Scope of implementation
* * * The economic security mechanism of the basic medical insurance for employees is applicable to all employees and retirees who participate in the basic medical insurance for urban employees in the city.
Treatment policy
Fully implement the policy of overall treatment and payment for general outpatient workers.
1. minimum payment standard. Within a natural year, the employee medical insurance outpatient co-ordination shall not calculate the Qifubiaozhun. Insured persons seek medical treatment in outpatient departments of primary, secondary and tertiary medical institutions, and the qifubiaozhun for medical insurance fund payment is 100 yuan, 200 yuan and 300 yuan respectively. The insured in the first, second and third level medical institutions outpatient medical treatment, according to the employee medical insurance general outpatient qifubiaozhun implementation of cumulative makeup calculation.
2. Payment ratio. For the medical expenses incurred by the insured in the general outpatient service within the policy scope, the proportion of fund payment for the employees in the first, second and third-level medical institutions is 70%, 60% and 50% respectively. The proportion of retirees' fund payment in first-,second-and third-level medical institutions is 75%, 65% and 55% respectively.
3. Maximum payment limit. In a natural year, the maximum payment limit of general outpatient medical expenses within the insured policy is 2000 yuan, which is gradually increased with the reform of personal accounts.
Reform the bookkeeping method of employees' medical insurance personal accounts.
The adjustment of personal account charging mode and the improvement of outpatient economic security mechanism were implemented simultaneously on June 65438+ 10/day, 2023.
1. Basic medical insurance premium paid by employees: all paid into individual medical insurance account.
2 basic medical insurance premium paid by the employer:
From June 5438+1 October1in 2023, the basic medical insurance premium paid by the employer will be reduced to 50% of the current standard, and the personal account policy for retirees will remain unchanged. Employees under 45 years old (including 45 years old) are included in personal accounts according to their own payment base; On-the-job employees over the age of 45 are included in personal accounts according to the payment base.
From June 5438+1 October1in 2024, the basic medical insurance premiums paid by employees will no longer be included in individual accounts, but will all be included in the overall fund; Individual accounts of retirees are allocated by the overall fund according to the quota. Retirees aged 70 and under will be uniformly adjusted to 2% of the average basic pension in Jining City in 2023, and retirees aged 70 and above will be uniformly adjusted to the average basic pension in Jining City in 2023. Employees who retire will enjoy the treatment of retirees' personal accounts from the next month.
4. If the flexible employees enjoy the basic medical insurance benefits for retirees according to the regulations, the personal account policy shall be implemented according to these regulations.
Standardize the use of employee medical insurance personal accounts
Further clarify the scope of personal account payment, broaden the channels of personal account payment, and standardize the management of personal account use.
1. Personal account funds are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions. Available for payment:
Medical expenses incurred by the insured, their spouses, parents and children in designated medical institutions and borne by individuals,
Expenses incurred by individuals in purchasing drugs, medical devices and medical consumables at designated retail pharmacies,
Spouses, parents and children participate in basic medical insurance for residents, long-term care insurance, inclusive commercial medical insurance guided by the government, and large medical insurance for retirees with flexible employment.
2. 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.
3. Personal account funds can be carried forward and inherited. When employees are transferred from our city, the balance of personal account funds can be transferred or allocated to me at one time.
Medical management service
Expand the scope of medical treatment and drug purchase for employees' medical insurance clinics. Cancel the fixed-point restrictions on co-ordination of staff outpatient services, and no longer implement contracted fixed-point medical services. The insured person can choose one, two or three designated medical institutions in the city for outpatient treatment.
Real name authentication for medical treatment. When the insured person goes to a designated medical institution for medical treatment, he shall issue his own medical insurance electronic certificate or social security card and other identification certificates. The doctor should carefully check the identity, truthfully record the medical situation, and ensure that it is consistent with the witness.
Optimize medical services. Designated medical institutions should be equipped with staff, strengthen the construction of information systems, add service windows, improve the medical environment and simplify the settlement process of medical expenses. Through the medical insurance information system, timely and accurately upload the medical information and medical expenses of the insured, and actively provide quality medical services for the insured.
Strict medical insurance fund payment scope. The employee medical insurance outpatient department shall co-ordinate the implementation of the unified medical insurance drug list, diagnosis and treatment project list and medical service facilities standard in the whole province. Medical institutions shall inform patients or their relatives when using articles outside medical insurance coverage. Beyond the scope of the catalogue, the medical insurance fund will not pay.
Promote graded diagnosis and treatment. Do a good job in the connection between the contracted service of family doctors and the management measures of chronic diseases and special diseases in general outpatient clinics, guide the insured to seek medical treatment at the grassroots level, and promote the improvement of the primary medical and health service system.
Expense settlement
Outpatient fees should be settled online immediately. The outpatient expenses incurred by the insured in the designated medical institutions shall be settled online in real time, and the insured shall only pay the personal burden, and the rest shall be settled by the medical insurance agency and the designated medical institutions. Improve the policy of overall payment for medical treatment in general outpatient clinics in different cities and across cities, and simplify the classification and filing of medical personnel in different places. If the insured person goes to the designated medical institution for outpatient treatment, the general outpatient medical expenses that cannot be settled online outside the city shall be reimbursed by the medical insurance agency to which the insured person belongs.
Timely disbursement of outpatient medical insurance fund. In accordance with the principle of territorial settlement management, the allocation and management of outpatient medical insurance funds shall be unified in the whole city, and the cities and counties shall be responsible for the classification. Outpatient overall management and fund allocation shall be implemented in accordance with the settlement method of hospitalization and the scope of designated medical institutions. The municipal medical insurance agency is responsible for the settlement and liquidation of the outpatient co-ordination expenses of municipal medical institutions, and the county-level medical insurance agency is responsible for the settlement and liquidation of the outpatient co-ordination expenses of designated medical institutions within its jurisdiction. Medical insurance designated medical institutions at all levels should report the relevant settlement materials to the outpatient department on time, and the medical insurance agency should strictly review the outpatient medical expenses and timely allocate the outpatient medical insurance fund.
Improve the payment and settlement methods of medical expenses. Incorporate outpatient medical services into the agreement management of medical insurance designated institutions, and establish a statistical analysis system for outpatient expenses. Promote the reform of outpatient payment methods, and implement payment methods such as total control and per-head payment for general outpatient services; For outpatient expenses that are not suitable for package payment, they can be paid by project. Drugs negotiated by the state medical insurance paid separately are not included in the total medical insurance expenses of designated medical institutions.