In order to further improve the basic medical security level of rural residents, according to the Regulations on New Rural Cooperative Medical Care in Jiangsu Province, the Measures for the Administration of New Rural Cooperative Medical Care Fund in Jiangsu Province and the Provincial Health Department's Regulations on Standardization and

The Notice on Perfecting the Compensation Scheme of the New Rural Cooperative Medical System requires that the Administrative Measures of Suqian 20 12 New Rural Cooperative Medical System (hereinafter referred to as the "Measures") be formulated in combination with the actual situation of our city.

I. Basic Principles and Work Objectives

(1) Basic principles: individual contributions, social assistance and government support shall be adopted for fund-raising; Fund management in urban areas (including suyu district and Sucheng) and counties as a whole; The use of the fund is based on income and expenditure, with a balance of payments and a slight balance; The operation process is open, fair and just.

(II) Work objective: In 20 12 years, the population coverage rate of the new rural cooperative medical system (hereinafter referred to as the new rural cooperative medical system) will reach over 98%, among which the coverage rate of the recipients will reach100%; Outpatient co-ordination fund accounts for

20% of the total amount of funds raised in that year, and the hospitalization fund accounted for 70% of the total amount of funds raised in that year; The annual balance rate of the fund shall be controlled within 10% (including risk funds), and the cumulative balance rate shall be controlled within 20% (including risk base).

Within gold). The reimbursement rate of hospitalization expenses within the county and township policies reaches about 75%.

Second, the participants

Rural residents (including rural primary and secondary school students) participate in the new rural cooperative medical system in the overall planning area where the household registration is located.

Infants and retired soldiers born between the last payment period and the next payment period of the new rural cooperative medical system can participate in the new rural cooperative medical system in the current year according to the normal participation procedures. If parents apply to participate in the new rural cooperative medical system within fifteen working days from the date of birth, the medical expenses incurred since the date of birth shall be included in the compensation scope of the new rural cooperative medical system fund.

Three. Funding standard

The financing level of the new rural cooperative medical system is about 300 yuan per person per year. Counties (districts) in the fight for the provincial finance to give subsidies to the contestants, on the basis of the county (district) finance according to the contestants per person per year not less than 240 yuan to give subsidies. Rural minimum living security objects, five-guarantee objects, key entitled groups and other medical assistance objects are all included in the new rural cooperative medical system by the people's governments in the overall planning area, and their individual contributions are fully funded by the medical assistance fund.

Fourth, medical treatment and referral.

(a) all the first-level and above medical institutions in the city, abide by the regulations on the management of the new rural cooperative medical system, and sign a service agreement with the joint management office with the approval of the health administrative department, which can be used as the designated medical institutions of the new rural cooperative medical system. Develop rural areas

Village clinics under the integrated management of health institutions can carry out outpatient compensation for the new rural cooperative medical system. Urban insured persons can choose their own doctors in all designated medical institutions in urban areas; County contestants can see a doctor at all designated doctors in the county.

Medical institutions choose their own doctors and need referrals outside the county. County-level hospitals put forward opinions on the referral application. After the county joint management office has passed the examination, Nanjing Gulou Hospital Group Suqian People's Hospital and Shanghai Oriental Hospital Suqian Branch (specialist) are given priority.

Refers to cardiovascular and orthopedic diseases), municipal infectious disease hospital referral.

Urban insured persons who need to be referred to outside the city for treatment shall obtain a written certificate from Suqian People's Hospital of Nanjing Gulou Hospital Group, Suqian Branch of Shanghai Oriental Hospital (especially cardiovascular and orthopedic diseases) and the Municipal Infectious Disease Hospital, and can be referred only after being approved by the Municipal Joint Management Office.

(2) Critical, acute and severe patients can be referred first, and the procedures will be completed within 15 working days; The referral procedure is valid once and needs to be referred again.

The scope and standard of verb (verb's abbreviation) compensation

(A) the new rural cooperative medical expenses compensation is divided into fixed compensation and piecewise proportional compensation.

(two) in the first-class and above medical institutions, the scope of drug use is based on the Catalogue of Essential Drugs of New Rural Cooperative Medical System in Jiangsu Province (revised in 2009); The scope of drug use in village clinics shall be subject to the national list of essential drugs.

