standard with reference to the previous year's per capita income level of urban and rural residents to determine the maximum compensation limit of major medical insurance is temporarily set at 10 times the starting standard (including). Among them, Wenzhou city degree of major medical insurance subsidy starting standard is determined as 32,600 yuan, urban area of major medical insurance maximum limit unified adjustment for the starting standard of 10 times (including), participants in a medical insurance year by the basic medical insurance reimbursement of more than the starting standard of the standard of compliance with the medical expenses, included in the scope of payment of major medical insurance, reimbursement ratio in accordance with the following standards:
(1) employees Compliance costs above the starting payment standard of the major medical insurance shall be shared between the major medical insurance fund and individuals. The Employees' Major Disease Insurance Fund has implemented segmented reimbursement: 60% for the portion above the starting standard and below 5 times the starting standard (inclusive); 70% for the portion above 5 times the starting standard and below 10 times the starting standard (inclusive).
(2) The reimbursement rate of urban and rural residents' major medical insurance is 50% for the eligible expenses above the starting payment standard and up to and including 10 times of the starting payment standard.
Upon the expiration of the transition period, the contributions and treatment of employees' major medical insurance and urban and rural residents' major medical insurance will be determined separately.
(D) management
Before the municipal co-ordination, the specific financing standards, starting standards, treatment payment standards, etc., by the co-ordination of the place in accordance with the "Notice of the General Office of the People's Government of Zhejiang Province on accelerating the establishment and improvement of the major disease insurance system of the relevant issues" (浙政办发[2014]122号)文件规定的标准要求, in conjunction with the local actuality of the self-definition. Major disease insurance is organized and implemented by each coordinating place, and the specific management is managed by the coordinating place's management agency; commercial insurance companies are encouraged to be entrusted to undertake major disease insurance, and the bidding management of major disease insurance is strengthened, and the bidding behavior of major disease insurance is regulated in accordance with the requirements of the "Guidelines on the Bidding Management of Major Disease Insurance in Zhejiang Province (Provisional)" (ZJHNSH Letter 〔2015〕 No. 30), and the specific bidding management mode is determined by the coordinating place's human resources and social security departments in conjunction with the local The specific bidding management methods shall be determined by the human resources and social security departments of the co-ordination places in conjunction with the local financial departments. Increase the daily supervision of commercial insurance companies undertaking major disease insurance, and establish and improve the assessment system with performance and participants' satisfaction as the main content. Further improve the medical instant settlement system, as soon as possible to realize the basic medical insurance, medical assistance for major diseases and major disease insurance "one-stop" settlement.
Wenzhou urban workers commissioned by commercial insurance companies to undertake major illness insurance, through public bidding, follow the principle of balancing income and expenditure, the principle of capital preservation, reasonable control of the profitability of commercial insurance institutions, bear the risk of operation, and the establishment of excess balances and policy losses of the dynamic adjustment mechanism.
After the municipal co-ordination, the specific financing standards, starting standards, treatment payment standards, etc. by the Municipal Bureau of Human Resources and Social Security, in conjunction with the Municipal Bureau of Finance and reported to the Municipal People's Government agreed to separately determine the announcement.
Third, the work requirements
(a) serious organization and implementation
The work of major medical insurance involves the city, county (city, district) level, multiple departments and a number of systems convergence, the co-ordination of the place to effectively strengthen the organization and leadership of the work of major medical insurance, in accordance with the principle of balance of income and expenditure, scientific estimates, and reasonably determine the specific financing standards, treatment levels. The human resources and social security departments should effectively perform the duties of the leading departments, and together with the relevant departments, earnestly do a good job in policy formulation, organization and coordination, guidance and supervision; the financial (local tax) departments should do a good job in the allocation of funds from the financial special account, the collection of premiums for the major illness insurance, and financial supervision of the major illness insurance; the health care and planning departments should strengthen the supervision of the health care institutions and health care service behaviors; the market supervision departments should strengthen the supervision of the supply channels of the drugs, and improve the risk prevention and control measures; and the market supervision departments should strengthen the supervision of the drug supply channels. Health planning departments should strengthen the supervision of medical institutions and medical service behaviors; market supervision departments should strengthen the supervision of drug supply channels and improve risk prevention and control measures; insurance supervision departments should strengthen the supervision of commercial insurance companies' contracting behaviors and service quality; and health insurance agencies should do a good job of accounting, financial accounting and supervision of the implementation of the agreement on major disease insurance. At the same time, strengthen interdepartmental communication and collaboration, information sharing, the formation of synergies; strengthen publicity, and do a good job in a timely manner at different stages of the work of the policy guidance of the work of the city to ensure that the city's municipal coordination of major medical insurance work to advance in an orderly manner.
(B) strengthen the dynamic supervision
The relevant departments to scientifically develop the implementation of the program, do a good job of data measurement; the co-ordination of the place to do a good job of data measurement, analysis of the expenditure situation of the cost of special medicines, in particular to do a good job of the transition period of the policy articulation between major disease insurance and basic medical insurance. It is necessary to do a good job of maintaining information on special medicines and developing systems for related operations, and ensure that operational and technical implementation is in place. Risk assessment should be strengthened, and possible risk situations of municipal coordination should be grasped in a timely manner, and countermeasures and solutions should be proposed. It is necessary to strengthen the dynamic supervision of special drugs for major medical insurance, do a good job of statistical analysis of data, prevention and control of unreasonable medical behavior and costs, and safeguard the quality of medical services.
Fourth, the implementation of time
This opinion from January 1 shall come into force.
Wenzhou Municipal People's Government Office
August 21 ;