Chapter IV Outpatient Compensation
Article 12 Participants in the new rural cooperative medical care shall bring along their ID cards (or household registration certificates) and medical insurance cards to choose their own outpatient medical institutions within the scope of the city's outpatient designated medical institutions and enjoy the compensation for outpatient medical expenses according to the provisions of this program. Those who do not bring along the above cards when settling outpatient bills will not be reimbursed.
Article 13: The scope of outpatient compensation: medicine, injection, surgery, diagnosis and treatment, laboratory fees, examination fees, materials and other fees.
Article 14 Outpatient Compensation Standards: 10% of the outpatient medical expenses will be compensated. Outpatient effective medical expenses approved with specific reference to the new rural cooperative medical care in Cixi City and the relevant provisions of the basic medical insurance for urban workers in Zhejiang Province, but Class A and Class B drugs are uniformly calculated in accordance with Class A drugs.
Article 15 outpatient compensation: the outpatient settlement administrator of the designated medical institutions with the patient's ID card (or proof of household registration) and the medical insurance card, the patient or his/her relatives in the outpatient clinic to pay for the settlement of compensation procedures on the spot, regardless of the number of visits to the patient's limitations. If there is no computerized charge for nighttime emergencies, manual settlement of compensation can be given, but it must be entered into the outpatient computerized charging system on the following day. If the compensation cannot be settled on the spot due to irresistible factors such as interruption of the HIS network of the new rural cooperative medical care, interruption of the internal computer network of the hospital or interruption of the power supply, the patient can present his/her ID card (or certificate of household registration), medical insurance card and the original outpatient charging receipts (with a list) afterwards to go to the window of the new rural cooperative medical care settlement window of the medical institution he/she consults for the compensation formalities in the current co-ordination year. The fixed-point medical institutions shall submit the original outpatient fee receipts stamped with the "New Rural Cooperative Medical Care Outpatient Emergency Settlement Special Seal", settlement vouchers, patients' ID cards (or household registration certificates), and copies of their medical insurance cards, together with the monthly compensation statements, to the Municipal New Rural Cooperative Medical Care Management Center.
Article 16 suffers from the city's new rural cooperative medical system of six chronic diseases, and has been handled by the chronic disease outpatient medical records of patients in the outpatient fixed-point medical institutions, the fixed-point medical institutions relevant staff should fulfill the obligation to inform in advance, informed the patient of all the outpatient medical expenses incurred by the quarterly unified to the town of their household registration (streets, development zones) settlement service point to handle Settlement of compensation. The settlement service point in accordance with the "Cixi City, the new rural cooperative medicine chronic disease outpatient compensation measures" (Cihe medical management [2006] No. 4) of the relevant provisions of the implementation.
Article 17: Other cases not included in the scope of compensation:
1. Outpatient medical expenses incurred in non-outpatient designated medical institutions.
2. Expenses for examination, treatment and medicines that are not related to the disease suffered.
3. Outpatient medical expenses of those who have been verified to be dually insured under the New Rural Cooperative Medical Care and the Urban Medical Insurance, as well as outpatient medical expenses of those who have participated in the Urban Medical Insurance during the period of participation in the New Rural Cooperative Medical Care and the Urban Medical Insurance after the commencement of the period of enjoyment of the Urban Medical Insurance.
4. Outpatient medical expenses that are found to be the result of fraudulent behavior such as card transfer and drug exchange.
5. Outpatient medical expenses other than those stipulated in the New Rural Cooperative Medical Care and the Basic Medical Insurance for Urban Workers in Zhejiang Province.
Chapter V service system
Article 18 of the city's new rural cooperative medical management center and outpatient medical institutions signed a medical service agreement. The content of the agreement includes the service population, the scope of services, service content, service quality, outpatient medical fee settlement methods, outpatient medical fee payment standards, as well as outpatient medical fee audit and control. The agreement is valid for one year. Either party violates the agreement, the other party has the right to terminate the agreement, but must give one month's notice to the other party and participate in the new rural cooperative medical personnel.
Article 19 of the fixed-point medical institutions should be based on the outpatient software interface standard documents provided by the city's new rural cooperative medical care software development company, the new outpatient medical expenses compensation module on the current new rural cooperative medical care HIS software.