(3) outpatient compensation standard. Township (town) designated medical institutions outpatient medicine fee according to the proportion of 40% compensation, approved by the administrative department of health village clinics outpatient medicine fee according to the proportion of 45% compensation. village

(town) Prescription drug expense limit of designated medical institutions per person per day 100 yuan; The outpatient prescription drug fee limit of village clinic is 30 yuan per person per day, and the maximum compensation amount is 60 yuan per person per year. After the implementation of the basic drug system in village clinics,

According to the regulations, patients are charged the general medical treatment fee of 6 yuan, of which the patient pays 1 yuan, and the rest of 5 yuan is paid from the new rural cooperative fund, which is not included in the cumulative maximum compensation per person per year. General medical expenses are used for the participating population and the village.

The total amount of services is controlled.

The outpatient medical expenses of other medical institutions inside and outside the city will not be compensated.

(4) hospitalization compensation standard.

First-class hospitals can report medical expenses for compensation in two stages, with the compensation ratio below 400 yuan being 40% and above 400 yuan being 85%;

Secondary hospitals can report two levels of compensation for medical expenses, the proportion of compensation below 400 yuan is 40%, and above 400 yuan is 70%;

The deductible line of tertiary hospitals in the city is 400 yuan, and the medical expenses can be compensated in two phases. The compensation ratio of 40 1-20000 yuan is 50%, and the compensation ratio of more than 20000 yuan is 60%.

In 600 yuan, the deductible line of hospitals outside the city, medical expenses can be compensated in two stages. The compensation ratio of 60 1-20000 yuan is 45%, and the compensation ratio of more than 20000 yuan is 55%.

If the insured is hospitalized for more than two times within one year, only one deductible line will be set.

Guarantee and compensation for hospitalization medical expenses. The minimum compensation rate for patients with malignant tumor is 40%, and that for other diseases is 35%. For the participants who go through the referral procedures and go abroad for medical treatment, guaranteed compensation will be taken. 90% of the normal referral compensation standard shall be implemented for the participants who have not fulfilled the referral procedures.

(five) outpatient special disease compensation standard. The outpatient medical expenses such as radiotherapy and chemotherapy for malignant tumor, dialysis treatment for end-stage renal disease, anti-rejection treatment for organ transplantation, aplastic anemia and hemophilia are 75%.

Compensation, the maximum amount per person per year is 40 thousand yuan; The outpatient medical and treatment expenses of chronic hepatitis B complicated with cirrhosis, nephrotic syndrome, systemic lupus erythematosus, Parkinson's disease, etc. shall be compensated according to the proportion of 75%, per person per year.

The maximum amount is 20,000 yuan. The expenses for outpatient special diseases of participating personnel shall be compensated according to the patient's medical records and actual expenses issued by medical institutions at or above the second level.

The outpatient treatment expenses for insulin-dependent diabetes, stage III hypertension, apoplexy sequelae, severe psychosis and other diseases shall be compensated according to the proportion of 75%, and the annual compensation limit for each person is 2,000 yuan. Outpatient special disease expenses are compensated according to the patient's medical records and actual expenses issued by medical institutions at or above the first level.

In the outpatient treatment of the above-mentioned special outpatient diseases in medical institutions at the corresponding level outside the city, compensation shall be given according to 90% of the above compensation standards.

(six) medical institutions to implement price management of maternal hospital delivery costs. Namely: 800 yuan, the first-level hospital for normal delivery, 900 yuan, the first-level hospital for vaginal surgery and midwifery 1.25 yuan, and the second-level hospital 1.500 yuan; The first-level hospital for cesarean section is 2000 yuan and the second-level hospital is 2450 yuan. The part exceeding the price limit shall be borne by the designated medical institutions.

In accordance with the family planning policy of rural pregnant women in hospital delivery, in accordance with the new rural cooperative medical system in hospital compensation standard subsection compensation, less than 400 yuan according to 400 yuan calculation. The total compensation fee for the new rural cooperative medical system and the financial subsidy fee for hospital delivery shall not exceed the actual expenditure. Prenatal screening compensates 40 yuan for each case.

(7) Compensation standard for infectious diseases. Centralized treatment of infectious diseases, encouraging hospitalization. Infectious patients in urban areas were admitted by the Municipal Center for Infectious Disease Prevention and Control, and infectious patients in Shuyang, Siyang and Sihong counties were admitted by county hospitals.

Medical institutions designated by the administrative department of public health 1-2 are centralized for treatment, and the reimbursement expenses for outpatient service are compensated according to the proportion of 50%, and the reimbursement expenses for hospitalization are compensated according to the proportion of 80%. Infectious diseases in other medical institutions

Hospital expenses are not compensated.

(eight) to encourage the use of traditional Chinese medicine treatment. The use of traditional Chinese medicine treatment, outpatient and hospitalization expenses according to the "measures" compensation standards, the use of traditional Chinese medicine for patients with 30% compensation. Traction, acupuncture and other treatment items are compensated.

