The detailed rules for the implementation of the economic security mechanism of the basic medical insurance for urban workers in Benxi City
Chapter I General Provisions
Article 1 These Detailed Rules are formulated in accordance with the relevant provisions of "Implementation Opinions on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Our City" (No.202139 of Liao Zhengban) and "Notice on Printing and Distributing the Implementation Plan for Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Benxi City" (No.202219 of this Municipality) and in combination with the actual situation of this Municipality.
Article 2 Since June 5438+065438+ 10/day, 2022, the outpatient co-ordination system of the basic medical insurance for urban workers in Benxi City (hereinafter referred to as "employee medical insurance") has been established, and the general outpatient expenses have been included in the payment scope of the co-ordination fund, and the transfer mode of individual accounts has been reformed, the use scope of individual accounts has been adjusted, so as to improve the efficiency of fund use and gradually reduce the insured.
Article 3 All departments should take the establishment and improvement of the economic security mechanism for workers' medical insurance clinics as an important livelihood work, strengthen overall coordination and ensure that it is put in place.
The municipal medical security department is responsible for the organization, management, guidance and supervision of the city's overall outpatient service. The medical security departments of counties (districts) shall be responsible for the supervision and management of the outpatient co-ordination fund within their respective administrative areas, and make relevant publicity. Medical security institutions at all levels are responsible for outpatient medical service management, medical payment and fund settlement.
The municipal finance department shall be responsible for the supervision and use of the medical insurance fund within the scope of its duties, and cooperate with the medical insurance department to timely settle the expenses of designated medical institutions.
The municipal human resources and social security department is responsible for providing relevant data such as the average level of basic old-age insurance for retirees in our city in a timely manner.
Health departments at all levels are responsible for urging medical institutions to timely purchase drugs for the treatment of common diseases and frequently-occurring diseases, strengthening supervision and assessment of medical institutions, promoting designated medical institutions to standardize diagnosis and treatment behaviors, improving the level of medical technology, and providing quality medical services for the insured.
Market supervision and management departments at all levels are responsible for strengthening the supervision of drug production and circulation and cracking down on illegal activities such as drug reselling.
Chapter II Outpatient Overall Planning System
Article 4 On the basis of ensuring the medical expenses of outpatient special diseases with heavy burden on the masses, the outpatient co-ordination system of medical insurance for employees shall be established, and the general outpatient expenses of common diseases and frequently-occurring diseases in designated medical institutions and the emergency rescue observation expenses in the city shall be included in the payment scope of the co-ordination fund. Medical expenses incurred by long-term residents' outpatient clinics with special chronic diseases, high-value drugs and emergency rescue observation outside the city and in different places are not included in the overall scope of employee medical insurance outpatient clinics, and shall be implemented according to the original policy.
Article 5 These Detailed Rules shall apply to all employees' medical insurance participants in our city.
Article 6 The outpatient co-ordination fund shall be accounted for separately, and can be used as a whole with special diseases of hospitalization and outpatient service. The payment policy of general outpatient co-ordination treatment can be adjusted appropriately according to the operation situation. The insured person does not need to pay separately.
Seventh outpatient medical expenses are not included in the insured basic medical insurance cap line, large insurance will not be paid. The part of the compliant medical expenses paid by individuals below the overall qifubiaozhun and within the limit shall be included in the scope of reimbursement of national civil servants' Medicaid, and the reimbursement ratio shall be 50%.
Eighth in a natural year, outpatient qifubiaozhun for 300 yuan per person per year, the maximum payment limit of 3000 yuan per person per year. Compliance outpatient expenses above Qifubiaozhun and below the maximum payment limit shall be paid by the overall fund, and the overall proportion of outpatient services in tertiary comprehensive designated hospitals shall be 50% for employees and 55% for retirees respectively; The payment ratio of three-level Chinese medicine and two-level and below designated hospitals is 60%; The outpatient service of designated medical institutions at the grass-roots level and designated medical institutions specializing in mental illness and infectious diseases that implement basic drug management is 70%.
Ninth long-term residents in different places in the residence of the designated medical institutions online settlement outpatient medical expenses payment policy, with reference to the above-mentioned city outpatient treatment standards. Among them, the proportion of overall fund payment is implemented according to the level of designated medical institutions, and there is no distinction between Chinese medicine and specialties. Because of system maintenance, epidemic control and other reasons, it can not be settled immediately for a long time. The insured person can advance the medical expenses in full first, and then he or his entrusted agent will report the manual reimbursement procedures to the city and county medical insurance agencies according to the date of occurrence of outpatient medical expenses and the relevant provisions of outpatient co-ordination.
Tenth temporary medical personnel (including remote referral medical personnel, remote emergency rescue personnel and temporary medical personnel) in different places for medical treatment in the general outpatient expenses are not included in the scope of outpatient co-ordination payment.
Eleventh outpatient treatment payment scope unified in accordance with the national and provincial basic medical insurance drugs, diagnosis and treatment projects, medical service facilities and medical consumables and other project scope, payment standards and management measures.