Article 20 of the fixed-point medical institutions shall set up outpatient settlement service window of the new rural cooperative medical care, publicize the new rural cooperative medical care outpatient medical service guide, equipped with sufficient computer equipment and settlement staff, and make efforts to provide patients participating in the new rural cooperative medical care with high-quality, convenient, efficient and comfortable medical service environment.
Article 21 of the fixed-point medical institutions staff must adhere to the principle of identity verification when receiving patients participating in the new rural cooperative medical care. At the same time, should improve the quality of service, enhance the function of service, and constantly meet the needs of the masses to prevent and treat diseases, and effectively achieve civilized medical practice, polite service.
Article 22 of the designated medical institutions medical personnel should have good medical ethics and medical style, and constantly improve medical skills, adhere to the treatment of disease, and effectively achieve reasonable examination, reasonable medication, reasonable treatment, is strictly prohibited to prescribe large prescriptions and favors.
Article 23 of the fixed-point medical institutions should establish outpatient medical expenses compensation fund accounts, computerized management, a month to close the accounts, a month to report, so that the day and month, and timely reporting.
Supervision and management of the sixth chapter
Article 24 of the fixed-point medical institutions should be "Zhejiang Province, outpatient fee price standards" implementation of the wall, take the initiative to accept public supervision.
Article 25 of the fixed-point medical institutions once a month to publish a summary of outpatient medical cost compensation, including the number of visits, the total outpatient medical costs, the total outpatient effective medical costs, the total cost of compensation, etc., to ensure that the new rural cooperative medical care outpatient fund compensation is open, fair and just.
Article 26 of the implementation of outpatient compensation cost audit system, the designated medical institutions should be 10 days before the end of each month, to the municipal management center of the new rural cooperative medical care reported to the outpatient medical cost compensation for patients participating in the new rural cooperative medical care in the previous month, management and service, and take the initiative to accept the supervision and inspection.
Article 27 of the city's new rural cooperative medical care management center of outpatient medical institutions to implement a full range of monitoring and management of compensation, the establishment of surveys, visits, assessment, supervision system, and timely notification of outpatient outpatient coordinated fund use of the community, consciously accept the supervision of the financial, auditing and other departments.
Article 28 of the designated medical institutions shall establish a reporting and complaint system, publish a complaint phone number, set up a report box, and complaints are investigated in a timely manner to deal with and reply.
Chapter VII rewards and punishments
Article 29 in the implementation of the new rural cooperative medical outpatient clinic activities, the effective fulfillment of their responsibilities and obligations, and actively work and make significant achievements in the units and individuals, by the municipal management committee of the new rural cooperative medical care to give notice of commendation.
Article 30 of the fixed-point medical institutions and their staff in violation of the relevant provisions of the city's new rural cooperative medical care system, will be ordered to make improvements within a certain period of time, or notification of criticism, and in serious cases, the cancellation of the qualification of the fixed-point medical institutions, the relevant staff members are instructed to be dealt with by their units.
Article 31 of the new rural cooperative medical care participants in the fraud, its outpatient medical expenses are not compensated, have been compensated for all to be recovered, the circumstances are serious, cancel its participation in the new rural cooperative medical care qualifications.
Chapter VIII Supplementary Provisions
Article 32 of this program by the Municipal New Rural Cooperative Medical Care Management Center is responsible for the interpretation.
Article 33 of this program on a trial basis for the period from January 1, 2007 to December 31, 2007 tentatively.
Cixi City, the new rural cooperative medical inpatient hospitalization coordinated effective cost definition range
I. Not included in the scope of the effective cost of drugs, diagnostic and therapeutic items, etc.:
(a) outpatient costs
Participants in the outpatient treatment of various types of costs (malignant tumors, stroke, diabetes, chronic uremic syndrome, organ transplantation after follow-up treatment of the five chronic diseases, and so on. (Those who have not enjoyed the hospitalization subsidy in the current year are included in the hospitalization compensation, but it is stipulated that the end of the year will be unified settlement).
