From 1 in March, 2022, the threshold for hospitalization of basic medical insurance in tertiary hospitals was adjusted from 1500 yuan to 1200 yuan.

(2) Adjust the referral hospitalization treatment for adult residents.

From March 1 2022, the adult residents who participated in the medical insurance for urban and rural residents were referred by the contracted community health service institutions (township hospitals) and hospitalized in the second-class and above medical institutions in this city. The hospitalization expenses are above the deductible line to 40,000 yuan (inclusive), and the proportion of medical insurance fund payment is adjusted to 70%, and the proportion of medical insurance fund payment is adjusted to 75%.

(three) to adjust the medical insurance benefits of the old workers who participated in the revolutionary work before the founding of the People's Republic of China.

From March 1 2022, the medical expenses for outpatient, inpatient and outpatient special diseases of old revolutionary workers before the founding of the People's Republic of China will be paid by half on the basis of enjoying the basic medical insurance benefits for retired workers, and the half will be paid by the overall fund.

(four) adjust the city's COVID-19 screening treatment related expenses payment policy.

In order to do a good job in epidemic prevention and control, from June 5438+1 October1day, 2022, the notice of Ningbo Municipal Health and Health Commission, Ningbo Municipal Finance Bureau and Ningbo Municipal Medical Insurance Bureau on doing a good job in the settlement of expenses related to screening diagnosis and treatment in COVID-19 (No.88 [2020]) is no longer distinguished.

Two, adjust some medical management measures

(1) Adjust the expense settlement method during the suspension of medical insurance settlement service.

During the online and offline switching of the provincial smart medical insurance platform, the insured holds a social security card for medical treatment, and the outpatient medical expenses within the scope paid by the medical insurance fund enjoy emergency accounting treatment, of which 20% are borne by employees, 15% by retirees, 50% by urban and rural residents' medical insurance insured, and the rest are paid by the overall fund; 100% of the coordinator is paid by the fund. After the designated medical institutions keep accounts, they still upload the details of emergency accounting expenses according to the original channels, and the agencies will upload the payment information to the provincial smart medical insurance system after settlement and payment in the original medical insurance system.

After the smart medical insurance platform of the province is launched, when the medical insurance computer system of the medical insurance agency or the designated medical institution needs to suspend the medical insurance settlement service due to failure or maintenance, if the insured person has medical expenses in the designated medical institution, the individual shall bear all the expenses. After the system is restored, he will bring the original self-funded bill and his social security card (or medical insurance electronic certificate) to the original designated medical institution, and the medical institution will re-settle the medical expenses paid by the individual through the medical insurance system. Or apply for sporadic reimbursement to the medical insurance agency as required.

(two) adjust the settlement method of out-of-hospital examination (treatment)

From March 1 day, 2022, if the insured person needs out-of-hospital examination and treatment according to the regulations during hospitalization, the designated medical institution will handle the out-of-hospital examination (treatment) procedures for the insured person (registration of foreign inspection and purchase), and the related expenses will be reimbursed sporadically by the insured person at his own expense with valid bills, and he will enjoy out-of-hospital examination (treatment) according to the regulations.

(III) Temporary adjustment of the purchase method of external prescriptions Before the electronic circulation function of external prescriptions on the "Smart Health Insurance" platform is improved, the purchase method of external prescriptions will be temporarily adjusted. From March 1 day, 2022, the insured must have a paper prescription for external use issued by a designated medical institution to purchase drugs at designated retail pharmacies. When the designated medical institutions issue prescriptions for external use, they should strictly distinguish five types of prescriptions: general outpatient prescriptions for medical insurance, prescriptions for special diseases in medical insurance outpatient clinics, prescriptions for special drugs for serious diseases, prescriptions for hepatitis C drugs and prescriptions for external use at their own expense. The prescription for external use shall be stamped with the seal of the medical institution and the special seal of the doctor's name, and the settlement grade (category) of medical insurance shall be indicated on the prescription.

Designated retail pharmacies choose the corresponding medical insurance settlement treatment according to five types of prescriptions. Among them, when receiving medical insurance prescriptions for general outpatient clinics, you should choose "tertiary hospitals (general outpatient clinics)", "other hospitals (other outpatient clinics)" and "community hospitals (village clinics)" to upload information according to the settlement grades (categories) of medical institutions marked on the prescriptions, and the insured still enjoy the corresponding drug purchase treatment according to the settlement grades (categories) of designated medical institutions that prescribe. (4) standardize the payment scope of individual account funds over the years.

From March 1 2022, off-catalog drugs (including Chinese herbal pieces and self-made preparations), off-catalog services and materials with national codes were included in the payment scope of personal account funds over the years, and those without national codes were paid by individuals in cash. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance.

The personal payment of family doctor's contract service fee is paid by personal cash, and the payment of medical insurance fund is reviewed by the health administrative department where the medical institution is located, and the relevant information of the contract is provided to the medical insurance agency affiliated to the medical institution for payment according to the type of insurance.

The provisions of dental implant payment shall be implemented in accordance with the provisions of the Agreement on Promoting the Reform of Medical Insurance Payment Mode and Promoting the Implementation of Medical Insurance Dental Implant Project (hereinafter referred to as the Agreement) signed with Fuyu. Over the years, the payment scope of personal account was limited to dental implants in the brand catalogue of the agreement and the stipulated medical insurance payment standard.

(five) clear the scope of personal burden of medical expenses.

Personal burden of medical expenses includes personal expenses and personal expenses.

Personal expenses refer to medical expenses and other expenses that are not included in the payment scope of basic medical insurance and need to be paid by the insured individuals according to regulations.

Personal out-of-pocket payment refers to the medical expenses that are included in the basic medical insurance payment scope and need to be paid by the insured individuals according to the regulations, including the expenses paid in advance by individuals in proportion for Class B medical expenses, the expenses borne by individuals within Qifubiaozhun, and the expenses borne by individuals in proportion after entering the overall fund.

The over-limit expenses within the scope of the basic medical insurance catalogue are included in the personal out-of-pocket expenses, but are not included in the prescribed payment scope of supplementary reimbursement such as civil service subsidies, serious illness insurance and medical assistance.

The annual medical expenses of the basic medical insurance shall be calculated according to the medical expenses incurred, excluding out-of-pocket expenses beyond the payment scope of the basic medical insurance, out-of-pocket expenses of individuals for Class B medical expenses, out-patient emergency accounting expenses and out-of-hospital examination (treatment) expenses.

For the above policies implemented from March 1 2022, the actual effective time of medical expenses settlement is based on the time when our city is included in the provincial "smart medical insurance" system.

Legal basis: Article 55 of People's Republic of China (PRC) Social Insurance Law.

Maternity medical expenses include the following contents:

(1) Maternity medical expenses;

(two) family planning medical expenses;

(3) Other project expenses stipulated by laws and regulations.

Fifty-sixth employees in any of the following circumstances, can enjoy maternity allowance in accordance with state regulations:

(1) Female employees enjoy maternity leave;

(2) Enjoy family planning operation leave;

(3) Other circumstances stipulated by laws and regulations.

Maternity allowance is calculated and paid according to the average monthly salary of employees in the previous year of the employer.