Twelfth designated hospitals at all levels (including unclassified hospitals) and designated medical institutions at the grass-roots level that implement the management of basic drugs can undertake outpatient co-ordination business and be included in the service agreement management of designated medical institutions in Benxi City.
Thirteenth insured persons can choose the designated medical institutions for outpatient co-ordination and enjoy the treatment of outpatient co-ordination in real time. Outpatient expenses in non-outpatient medical institutions will not be reimbursed.
Fourteenth insured persons with social security card, ID card or medical insurance electronic certificate in designated medical institutions outpatient medical treatment, designated medical institutions doctors must check the patient and related documents, check the correct rear can give diagnosis and treatment. One-time prescription of chronic diseases should be controlled within 4 weeks, and it can be appropriately extended due to special circumstances such as epidemic prevention and control, and the longest time should not exceed 12 weeks.
Fifteenth insured medical expenses in accordance with the provisions, paid by the outpatient fund in accordance with the provisions. The medical expenses paid by the overall fund shall be settled by the medical insurance agency and the designated medical institutions in accordance with the relevant provisions of the Measures for the Administration of Medical Settlement of Benxi Basic Medical Insurance, and the specific settlement management shall be implemented in accordance with the provisions of the medical insurance service agreement.
Chapter III Personal Account Management
Sixteenth reform unified accounts and personal accounts of insured persons included in the way. From June 5438+1 October1in 2023, employees' personal accounts will be credited according to 2% of their insurance payment base, and retirees' personal accounts will be credited according to the quota, and the amount credited will be 2% of the average basic pension of retirees in 2022 (when the city was reformed), that is, 60 yuan per person per month.
Seventeenth regulate the use of personal accounts. Personal account funds (including the accumulated balance of the original personal account before the reform) are mainly used to pay the out-of-pocket expenses of the insured within the policy scope of designated medical institutions. 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 within the designated retail pharmacies. Gradually realize the spouse, parents, children to participate in the basic medical insurance for urban and rural residents, long-term care insurance, large medical subsidies for employees, health business insurance personal accounts to the municipal medical security administrative department for the record. Personal accounts shall not be used for public health expenses (except those permitted by national policies), 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.
Article 18 Medical expenses paid by individual account funds, employee medical insurance pooling funds, employee large-sum Medicaid insurance, civil servant Medicaid, medical assistance and other medical insurance funds shall not be reimbursed repeatedly.
Chapter IV Strengthening Fund Management
Article 19 The medical security department should reasonably adjust the budget of the medical insurance fund, do a good job in the collection and management of the outpatient co-ordination fund, strengthen the intelligent monitoring of medical insurance, strengthen daily supervision, and crack down on outpatient fraud and insurance fraud in conjunction with the financial and health departments to ensure the safe operation and rational use of the outpatient co-ordination fund. Medical insurance agencies should strengthen the audit work, in violation of the provisions of the outpatient co-ordination caused by unreasonable outpatient co-ordination costs, according to the relevant provisions of the medical insurance service agreement.
Article 20 All designated medical institutions shall meet the requirements in terms of service places, staffing, technical equipment, service items and service hours in accordance with relevant regulations, improve the hospital information management system, and realize data docking with the electronic settlement system of basic medical insurance in accordance with the interface requirements of the unified outpatient real-time settlement software of the whole city to realize real-time settlement of medical expenses.
Article 21 All designated medical institutions and their staff must strictly implement the diagnosis and treatment norms formulated by the relevant state departments, practice medicine reasonably and legally, and may not collude with patients to fabricate medical records and examination materials, exchange drugs, or illegally take out outpatient co-ordination funds; Once discovered, the illegally obtained outpatient co-ordination fund will be recovered, and the municipal medical security department will order rectification, informed criticism and cancellation of designated qualification according to the seriousness of the case until the relevant legal responsibilities are investigated.
Article 22 The insured shall respect the medical staff's decision on diagnosis and treatment, and shall not interfere with the medical staff's diagnosis and treatment behavior, and shall not resort to fraud, impersonate or alter documents without authorization. Once found, the directly responsible person shall recover the paid outpatient co-ordination fee and suspend the outpatient co-ordination treatment according to the seriousness of the case. If you have any objection to the outpatient co-ordination payment, you can inquire and reflect it to the medical insurance agency or designated medical institution, or you can complain to the medical security department.
Chapter V Supplementary Provisions
Twenty-third outpatient co-ordination fund raising standards and methods, medical payment ratio, limit, scope and other adjustments, by the municipal medical security department according to the city's economic development, medical consumption level and outpatient co-ordination fund revenue and expenditure to make corresponding adjustments.
Article 24 These Detailed Rules shall come into force on June 1 65438+1October1day, 2022. If the previous policy is inconsistent with the spirit of these rules, these rules shall prevail.
Twenty-fifth these rules shall be interpreted by the Municipal Medical Security Bureau.