Methods for the Administration of the Scope and Payment Standards of Diagnostic and Treatment Items, Medical Service Facilities, and Special Medical Materials of Basic Medical Insurance for Urban Workers in Nanjing (for Trial Implementation)
Nanjing Bureau of Labor and Social Security
Nanjing City Finance Bureau
Nanjing Price Bureau
Nanjing Health Bureau
NinglaoSocialSecurityMedicine [2005] No. 2
Nanjing Urban Workers' and Cities' Basic Medical Insurance Diagnostic and Treatment Items, Medical Service Facilities, and the Scope and Payment Standards of Special Medical Materials (for Trial Implementation)
Article 1: In order to improve the basic medical insurance policy and standardize the basic medical insurance treatment items, medical service facilities, special medical materials and payment standards (for trial implementation) Notice on Issuing Jiangsu Province Basic Medical Insurance Diagnostic and Treatment Items, Scope of Service Facilities and Payment Standards (Su Laoshe [2005] No. 49) and Interim Provisions of Nanjing Municipal Urban Employees' Basic Medical Insurance (Ning Zhengfa [2000] No. 259), the spirit of the formulation of these measures.
The second basic medical insurance diagnosis and treatment items, medical service facilities, special medical materials refers to the basic medical insurance designated medical institutions for the insured in accordance with the scope of the "price of medical service items in Jiangsu Province" (Su Price Fei [2005] No. 213) and "Jiangsu Province, special medical materials price management methods" (Su Price Fei [2005] No. 214) to provide a variety of medical technical labor items and the use of medical instruments. Technical labor projects and the use of medical instruments, equipment, medical materials for inspection, diagnosis and treatment projects, as well as disposable medical materials that can be charged separately.
Article 3 of the city's basic medical insurance diagnosis and treatment items, medical service facilities and special medical materials range in accordance with the five departments of the Jiangsu Provincial Labor and Security Department and other departments of the development of the "basic medical insurance diagnosis and treatment items, medical services and facilities catalog" (hereinafter referred to as the "Medical Services Catalog"), and according to the regulations are divided into basic medical insurance allowed to pay for the cost of medical services (Class A directory), the medical service items (Class B directory), to pay for part of the cost of medical services (Class B directory). The medical service items that are partially paid (Class B Catalog) and the medical service items that are not paid (Class C Catalog) are divided into three categories as stipulated by the basic medical insurance.
The scope and standard of diagnostic and treatment items, medical service facilities, and special medical materials of the city's basic medical insurance shall be unified and standardized, and the management and payment of such items shall be carried out in a graded and classified manner.
Article 4 of the city's labor and social security departments are responsible for the city's basic medical insurance diagnosis and treatment projects, medical services, special medical materials, scope and payment standards of supervision and management, and in conjunction with the financial, health, pricing and other departments, in accordance with the principle of "low level, broad coverage", taking into account the city's economic development, basic medical insurance fund's ability to pay and medical technology, the basic medical insurance fund to pay. Medical insurance fund payment capacity and the development of medical technology, to develop the city's basic medical insurance diagnosis and treatment programs, medical service facilities, special medical materials, specific payment standards; and may be adjusted in accordance with the basic medical insurance fund's ability to pay and the development of medical technology, at the appropriate time.
Establishing the city's unified and standardized diagnostic and treatment items, medical service facilities catalog library (hereinafter referred to as "diagnostic and treatment items library") and special medical materials catalog library (hereinafter referred to as "materials library").
Article 5 according to the level, type and specialty characteristics of medical institutions, respectively, to determine the basic medical insurance at all levels of designated medical institutions diagnostic and treatment items, medical service facilities and special medical materials, and in accordance with the technical maturity of large-scale diagnostic and treatment items and standardized requirements, strict control of the scope of basic medical insurance designated services.
