The contents of the new regulations:
1, strengthen the outpatient service * * * economic security function.
(1) Establish and improve the overall guarantee mechanism for general outpatient expenses of employee medical insurance.
Establish and improve the overall guarantee mechanism for the general outpatient expenses of employee medical insurance, and gradually include the general outpatient expenses of frequently-occurring diseases and common diseases into the payment scope of the overall fund on the basis of doing a good job in the medical security work for chronic diseases and special diseases (hereinafter referred to as outpatient chronic diseases and special diseases) with heavy burden on the masses such as hypertension and diabetes.
(2) The payment of benefits can be appropriately tilted towards retirees.
The general outpatient service covers all insured employees in medical insurance as a whole, and the payment ratio within the policy scope starts from 50%. With the strengthening of the affordability of the medical insurance fund, the level of protection is gradually improved, and the payment of benefits can be appropriately tilted towards retirees.
(3) Simultaneously improve the outpatient co-ordination of basic medical insurance for urban and rural residents.
According to the characteristics of outpatient medical service, scientifically calculate the minimum payment standard and maximum payment limit, and make a good connection with the hospitalization expense payment policy. Simultaneously improve the outpatient co-ordination of basic medical insurance for urban and rural residents, and gradually improve the level of protection.
(4) gradually expand the scope of outpatient chronic diseases and special diseases paid by the overall fund.
According to the affordability of the medical insurance fund, the scope of chronic diseases and special diseases paid by the overall fund will be gradually expanded, and the outpatient expenses of some diseases with long treatment cycle, great harm to health and heavy cost burden will be included in the * * * economic security, and some special treatments that are suitable for outpatient service and more economical and convenient than hospitalization can be managed with reference to hospitalization.
(5) Gradually transition from disease protection to cost protection.
Constantly improve the outpatient service economic security mechanism, and gradually transition from disease security to cost security. Will meet the conditions of the designated retail pharmacies to provide drug protection services into the scope of outpatient services, support the settlement and adjustment of external prescriptions in designated retail pharmacies, and give full play to the convenience and accessibility of designated retail pharmacies. Explore the inclusion of qualified "internet plus" medical services in the scope of protection.
2. Improve the personal account counting method.
(1) Methods and levels for scientifically and reasonably determining personal accounts.
Personal accounts of employees are included in the basic medical insurance premiums paid by individuals, and the inclusion standard is controlled in principle at 2% of the base of my insured payment, and all the basic medical insurance premiums paid by the unit are included in the overall fund; In principle, the individual accounts of retirees are allocated by the overall fund according to the quota, and the allocated amount is gradually adjusted to about 2% of the average basic pension level in the year when the reform was implemented in the overall planning area according to this opinion.
(2) Improve the outpatient treatment of the insured.
The specific proportion or standard of individual accounts shall be determined by the provincial medical insurance department in conjunction with the financial department in accordance with the above principles, guiding the overall planning area and combining local actual research.
After adjusting the overall fund and personal account structure, the increased overall fund is mainly used for outpatient economic security and improving the outpatient treatment of insured persons.
3. Standardize the scope of personal accounts.
(1) Personal account is used for individual contributions of spouses, parents and children participating in the basic medical insurance for urban and rural residents.
Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies.
It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies. Explore the personal accounts of spouses, parents and children participating in the basic medical insurance for urban and rural residents.
(2) Improve the management measures for the use of personal accounts and make statistics on revenue and expenditure information.
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. Improve the management measures for the use of personal accounts and do a good job in the statistics of income and expenditure information.
4. Strengthen supervision and management.
(1) Strictly implement the budget management system of medical insurance fund.
Improve the management service measures, innovate the system operation mechanism, guide the rational use of medical resources, ensure the stable operation of medical insurance funds, and give full play to the guarantee function. Strictly implement the budget management system of medical insurance fund, and strengthen the construction of fund audit system and internal control system.
(2) Seriously investigate and deal with "hanging bed" hospitalization, induced hospitalization and other illegal acts.
Establish a dynamic management mechanism for the whole process of personal accounts, and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of medical behavior and medical expenses, and seriously investigate and deal with illegal acts such as "hanging bed" hospitalization and inducing hospitalization.
(3) Guide designated medical institutions to provide standardized diagnosis and treatment services.
Establish a safety prevention and control mechanism for medical insurance funds, severely crack down on insurance fraud, and ensure the safe, efficient and rational use of funds. Innovate the management mode of outpatient medical services, improve the monitoring, analysis and assessment system of medical services, and guide designated medical institutions to standardize the provision of medical services.
(4) standardize the diagnosis, treatment and referral of designated medical institutions at the grass-roots level.