(9) The Provincial Department of Human Resources and Social Security, the Provincial Civil Affairs Department and other five departments issued the Notice of Jiangsu Province on the Implementation Measures for Including Some Rehabilitation Projects in the Scope of Basic Medical Security (Su Ren She Fa [2065438+00] No.479), which included some medical rehabilitation projects, rescue rehabilitation and assistive devices for disabled children aged 0-6 years into the scope of hospitalization compensation.

(ten) the full implementation of the reform of payment methods such as payment by disease, and the number of paid diseases in secondary and above medical institutions should reach more than 20.

We will comprehensively promote the protection of eight major diseases, including childhood leukemia, congenital heart disease, end-stage renal disease, women's breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis and opportunistic infection of AIDS, and continuously improve the level of protection. 12 diseases such as hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer and rectal cancer will be included in the pilot scope of major disease security for rural residents.

(eleven) trauma patients according to the compensation standard of 70% compensation.

(twelve) compensation cap line. The cumulative compensation limit for the expenses of the new rural cooperative medical system is 6.5438+0.4 million yuan per person per year, including hospitalization expenses of 6.5438+0.4 million yuan and outpatient expenses of 40,000 yuan.

(13) compensation time. In principle, the compensation for the new rural cooperative medical system is completed within a natural year, and the inter-annual compensation for special circumstances does not exceed 6 months.

VI. No scope of compensation

The following expenses do not belong to the compensation scope of the new rural cooperative medical fund:

(1) The expenses incurred by participants in using drugs outside the catalogue shall not be compensated. Designated medical institutions should control the proportion of drug expenses outside the catalogue used by participants. Village clinics must all use drugs in the catalogue.

Products, the off-list expenses of drugs used by first-level medical institutions shall not exceed 5%, the off-list expenses of drugs used by second-level medical institutions shall not exceed 10%, and the off-list expenses of drugs used by third-level medical institutions shall not exceed 15%. Designated medical machine

The construction and use of drugs outside the catalogue must be informed in advance and signed by the participants or immediate family members.

(two) according to the provisions should be paid by the industrial injury or maternity insurance fund; Fees payable for medical insurance for urban workers and residents; Expenses borne by a third party; Expenses borne by the public health department; Overseas medical expenses.

(3) Non-basic medical expenses (mainly referring to senior wards, special wards, special care, family beds, etc.) are in medical institutions at all levels.

(four) without the approval of the price and health departments of medical institutions, medical services, inspection and treatment projects, without authorization to raise the fees.

(five) fighting, alcoholism, drug abuse, sexually transmitted diseases, traffic accidents, intentional self-injury, unproductive pesticide poisoning, medical accidents (disputes), family planning expenses.

(6) Registration fee, medical record fee, visiting fee, registration fee, Chinese medicine decoction fee, medical travel fee, ambulance fee, escort bed fee, bed-wrapping fee, consultation fee, food (nutrition) fee, daily necessities fee, certificate fee, health care file bag fee, stretcher fee, air conditioning (including heating) fee, TV fee, telephone fee and personal cooking fee.

(seven) all kinds of weight loss, bodybuilding and treatment of freckles, pigmentation, gray hair and medical beauty expenses; Rhinoplasty, breast augmentation, double eyelid surgery, nevus removal, ear piercing, verruca plana, tooth inlay, tooth washing, dentition correction and treatment.

Dyed teeth, glasses, myopia treatment, and the cost of assembling artificial eyes, wigs and artificial limbs; Expenses for using traction equipment, crutches, leather steel carapace, waistline, deformed insole, medicated pad, medicated pillow and cold and hot compress bag; Massage, magnetic therapy,

The cost of hyperthermia (except for tumor patients).

(eight) all kinds of medical consultation, medical appraisal and health prediction fees, commercial medical insurance fees, physical therapy fees, male and female infertility, sexual dysfunction examination and treatment fees.

(nine) the nominal hospitalization or hospitalization expenses that obviously do not meet the hospitalization conditions; I live in a super-standard ward, which exceeds the cost of ordinary beds.

(ten) the cost of transplanting various organs or tissues, installing artificial organs and placing materials in the body during the treatment.

(eleven) other circumstances in which no compensation is provided by the state or province.

Seven. indemnifying measure

(a) participants in the city designated medical institutions outpatient treatment need to provide the new rural cooperative medical certificate (card), hospitalization need to provide the new rural cooperative medical certificate (card), the original and photocopy of the ID card, outpatient medicine fees, hospitalization fees reported on the spot.

