"Chengdu to establish and improve the basic medical insurance outpatient * * * economic security mechanism implementation rules" has been approved by the municipal government, is issued to you, please seriously implement the actual.
First, actively and steadily advance.
It is necessary to fully understand the importance of establishing and improving the economic security mechanism for employees' basic medical insurance outpatient service, make overall arrangements, improve relevant supporting measures, and ensure the timely implementation of policies and the smooth transition of the treatment of insured personnel.
Second, strengthen work coordination.
The establishment of medical insurance, finance, health, market supervision and other departments to coordinate the supervision and service mechanism, severely investigate and deal with the illegal acts of designated medical institutions, insured persons and medical insurance agencies, strengthen the supervision and assessment of medical institutions, and promote the standardized diagnosis and treatment behavior of designated medical institutions. Establish a data exchange mechanism between human resources, social security and medical insurance departments, and enjoy relevant data such as the average level of basic pension for retirees in Chengdu in time. Do a good job in the convergence of outpatient expenses and hospitalization expenses payment policies, and steadily improve the level of outpatient security treatment. Strengthen the supervision of drug circulation and use, and severely crack down on illegal activities such as drug reselling.
Third, pay attention to publicity and guidance
Innovate propaganda methods, enrich propaganda means, widely publicize and accurately interpret policies. Grasp the correct direction of public opinion, reasonably guide expectations, fully publicize the important role of establishing and improving the economic security mechanism of basic medical insurance outpatient service for employees in reducing the burden of medical expenses of insured personnel and promoting a fairer and more sustainable system, and vigorously publicize the significance of * * * building * * medical insurance to help each other. Establish public opinion monitoring and disposal mechanism, actively respond to social concerns, and create a good public opinion atmosphere.
General Office of Chengdu Municipal People's Government
65438+1October 1 1, 2022
Chengdu has established and improved the basic medical insurance for employees.
Detailed rules for the implementation of outpatient economic security mechanism
Chapter I General Provisions
Article 1 In order to further improve the system of mutual assistance and sharing of employees' basic medical insurance (hereinafter referred to as employee medical insurance), better solve the problem of outpatient treatment guarantee for Chengdu medical insurance insured employees (hereinafter referred to as insured personnel), and effectively reduce their medical expenses burden, According to the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance (Guo Ban Fa [202 1] 14) and the Notice of the General Office of Sichuan Provincial People's Government on Printing and Distributing the Implementation Measures for Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance in Sichuan Province (Chuan Ban Fa [202 1]85438).
Article 2 According to the principle of doing one's best and according to one's ability, everyone should do his duty and enjoy it, improve the system and guide expectations, speed up the reform of key areas and key links of medical insurance, include outpatient expenses in the payment scope of employee medical insurance pooling fund, reform individual accounts of employee medical insurance, establish and improve the outpatient medical insurance mechanism, improve the use efficiency of medical insurance fund, gradually reduce the burden of medical expenses of insured personnel, and realize a fairer and more sustainable system.
Article 3 These Detailed Rules are applicable to the insured persons (including retirees and flexible employees) who participate in the medical insurance for employees in Chengdu.
Chapter II Perfecting Personal Account Management
Fourth, improve the personal account of employee medical insurance, and all the basic medical insurance premiums paid by the unit will be included in the overall fund.
On-the-job employees (including flexible employees, the same below) who participate in the insurance payment in the overall account, the basic medical insurance premiums paid by individuals are included in the personal account, and the inclusion standard is 2% of the base of my insurance payment.
The individual accounts of retirees who are insured by the overall account are allocated by the overall fund according to the quota, and the amount allocated is 2.8% of the average level of basic pension in Chengdu in 2022, which is included in the individual accounts on a monthly basis. Before the average level of basic pension in Chengdu is determined in 2022, it will be implemented according to the average level of basic pension in Chengdu in 20021year, and the difference will be made up after the average level of basic pension in Chengdu in 2022 is determined.
Personnel who participate in the insurance in the form of single construction and overall planning do not establish personal accounts.
Article 5 Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions and designated retail pharmacies.
Personal accounts can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies, and the personal contributions of social insurance related to medical security such as basic medical insurance, supplementary medical insurance and long-term care insurance for urban and rural residents carried out by the government.
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. Strengthen the use and management of personal accounts, and incorporate the income and expenditure information of personal accounts into the monitoring and management of the medical security information management system.
Article 6 Individual account funds (including the balance of individual accounts over the years before the reform) can be carried forward in accordance with the provisions and inherited according to law. When the insured workers transfer the medical insurance relationship across the overall planning area, the personal account funds will be transferred accordingly. Except for special reasons such as the death of the insured, going abroad to settle down, etc., personal account funds shall not be withdrawn in principle.
Chapter III Strengthening the Economic Security of Outpatients
Article 7 After adjusting the structure of the employee medical insurance pooling fund and individual account, the increased pooling fund is mainly used to enhance the outpatient economic security and improve the outpatient security level of the insured. The general outpatient expenses and drug purchase expenses of the insured within the policy scope of designated medical institutions and qualified designated retail pharmacies shall be included in the payment scope of the employee medical insurance pooling fund according to regulations. Constantly improve the outpatient economic security mechanism, and gradually realize the transformation from disease security to cost security.