(B) Drugs
1, Zhejiang Province Basic Medical Insurance "Drug Catalog Guide" and "Supplementary Catalog" in the clear category C drugs, as well as not yet included in the Drug Supplementary Catalog of all types of newly listed drugs;
2, blood products, protein products (except for special indications and first aid, rescue);
3, all types of drugs in the fruit-flavored preparations, Oral effervescent agent;
4, all kinds of wine preparations made from Chinese herbs and Chinese herbal medicines;
5, some of the animals and animal organs that can be used as medicine, dried (water) fruits.
(3) service items category
1, registration fees, out-of-hospital consultation fees, home beds, medical records cost;
2, consultation fees, transportation fees, private rooms (of which 50 yuan can be included in the effective cost), accompanied by the cost of meals, reclining chairs, air-conditioning fees, special medical services.
(4) non-disease treatment program category
1, a variety of beauty, fitness programs and some functional cosmetic and orthopedic surgery (such as: blepharoplasty, strabismus orthopedic surgery, correction of stuttering, hare lip, treatment of freckles, dentures, orthodontics, optometry, etc.);
2, a variety of weight loss, gain weight, increase in height projects;
3, a variety of health checkups;
4, a variety of preventive, health care treatment programs;
5, a variety of medical consultation, medical appraisal.
(E) diagnostic and therapeutic equipment and medical materials
1, the application of positron emission tomography device (PET), electron beam CT, ophthalmology excimer laser therapy, body information diagnostic equipment, such as inspection and treatment programs;
2, denture, eye prosthesis, prosthetics, hearing aids and other rehabilitative appliances;
3, a variety of self-use health care, massage, Qigong, examination and treatment equipment;
4, Chinese medicine decoction fee;
5, pacemakers exceeding 20,000 yuan or more;
6, price authority department regulations can not be charged separately for disposable medical materials;
7, disposable materials: patient marking tape, swabs, disposable maternity mattresses, disposable mattress, disposable oral care, disposable medicine cups, disposable Mouth cups, disposable medicine cups, disposable toothbrushes, disposable bed brushes, disposable medication changing bowls, disposable therapeutic wipes, disposable diapers, disposable garbage bags, disposable latex gloves, blood pressure cuffs, humidified paper, list fee, thermometers, urinals;
8, ultraviolet irradiation, air purifiers.
(F) treatment items category
1, all types of organ or tissue transplantation of organ source or tissue source (except for skin transplantation for burn patients);
2, in addition to the rest of the kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplantation;
3, surgery, anesthesia treatment part of the project: disposable surgical gowns, laminar flow Operating room, OB gel, medical sodium hyaluronate, pre-calcitonin (PCT), three-way extension tubes, blood cross, analgesic pumps, skin staplers, negative pressure drains, inhalation anesthetic adsorbents, heparin caps, 3M bandages, respiratory threaded catheters, intravenous hypernourishment therapy, medical bio-protein gel, anti-tumor chemical configuration, surgical specimen fees, medical waste disposal fees, special infection treatment;
4, Radiology, Special Inspection Division part of the project, endoscopic graphic reports, film fees, digital processing fees;
5, myopic orthopedics;
6, qigong therapy, music therapy, health care nutritional therapy, magnetic therapy and other complementary therapeutic programs.
(7) Others
1, pregnancy, miscarriage, abortion, normal delivery (medical expenses caused by hospitalization for difficult deliveries, after the effective cost is reduced by 1,500 yuan, will enter into the hospitalization co-ordination and compensation procedure, except for those who are in violation of the Family Planning Act);
2, various kinds of infertility (pregnancy) and sexual dysfunction treatment programs (e.g., treatment of male infertility, female infertility);
3. The portion of hospitalization medical expenses paid for injuries caused by a third party to a person enrolled in the cooperative medical inpatient coordination system that should be borne by the third party in accordance with the law. (e.g., after a traffic accident, the at-fault party shall be responsible for the compensation costs);
4. Inpatient medical expenses paid for injuries caused by accidents at work and other accidents;
5. Inpatient medical expenses caused by fraudulent acts such as not being hospitalized under a registered name or being hospitalized under an impostor;
6. Injuries caused by intentional acts of breaking the law, committing crimes, committing suicides, fighting and assaults, taking drugs, abusing alcohol, medical malpractice and other intentional acts and the intentional acts of their family members;
7.
