In order to conscientiously implement the national and provincial views on the "Twelfth Five-Year" period to deepen the reform of the medical and health system of the spirit, and to further increase the financing standards of the New Rural Cooperative Medical Scheme, expand the scope of compensation for major diseases, increase the degree of benefit to the participating masses
In order to further improve the financing standard of the new rural cooperative medical care (hereinafter referred to as the new rural cooperative medical care), expand the scope of compensation for major diseases, improve the degree of benefit to the participating public, and effectively reduce the burden of medical expenses on the participating patients, the new rural cooperative medical care (hereinafter referred to as the new rural cooperative medical care) financing standards and compensation program adjustment in 2013 are as follows:
I. Financing standards
District government decided to 2013 will be the new rural cooperative medical care in our district financing standard from 350 yuan per capita to 380 yuan, of which the provincial, municipal and district financial subsidies from 285 yuan to 305 yuan, individual participation funds from 65 yuan to 75 yuan. Low-income households, the five guaranteed households and key beneficiaries of the individual participation funds by the district finance in the medical assistance funds.
Second, the object of participation
Jurisdictional residents, urban residents living in townships and agricultural household primary and secondary school students to participate in the New Farmers' Cooperative as a whole as a family unit, individual contributions to participate in commercial insurance can also participate in the New Farmers' Cooperative; in the New Farmers' Cooperative in the last payment period to the next payment period of the birth of infants, retired soldiers, can participate in the current year's New Farmers' Cooperative; has been participating in the township workers, urban residents and primary and secondary school students medical insurance. and urban residents and primary and secondary school students shall not be allowed to repeat participation and enjoyment.
Three, the scope of compensation
(a) unified medication catalog. Designated village health clinics (community health service stations) all use the "national essential drugs catalog (grass-roots level)" within the drugs; township-level designated medical institutions all use the "National Essential Drugs Catalog (grass-roots level)" and "Jiangsu Province, primary health care institutions to supplement the drug list (grass-roots level)" within the drugs; district-level designated medical institutions to use the province's unified basic drug list and the provincial list of drugs added to the list of inpatient hospital patients The use of drugs in the catalog reaches 90%, and those that do not reach this standard are settled with the patients according to this ratio, and the agency settles with the medical institutions accordingly.
(2) Unified diagnostic and treatment program catalog (see the attached table: New Rural Cooperative Diagnostic and Treatment Program Table).
(3) Unified implementation of outpatient special disease compensation. Outpatient drug and treatment fees for insulin-dependent diabetes mellitus, stage III hypertension, systemic lupus erythematosus, aplastic anemia, post-stroke sequelae, Parkinson's disease, hemophilia, and severe mental illnesses are included in the compensation for outpatient special diseases.
Four, compensation standards
(A) outpatient compensation
1, general outpatient medicine compensation does not set a starting line, the town and village compensation ratio of 45% and 50%, respectively, the annual maximum payment limit of 700 yuan. Referral to the district-level designated medical institutions for outpatient treatment, belonging to the scope of compensation for the medical expenses are compensated at 20%; municipal and above medical institutions general outpatient medical expenses are not included in the scope of compensation.
2. The daily outpatient prescription limit for town and village-level designated medical institutions is 50 yuan and 30 yuan respectively.
3. The treatment of special outpatient diseases is mainly borne by district and town fixed-point medical institutions, with an annual compensation ceiling of 1,000 yuan.
4. The general diagnostic and treatment fees charged by town and village medical institutions are included in the scope of payment of the New Rural Cooperative in accordance with the regulations and are compensated at 80%.
(2) hospitalization compensation
1, the starting line. Compensation for hospitalized medical expenses set a starting line, town, district, city and provincial fixed-point medical institutions each time the starting line of 200, 400, 500 and 600 yuan, respectively. Radiotherapy for malignant tumors, organ transplantation and anti-rejection outpatient treatment, the cumulative settlement of medical expenses within the scope of the policy, minus 10% of the starting line, and then settled according to the standard of inpatient hospitalization compensation of the same level of medical institutions, with the annual cumulative compensation of up to 10,000 yuan.
2. Policy compensation ratio.
Township
District
Municipal
Provincial
85
70
60% for up to 30,000 yuan
65% for more than 30,000 yuan
50% for up to 30,000 yuan
60% for more than 30,000 yuan
3. Capping line. Individual annual medical expenses compensation ceiling line of 100,000 yuan, the annual cumulative calculation including outpatient, hospitalization and other compensation.
(C) compensation for major diseases
1, included in the pilot project to improve the level of medical insurance for rural residents with major diseases, after referral to the signing of a major disease "service agreement" of the designated hospitals for treatment, according to the standard of the region's limited medical cost compensation of 70%. Participating patients choose their own medicines, diagnostic and treatment items or go to medical institutions outside the region, the medical fees in accordance with the relevant provisions.
2. The compensation for hospitalization medical fees for referral to major disease designated hospitals is not subject to the individual annual compensation ceiling.
V. Other regulations
1. If a family is not fully enrolled in the program, the medical expenses in line with the compensation policy will be compensated according to the proportion of the family's enrolled population.
2. Patients who are hospitalized across years must be continuously enrolled in order to enjoy continuous compensation. New participants in the region (except for marriage, newborns and retired soldiers) can only be compensated for medical expenses incurred after April 1st.