Article 8 The economic security of outpatient service mainly includes the overall expenses of general outpatient service, the drug security of outpatient service for "two diseases" (hypertension and diabetes) and the security of outpatient service for special diseases.
Ninth insured persons in accordance with the provisions of the outpatient economic security benefits, shall not be repeated.
Tenth outpatient * * * economic security fund payment scope and standards should strictly implement the basic medical insurance payment scope and standards.
Eleventh to participate in the medical insurance for employees in our city and enjoy the benefits, and enjoy the general outpatient expenses as a whole according to the regulations.
Article 12 The general outpatient expenses of medical insurance for employees shall be guaranteed as a whole, and the deductible line and annual payment limit shall be set according to the natural year and accumulated in a natural year. The deductible line for employees and retirees is 150 yuan; The payment ratio is 50% for the third-level designated medical institutions and qualified designated retail pharmacies, and 60% for the second-level and below designated medical institutions, and the retirees will increase by 10 percentage point on the basis of the above corresponding payment ratio; The annual payment limit for employees who participate in the insurance payment by unified account is 2000 yuan, and the annual payment limit for retirees is 2500 yuan; The annual payment limit for single-building co-ordinate insured employees is 880 yuan, and the annual payment limit for retirees is 1 100 yuan.
Thirteenth people who participate in the insurance in the form of single construction and overall planning may apply for changing to the mode of unified account, and may not change it again after changing the mode of participation.
If an employee who is insured in the form of single-building co-ordination applies for changing the mode of insurance, he/she will pay the fee according to the co-ordination account and establish a personal account from the second month after the change, and enjoy the corresponding medical insurance benefits according to the regulations.
Insured persons who have reached the statutory retirement age but do not meet the conditions of enjoying the retirement medical insurance benefits of combining unified account with single account may voluntarily make up the payment difference between unified account and single account in one lump sum in accordance with the relevant provisions of the current basic medical insurance for urban workers in Chengdu, and enjoy the corresponding medical insurance benefits from the next month after one lump sum; If it is not made up, it will enjoy the treatment according to the single construction plan, until the difference is made up according to the regulations.
After the implementation of these rules, the new personnel will no longer be insured in the form of individual construction and overall planning.
Fourteenth to participate in employee medical insurance "two diseases" outpatient identification standards, medication scope, drug security level and management services are consistent with urban and rural residents.
Patients with "two diseases" meet the standards of outpatient special diseases, and are included in the scope of outpatient special disease management, and the outpatient special disease policy is implemented.
Article 15 The Municipal Medical Insurance Bureau can dynamically adjust the treatment level of outpatient special diseases according to the affordability of the medical insurance fund, gradually expand the scope of outpatient special diseases paid by the overall fund, and include the outpatient expenses of some diseases with long treatment cycle, great harm to health and heavy cost burden into the scope of outpatient special diseases protection; Some special treatments suitable for outpatient service and more economical and convenient than hospitalization can be managed with reference to hospitalization.
Article 16 The insured persons who participate in Medicaid for civil servants shall be included in the scope of payment of Medicaid for civil servants, and the general outpatient expenses and medical expenses within the scope of drug guarantee policy for "two diseases" outpatients in designated medical institutions shall be implemented according to the reimbursement policy for civil servants' medical expenses.
Seventeenth workers' medical insurance outpatient * * * economic security benefits are limited to the insured himself, and the annual payment limit is not carried forward.
Eighteenth insured persons from on-the-job to retirement, from the month when they enjoy the retirement benefits of medical insurance, their personal account has changed.
Chapter IV Service and Settlement Management
Article 19 Relying on the unified medical security information platform of the whole province, we will continue to promote direct settlement management services for medical treatment in different places, such as general outpatient service, "two diseases" outpatient service and outpatient special diseases, and effectively protect the rights and interests of insured persons in different places.
Article 20 Expand the overall service scope of general outpatient clinics, and include the drug guarantee services provided by designated retail pharmacies that are qualified and compliant, standardized in management, good in reputation, reasonable in layout, connected with the medical insurance system, support electronic medical records and electronic prescriptions, and meet the electronic traceability conditions of sold drugs.
Support the settlement and adjustment of external prescriptions in qualified designated retail pharmacies. When the demand for outpatient drugs in designated medical institutions cannot be met, the insured can dispense drugs in qualified designated retail pharmacies and enjoy corresponding treatment according to the proportion of payment in designated retail pharmacies. Explore the inclusion of qualified "internet plus" medical services in the scope of protection.
Article 21 When the insured purchases medicines at designated medical institutions with direct settlement conditions, they shall be directly settled by social security card or medical insurance electronic certificate, and the medical expenses borne by the individual shall be paid by the insured, and the medical expenses paid by the medical insurance fund shall be settled regularly by the medical insurance agency and the designated medical institutions; Due to special circumstances, designated medical institutions can not directly settle accounts, designated medical institutions shall inform the insured of the reasons, disposal methods and supplementary settlement procedures. Outpatient medical expenses incurred by non-designated medical institutions (except emergency and rescue) shall not be paid by the medical insurance fund.