(II) The hospitalization expenses incurred by the participants outside the city, and the materials of the participants in Shuyang County, Siyang County and Sihong County shall be reviewed by the county joint management office and the compensation procedures shall be handled; The materials of urban participants shall be reviewed by the municipal joint management office and the compensation procedures shall be handled.

1. Participants should provide the following information when applying for compensation: new rural cooperative medical certificate (card); Original and photocopy of ID card; City and county joint management office agreed to referral approval form; Valid bills issued by the hospital (original), computer-printed hospitalization expense settlement list, and discharge summary.

2. Participants who go out to work or live outside the city for a long time should provide the following information when applying for compensation for going abroad for medical treatment: the new rural cooperative medical certificate (card); Original and photocopy of ID card; Proof of the village (neighborhood) committee or work unit with long-term residence; Valid bills issued by the hospital (original), computer-printed hospitalization expense settlement list, and discharge summary.

(three) Shuyang County, Siyang County, Sihong County township (town) joint management office in the township (town) health centers and village clinics monthly publicity of medical expenses compensation. Designated medical institutions in urban areas are responsible for publicizing the hospitalization compensation of urban insured persons on a monthly basis.

Eight. Fund raising, management and supervision

(a) Shuyang County, Siyang County, Sihong County urban new rural cooperative fund into the financial new rural cooperative fund account management, earmarking, balance into the next year to continue to use.

(two) the township (town) people's government is responsible for raising the fees paid by individual farmers, the county (District) finance and health departments are responsible for striving for provincial funds, and the county (District) finance department is responsible for implementing financial matching funds. County finance

The department is responsible for the new rural cooperative medical fund into the county-level new rural cooperative medical account, and the financial departments of suyu district, Sucheng District and Yanghe New Town are responsible for the new rural cooperative medical fund into the new rural cooperative medical account. The audit department is responsible for regularly auditing the management and use of the new rural cooperative medical fund.

Conduct a special audit.

(III) The handling institution shall, in accordance with the provisions of the state, withdraw risk funds from the New Rural Cooperative Fund to make up for the temporary difficulties in capital turnover caused by the abnormal overspending of the New Rural Cooperative Fund, and the accumulated withdrawal of risk funds shall not exceed 65,438+00% of the total amount raised in the current year.

(4) In the process of fund-raising, it is strictly forbidden to collect fees for hitchhiking, change the fund-raising standard without authorization, advance funds for those who have not participated, and avoid discrepancies between accounts and facts, and it is strictly forbidden to intercept, occupy or misappropriate funds.

(5) Designated medical institutions shall pay the service performance bond to the local city and county joint management office, and the city and county joint management office shall deduct the deposit for the violation of the designated medical institutions according to the service agreement, and the deducted deposit shall be used for the normal operation funds of the city and county joint management office.

(VI) Designated medical institutions and their staff shall provide medical services in accordance with the requirements of the agreement, abide by laws and regulations, abide by professional ethics, implement clinical technical operation norms, carry out business training, improve service quality and efficiency, and ensure reasonable examination and treatment, rational drug use and control of medical expenses.

(seven) designated medical institutions to cheat the new rural cooperative medical fund fees by means of forged documents, etc., shall be ordered by the administrative department of health to return the defrauded fund fees, and impose a fine of more than two times and less than five times the amount defrauded.

Paragraph, the agency shall terminate the new rural cooperative medical service agreement with it; If the directly responsible person in charge and other directly responsible personnel have obtained the qualification for practice, the administrative department of health shall revoke their practice certificates according to law.

(eight) by forging proof materials, using other people's new rural cooperative medical certificate and other means to defraud the new rural cooperative medical fund fees, the administrative department of health shall order it to refund the compensation fees defrauded, and impose a fine of more than two times and less than five times the amount defrauded. If the case constitutes a crime, it shall be handed over to judicial organs for handling.

Nine. supplementary terms

(1) These Measures shall be implemented as of the date of issuance. "Suqian 20 10 new rural cooperative medical care management measures" shall be abolished at the same time. Where the relevant provisions of the new rural cooperative medical system are inconsistent with these measures, these measures shall prevail.

(two) the "measures" by the Municipal Health Bureau is responsible for the interpretation of.

Keywords: Notice of the Measures for the Administration of Health and Rural Cooperative Medical Care

Cc: Office of the ministries and commissions of the Municipal Party Committee, Office of the Standing Committee of the Municipal People's Congress and CPPCC Office.

Suqian military sub-district municipal court and municipal procuratorate.

Suqian Municipal People's Government Office issued on July 20 12 19.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.