3. Strengthening the management of referrals for medical treatment, striving to control the rate of referrals from outside the district to less than 10%, and the rate of referrals from outside the city to less than 5%, and conscientiously carrying out the system of referrals from one level to the next; for the participants who are timely for the referral procedures, and who are referred to the district, municipal, or provincial level fixed-point medical institutions for hospitalization and treatment, the incurred medical expenses are compensated by a guaranteed compensation method, with an actual compensation percentage of 35%; and for the participants who have been hospitalized in district and out-of-district fixed-point medical institutions without referral, the actual compensation percentage is 35%. The actual compensation rate is 35%; medical expenses incurred in hospitalization at designated medical institutions at the district level and outside the district without referral are compensated at 60% of the stipulated standard (except for emergencies and migrant workers).
4. In addition to the government subsidy of RMB 500 yuan, the remaining part of the medical expenses for normal delivery, vaginal surgery for assisted delivery and cesarean section will be compensated in accordance with the standard of single-disease settlement.
5. Reforms of payment methods such as total prepayment for outpatient services in districts, towns, and village designated medical institutions, total control, settlement by type of disease, and payment by bed day have been fully implemented.
6. Participants who are subject to medical assistance validated by the civil affairs, trade unions, labor security and other departments will be compensated for their medical expenses according to the Yandu District Medical Assistance Compensation Standard in addition to the New Rural Cooperative Medical Insurance in accordance with the regulations, and will be compensated according to the corresponding one-stop medical assistance compensation standard in Yandu District at the same time.
7. According to the spirit of the document "Opinions on Further Strengthening Orphans' Living Relief and Medical Treatment for Mental Disease Patients" (Du Zhengban Fa (2012) No. 89) issued by the Office of the District Government, the principle of "designated hospitals and free treatments" has been implemented for mental disease patients, and the designated hospital of our district is the District Psychiatric Prevention and Treatment Hospital, and the District Cooperation and Management Office has been working on this issue in the past year. The previous year, the district elite prevention hospital on the basis of the new rural cooperative settlement funds, according to this year's new rural cooperative fund-raising increase to determine the total amount, month by month, the rest of the cost of the district charitable associations, the Red Cross, the Civil Affairs Bureau and the district financial *** with the same commitment.
Sixth, standardize the management of designated medical service institutions
1, between the townships to abolish the referral system, the implementation of the participants in the information interoperability, timely settlement of medical fees; township health hospitals (first-class hospitals) due to conditions can not be diagnosed and treatment of patients, depending on the condition of the nearest referral to the center with the ability to serve the health hospitals (second-class hospitals) to be treated. The implementation of the first and second level health hospitals hierarchical diagnosis and treatment, and through the recurrent revenue and expenditure difference adjustment, to realize the orderly development of the first and second level hospitals.
2, the strict implementation of the district, town, village hierarchical publicity system, the designated medical service institutions should be publicized service charges, drug prices, cooperative medical fund income and expenditure, supervision and reporting telephone number, etc.; 15 days before the end of each month to publicize the jurisdiction of the last month's compensation of participants, the location of the publicity should be conspicuous, the content should be clear, to ensure that the public participation in the right to know and the right to supervise.
3, the implementation of performance assessment management of designated medical institutions, the failure to perform the duties of cooperative medicine, do not comply with the relevant provisions of cooperative medicine, unreasonable examination, medication, treatment, outpatients transferred to inpatient hospitalization, "bed" hospitalization or decomposition of hospitalization of the unit, according to the actual cost of the 2-3 times to be punished; to the The relevant personnel who cheated the settlement funds by favoritism and fraud, shall be punished with a fine of 2-5 times of the cheated amount, and the responsible units shall be notified and criticized, and rectified within a time limit, and the qualification of the fixed-point medical service institutions shall be suspended or cancelled if the rectification is overdue or is not in place, and the relevant personnel shall be held responsible for their actions.
4, the implementation of the new rural cooperative service agreement management of the designated medical institutions physicians, strengthen the role of medical insurance monitoring of medical services, the establishment of incentives and penalties and effective constraints on the mechanism, to improve the quality of the new rural cooperative service for physicians practicing in the designated medical institutions, to promote the rational examination, reasonable use of medication, reasonable treatment, and to achieve the goal of providing high quality services at a low cost.
5, the participating public in the designated medical institutions, according to the compensation program directly for the compensation of medical expenses, the cost of the first advance by the designated medical institutions, month by month statistics reported to the District Office of the Joint Management, after verification, according to the total amount of the designated medical institutions throughout the year approved by the sequential allocation. In principle, the fixed-point medical institutions to implement the new rural co-operation funding quota management, total control, overspending self-responsibility approach to strengthen self-restraint.
6, the fixed-point medical institutions according to the participating masses of hospitalization medical fees of 1% of the total settlement of the funds, the end of each year, unified remittance to the district co-management office, as a cooperative medical work assessment incentive fund.
7, improve the fixed-point medical service institutions service attitude and conditions, improve the quality and efficiency of service, so that the masses of participants in the comprehensive satisfaction remains above 95%.
Yancheng City, Yandu District, a new rural
Cooperative Medical Management Committee
January 15, 2013
Copies: District Party Committee Office, the District People's Congress Standing Committee Office, the District Government Office, the District Office of the Chinese People's Political Consultative Conference, the District Court, the District Prosecutor's Office, the District People's Armed Forces Department.
Yancheng Yandu District New Agricultural Cooperation Management Committee Office Issued on January 15, 2013