Chapter V Supervision and Administration
Article 22 Establish and improve the supervision and management mechanism that is compatible with the economic security mechanism of employees' basic medical insurance outpatient service, improve the management service measures, innovate the system operation mechanism, guide the insured to rationally use medical resources, ensure the smooth operation of the medical insurance fund, and give full play to the security function. Strictly implement the budget management system of medical insurance fund, and strengthen the construction of fund audit system and internal control system.
(1) Establish and improve the safety prevention and control mechanism of medical insurance funds, strictly implement the Regulations on the Supervision and Management of the Use of Medical Insurance Funds (Order No.735 of the State Council), comprehensively strengthen the supervision and management of the purchase, sale and storage of medical services, drugs and medical consumables in designated medical institutions, and realize the full-field, whole-process and all-round supervision of medical insurance funds.
(2) Strengthen the intelligent monitoring of outpatient medical expenses and medical insurance big data, and severely crack down on illegal activities such as excessive diagnosis and treatment, irrational drug use, and personal account cashing. Designated retail pharmacies that are included in the scope of outpatient economic security services should regularly submit prescription circulation, drug purchase and sale ledger and financial accounting accounts to medical insurance agencies to realize the transformation of medical insurance fund supervision to "managing services, technology and price" and ensure the safe, efficient and rational use of medical insurance funds.
Twenty-third establish a dynamic management mechanism for the whole process of personal accounts, further improve the personal account management methods, strictly implement the budget management of medical insurance funds, and strengthen the audit of the use, settlement and payment of personal accounts. Realize the dynamic management of personal accounts in the whole process and ensure the smooth operation of medical insurance funds. Establish and improve the internal control system of medical insurance fund management, improve the mutual restraint mechanism between handling and auditing, accounting and cashier, business and finance, and prevent and resolve internal regulatory risks.
Twenty-fourth to promote the construction of primary medical service system, improve the graded diagnosis and treatment and family doctor contract service, standardize the long-term prescription management, and guide the insured to the primary medical treatment. Combined with the improvement of outpatient chronic diseases and special diseases management measures, standardize the diagnosis, treatment and referral of primary medical institutions.
Strengthen the agreement management of designated medical institutions. Improve the service agreement of designated medical institutions, and timely bring the economic security of general outpatient service of employee medical insurance into the scope of agreement management. Implement the consultation and negotiation mechanism and strictly evaluate the designated medical institutions according to the principle of "good technology, excellent service, low price and reasonable layout"; According to the principle of step-by-step classification and dynamic adjustment, improve the management mechanism of designated medical institutions. The requirements of giving priority to the use of drugs in the medical insurance catalogue (diagnosis and treatment items), controlling the proportion of self-expense, prohibiting inducing drugs to purchase outside the hospital, not issuing "big prescriptions" in violation of regulations, and the drug price of designated retail pharmacies not higher than the online price of similar products in Sichuan Province's centralized procurement of medical devices and medical price supervision platform, and meeting the standards for outpatient information construction were included in the agreement management, and the terms and indicators of the agreement were strengthened.
Improve the monitoring, early warning, reminding, analysis and assessment mechanism of medical service behavior, regularly monitor the growth of medical expenses, the average cost, the use of off-catalogue items and other indicators, and guide designated medical institutions to standardize the provision of medical treatment and drug security services.
Incorporate the use of medical insurance funds by designated medical institutions into medical insurance credit management, strengthen the daily management and regular assessment of designated medical institutions, link the assessment results with medical insurance expense settlement and agreement renewal, encourage designated medical institutions to strengthen self-management, standardize diagnosis and treatment behavior, and give play to the regulatory incentive and restraint role of medical insurance funds.
Twenty-fifth improve the payment mechanism to adapt to outpatient economic security, and strengthen the data collection, analysis and application of outpatient medical expenses. Primary medical services are paid per head, and the combination of payment per head and chronic disease management is actively explored; Day surgery and eligible outpatient special diseases are paid according to the disease type. We can explore the reform of outpatient co-ordination payment mode in combination with the actual work of paying by group and paying by disease points related to disease diagnosis. For outpatient expenses that are not suitable for package payment, they can be paid by project. Scientifically and reasonably determine the payment standard of medical insurance drugs, and guide medical institutions and patients to take the initiative to use drugs with definite curative effect and reasonable price.
Chapter VI Supplementary Provisions
Twenty-sixth Municipal Medical Insurance Bureau and Municipal Finance Bureau may, according to the superior deployment, the payment ability of medical insurance fund and the development of medical technology, timely adjust the policies related to outpatient economic security and personal accounts.
Twenty-seventh the detailed rules for the implementation by the medical insurance bureau city is responsible for the specific interpretation.
Article 28 These Measures shall come into force on June 65438+1 October1day, 2023, and shall be valid until June 65438+1October 3/day, 2027. Where the previous provisions are inconsistent with these Rules, these Rules shall prevail.