7, unauthorized medical expenses in non-designated medical institutions;
8, unauthorized examination of high, precise and sharp medical instruments and special treatment;
9, hospitalization medical expenses due to a major public ****health emergencies.
The medicines, diagnostic and therapeutic items that can be partially included in the scope of effective costs and the proportion that is not included in the compensation (hereinafter referred to as the "self-responsibility ratio"):
(a) Medicines
In the case of hospitalization in designated medical institutions within the province, the drugs specified in the "Drug Catalog Guidelines" of the Zhejiang Basic Medical Insurance and the "Supplementary Catalog" are class B medicines. Catalog" specified in the Class B drugs at their own expense 5%.
(2) Diagnostic and therapeutic equipment and medical materials
1, the application of CT (including ECT, SPECT), magnetic resonance imaging (MRI), cardiac and angiographic imaging, color ultrasound, dynamic electroencephalography, ultrasound gastroscopy, digital subtraction X-ray examination, linear gas pedal and other large-scale medical equipment for the examination and treatment of the project, the deductible of 15%;
2, extracorporeal Shockwave lithotripsy, hyperbaric oxygen chamber treatment, radiofrequency treatment and other items, 10% self-responsibility;
3, stereotactic radiation therapy device Acme knife (X-knife), Gamma knife (r-knife), photon knife, etc., 40% self-responsibility;
4, cardiac pacemakers (the maximum payment limit of 20,000 yuan), artificial crystals, artificial joints, artificial laryngeal and femoral heads and other artificial organs for in vivo replacement, the Disposable medical materials (including implantable materials) for which the price authority department stipulates that separate charges can be made and the price of a single item is more than 1,500 yuan (including 1,500 yuan). Self-responsibility ratio of 10% for domestic products, 15% for Sino-foreign joint venture products, and 20% for imported products.
(C) treatment project category
1, hemodialysis, peritoneal dialysis project, 10% self-responsibility;
2, cardiac laser perforation, anti-tumor cellular immunotherapy, fast neutron therapy project, 15% self-responsibility;
3, kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplants, cardiac bypass and cardiac catheterization balloon dilatation, etc.
4. Intervention fee, 10%; intervention procedure fee, 15%; intervention material fee, 20%.
Third, on the hospitalization treatment of drugs, diagnostic and therapeutic items in designated medical institutions outside the province effective
Cost definition:
In the case of hospitalization treatment in designated medical institutions outside the province, if the list of costs provided has been clearly defined categories, then according to the list of categories specified in the effective cost of reference to the proportion of the out-of-pocket expenses of the local; do not specify the category, the category according to the provincial standards, the proportion of the out-of-pocket expenses of reference to provincial standards. refer to the provincial standard.
In the process of actual operation, if there is any contradiction between some medicines and treatment items and the original reference standard (the scope of treatment items of basic medical insurance for urban workers and other regulations), the scope of the definition will be implemented according to this definition.
Unification (II) Funding
In accordance with the principle of individual (family) contributions and appropriate financial subsidies, a comprehensive fund for urban residents' medical insurance is established.
1. Annual financing standards
Adults are financed 365 yuan per person per year, of which the individual contribution is 200 yuan per person per year; minors (under the age of 18) are financed 245 yuan per person per year, of which the individual contribution is 80 yuan per person per year. Town (street), development zone finance according to the number of participants in the jurisdiction to give 40 yuan per person per year, the city finance according to the number of participants to give 110 yuan per person per year, the Ningbo municipal finance according to the number of participants to give 15 yuan per person per year.
The individual contributions and financial subsidies of the newly-acquired municipal household members in the integrated year are collected and subsidized in the proportion of the month of enjoyment to the month of the year.
To participate in the urban residents' medical insurance system in the household as a unit of the five guaranteed households, low-income households, the key preferential object, "three old" people, the loss of the ability to work of the certified disabled and other special groups of individual contributions to be borne by the city and the town (street), the development zone of the finance of each 50%, the model worker (men aged 60 years old, women aged 55 years old), the individual contributions to be borne by the city. The individual contributions of model workers (men over 60 years of age, women over 55 years of age) are fully borne by the municipal finance.