Article VI of the basic medical insurance participants incurred diagnostic and treatment items, medical service facilities, belonging to the scope of Category A directory, in accordance with the provisions of basic medical insurance payments; belonging to the scope of Category B directory, the first by the participants were required by the provisions of the 20?60% (a small number of special diagnostic and treatment items can be determined as 70?80%) proportion of out-of-pocket, and then pay the rest in accordance with the provisions of the basic medical insurance; If it belongs to the scope of the C category catalog, the basic medical insurance fund and the fund of assistance for major diseases will not pay, and the cost will be fully paid by the individual.
The basic medical insurance co-ordination fund pays the hospital bed fee of 30 yuan per bed day, and the rest is still in accordance with the standards stipulated in the first paragraph of Article 2 of the Ninglao medical word [2000] No. 9.
Article 7 of the participants incurred in accordance with the basic medical insurance medical services catalog range of special medical material costs, where there is an upper limit on the cost of payment provisions, above the limit of part of the participants to pay; within the limit of the cost of clinical diagnosis and treatment of essential, safe and effective, inexpensive, in accordance with the provisions of the basic medical insurance payment; belong to the auxiliary materials, the cost is relatively expensive, high-tech, first by the The participant shall pay 20-60% out-of-pocket, and the remaining part shall be paid according to the basic medical insurance regulations; other special medical materials outside the above scope shall not be paid by the basic medical insurance fund and the fund for assistance to major diseases. At the same time, to standardize medical insurance special medical materials settlement price management.
Article VIII of the following circumstances occur in the diagnosis and treatment items, medical service facilities and special medical material costs basic medical insurance will not be paid:
(a) not included in the "Jiangsu Province, the price of medical services" and "Jiangsu Province, the price of special medical materials," the scope of, or without the provincial or municipal price authorities to approve the charges for new diagnostic and treatment items and special medical materials Costs, without the approval of the provincial and municipal health departments to carry out medical equipment or diagnostic and treatment project costs, without access to the municipal labor and social security departments or does not meet the requirements of grading, fixed-point management of diagnostic and treatment projects and special medical materials costs.
(2) other national, provincial and municipal regulations do not belong to the basic medical insurance payment scope of diagnostic and treatment programs, medical service facilities and special medical materials costs.
Article IX strengthens and standardizes the city's basic medical insurance diagnostic and treatment items, medical service facilities, special medical materials, grading, fixed-point management and diagnostic and treatment items library, materials library management and maintenance work. For the price, the health department approved by the new diagnostic and treatment items, special medical materials and basic medical insurance materials outside the scope of the library of new medical materials and increased grading, fixed-point management of diagnostic and treatment items outside the scope of the fixed-point medical institutions should be submitted to the municipal department of labor and social security department of the written application for access procedures, and submit the following materials:
(a) the competent department of health approval;
(ii) the approval of the price authority for the approved charges;
(iii) clinically relevant information.
The municipal administrative department of labor and social security shall, upon receipt of the application materials of the designated medical institutions, organize relevant experts to evaluate, approve and announce the application in due course.
Article X strengthens and standardizes the supervision and management of the city's basic medical insurance diagnosis and treatment items, medical service facilities and special medical materials payment standards. For violation of national, provincial and municipal diagnosis and treatment programs, medical service facilities and special medical materials, by the relevant competent departments in accordance with relevant laws and regulations for punishment.
Article 11 of the city to implement a separate coordination of districts and counties, the unified implementation of the municipal diagnostic and treatment items and materials database, and may be based on these measures, combined with the actual situation in the local community, the development of basic medical insurance diagnostic and treatment items, medical service facilities and special medical materials payment standards.
Article XII of these measures by the municipal labor and social security departments responsible for the interpretation. The original Ninglao medical word [2000] No. 9 and the content of these measures are inconsistent with these measures shall prevail.
Article XIII of these measures since October 1, 2005 shall come into force.
Article XIII of these measures shall come into force on October 1, 2005.