Encouraging conditional employers to give full or partial subsidies to the individual contributions of employees' families (including minors). Social organizations and individuals are actively encouraged to subsidize the medical insurance system for urban residents.
2. Trial stage financing standards
Adults 182.5 yuan per person, of which the individual contribution is 100 yuan per person; minors 122.5 yuan per person, of which the individual contribution is 40 yuan per person. Town (street), development zone finance according to the number of participants in the jurisdiction to give 20 yuan per person, the city finance according to the number of participants to give 55 yuan per person, the Ningbo municipal finance according to the number of participants to give 7.5 yuan per person.
The individual contributions of special groups such as five-guaranteed households, low-income households, key preferential objects, "three old men", and certified disabled persons with loss of working ability in households participating in the urban residents' medical insurance system are borne by the municipal government and the finance of towns, streets and development zones at 50% each, and the individual contributions of model workers (men aged 60 and over, women aged 55 and over) are borne by the municipal government and the finance of towns and development zones at 50% each. The model worker (male over 60 years of age, female over 55 years of age) individual contribution portion of the municipal finance to bear the full amount.
New rural cooperative medical annual participants, adults and then contribute 85 yuan, minors and then contribute 25 yuan; municipal finance according to the number of participants and then give each person 30 yuan of subsidies; new rural cooperative medical co-ordination fund according to the number of participants per person transferred 67.5 yuan, including personal contributions of 15 yuan, town (street), development zones, financial subsidies of 20 yuan, municipal financial subsidies of 25 yuan, Ningbo municipal financial subsidies of 7 yuan, the city of Ningbo financial subsidies of 7 yuan. yuan, Ningbo City financial subsidies 7.5 yuan. New rural cooperative medical care midway participants, adults individual contributions to another 85 yuan, minors individual contributions to another 25 yuan; town (street), development zones, the financial district according to the number of participants in the jurisdiction of another 20 yuan per person subsidy, the municipal finance according to the number of participants another 55 yuan per person subsidy, ningbo municipal finance according to the number of participants and then give each person a subsidy of 7.5 yuan; new rural cooperative medical care co-ordination fund according to the number of participants 15 yuan per person for transferring the individual contribution portion.
(3) Fund use and management
In the urban residents' medical insurance co-ordination fund to withdraw 5% as a risk fund, used to balance the fund's profit and loss between years, withdraw 12% as a general disease outpatient fund, used for outpatient compensation for general diseases in the co-ordination year of the participants; in the urban residents' medical insurance co-ordination fund of the part of all levels of financial subsidies listed in the participants Each person annual degree of 5 yuan to establish a big disease relief fund, for the relief of participants in the integrated year of large medical expenses incurred above the limit compensation ceiling line of the life of people in difficulty; the rest of the hospitalization fund.
The urban residents' medical insurance co-ordination fund to implement municipal co-ordination, financial supervision and management, and the new rural cooperative medical co-ordination fund accounted for in separate households, the annual balance is still insufficient by the municipal finance to make up for the full amount.
The urban residents' medical insurance co-ordination fund shall strictly implement the pre-budgeting system, financial accounting system, and the fund revenue and expenditure and management of the implementation of the annual audit and publicity system.
The urban residents' medical insurance fund shall be collected on an annual basis, with the year determined to be from January 1 to December 31 of the current year, and the annual fee shall be paid in one lump sum. The implementation of the fund collection into the treasury deadline system, all participants in the urban residents of the medical insurance system should be stipulated in each year before the deadline for the whole household to pay, in the next year to start enjoying the annual payment deadline for December 20. December 25 before the town (street), the development zone of the financial subsidies and the town (street), the development zone is responsible for the collection of the individual part of the funds to the town (street), development zones as units. Units uniformly transferred to the city residents of urban medical insurance management center income transition account.
June 20, 2007 for the trial phase of the payment deadline, June 25 before the towns (streets), development zones of the financial subsidies and the collection of individual contributions part of the funds transferred to the municipal urban residents of medical insurance management center income transition account.
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