There is no deductible for outpatient expenses of primary medical institutions and primary medical institutions.

The maximum reimbursement for employees and retirees is 1500 yuan and 2000 yuan respectively.

The general outpatient co-ordination system covers all insured personnel of employee medical insurance. Not only the insured person with unified account mode can enjoy the reimbursement policy of general outpatient service, but also those who have difficulties in single construction and overall planning can enjoy the reimbursement policy of general outpatient service.

Our province medical insurance insured workers in primary medical institutions and primary medical and health institutions. There is no qifubiaozhun for outpatient medical expenses within the scope of the policy, and 70% is paid by itself; In secondary medical institutions, the outpatient medical expenses within the scope of the policy Qifubiaozhun 200 yuan are paid at 60%; For medical treatment in tertiary medical institutions, the minimum threshold for outpatient medical expenses within the policy scope is 300 yuan, which is paid at the rate of 60%.

In a natural year, the cumulative minimum payment standard shall not exceed that of 300 yuan, and the maximum payment limit of the on-the-job employee pooling fund shall be 1.500 yuan, and the maximum payment limit of the retirees pooling fund shall be 2,000 yuan. The maximum payment limit of the overall fund refers to the maximum amount that the overall fund can actually reimburse the insured.

"At present, the payment limit determined by the general outpatient co-ordination policy, plus the amount transferred from the personal account, can basically meet the outpatient medical needs of the insured." Wu, a member of the party group and deputy director of the Provincial Medical Insurance Bureau, said that the overall policy design of the general outpatient service of medical insurance for employees in our province reflects the appropriate inclination of treatment payment to the elderly, which is also conducive to promoting the implementation of the graded diagnosis and treatment system and guiding the insured to seek medical treatment at the grassroots level.

Outpatient support for chronic and special diseases

After enjoying special outpatient treatment, you can also enjoy reimbursement for general outpatient service.

The same expense will not be processed repeatedly, and the reimbursement amount will be settled separately.

The medical security of chronic diseases and special diseases such as hypertension and diabetes (hereinafter referred to as outpatient chronic diseases and special diseases) has always been concerned.

Hunan has gradually expanded the scope of payment of outpatient chronic diseases and special diseases, and included some outpatient expenses of diseases with long treatment cycle, great harm to health and heavy burden of outpatient expenses into mutual aid security.

Our province has studied and formulated the Measures for the Management of Outpatient Treatment of Chronic Diseases and Special Diseases in Employee Medical Insurance, unified the diagnostic criteria of chronic diseases and special diseases in the province, clarified the evaluation procedures for the inclusion of chronic diseases and special diseases in the outpatient medical insurance fund, and implemented the separate payment management of drugs for chronic diseases and special diseases.

At present, clinical experts have been organized to formulate the diagnosis and treatment norms and medication guidelines for chronic and special diseases in outpatient clinics. At present, 43 diseases are included in the scope of reimbursement for chronic diseases and special diseases, and the proportion and amount of reimbursement for various diseases are determined, and a dynamic adjustment mechanism for chronic diseases and special diseases will be established. Outpatient medical expenses within the policy scope of chronic diseases and special diseases of on-the-job employees are paid at the rate of 80%, and outpatient medical expenses within the policy scope of chronic diseases and special diseases of retirees are paid at the rate of 85%.

It is worth mentioning that after the implementation of the system of co-ordination and mutual aid for employees' medical insurance clinics, insured persons who enjoy special outpatient treatment can also enjoy reimbursement for ordinary outpatient services. After the implementation of the system of co-ordination and mutual aid for workers' medical insurance outpatient service, the insured who enjoys the special outpatient treatment can also enjoy the reimbursement treatment for ordinary outpatient service, but the charges will not be repeated. The amount of reimbursement for special outpatient service and general outpatient service shall be settled and reimbursed respectively.

For example, the insured enjoys the special treatment of "hypertension", and the monthly treatment standard is 260 yuan. In addition to enjoying preferential treatment every month, the insured person goes to the hospital for outpatient treatment due to illness, and the related medical expenses can be reimbursed according to the outpatient co-ordination policy, which does not conflict with the preferential treatment expenses. The same expenses (including personal out-of-pocket expenses) are no longer included in the reimbursement for special outpatient services. Similarly, expenses that have enjoyed special outpatient treatment (including personal out-of-pocket expenses) are no longer included in the scope of outpatient reimbursement.

Personal account entry method

Personal contributions are all included in personal accounts, allowing family members to use each other.

After the implementation of "outpatient mutual aid" in employee medical insurance, the way of personal account transfer will be improved. The basic medical insurance premiums paid by individual employees are all included in personal accounts, and the inclusion standard is 2% of the base of my insured payment. Individual accounts of retirees are allocated by the overall fund on a monthly basis, with a quota of 75 yuan/month. From June 65438+1 October1in 2023, it will be implemented according to the unified standards of the whole province.

After adjusting the overall fund and personal account structure, the increased overall fund is mainly used for outpatient mutual aid security and improving the outpatient treatment of insured persons.

Wu Shuo, according to the calculation, after the personal account is perfected, about 9 billion yuan will be used to strengthen outpatient service. This money can be turned into real fund investment in the current period, which can be really used for the sick, especially the elderly, and for the payment of medical services, thus supporting the development of primary medical service institutions and the utilization of medical resources. Therefore, this is a great activation and promotion in the efficiency of fund use. There are no new insured units and individuals to pay fees, and the system transition has been implemented under the existing conditions, which has improved the system efficiency.

After the reform, family members will be allowed to help each other use personal accounts, but personal accounts will not be used for public health expenses, physical fitness or health care consumption and other expenses not covered by basic medical insurance.

It is understood that the medical insurance department is expanding the coverage of workers' medical insurance clinics and exploring the inclusion of "internet plus" outpatient medical services that meet the requirements. Do a good job in the connection between outpatient expenses and hospitalization expenses payment policies.

Implementation progress and guarantee

Before the end of the year, the province will establish a general outpatient co-ordination system for employee medical insurance.

At the provincial level, the first batch of 149 designated medical institutions have been identified, and the outpatient co-ordination expenses are directly settled through networking.

At present, the policy of mutual aid for workers' medical insurance clinics in Hunan Province has been formally implemented at the provincial level, and Changsha, Zhuzhou, Xiangtan, Shaoyang and Chenzhou will be launched one after another before the end of the year.

In the next two months, Huaihua, Yueyang, Zhangjiajie, Yiyang, Yongzhou, Loudi, Xiangxi Tujia and Miao Autonomous Prefecture, Changde and Hengyang will also launch this policy one after another. Before the end of the year, our province will comprehensively establish a general outpatient medical insurance system for employees.

The New Deal will benefit 10.4 million employees in the whole province. In order to facilitate outpatient medical treatment and expense reimbursement for insured people, the medical insurance department has continuously simplified and optimized business processes and introduced convenience service measures.

As long as the medical institutions and qualified retail pharmacies that provide basic medical insurance for hospitalization are opened, in principle, they can be directly identified as designated medical institutions for outpatient co-ordination. At present, the first batch of 149 designated medical institutions are directly recognized at the provincial level, covering primary medical and health institutions and first, second and third-class hospitals.

The medical insurance registration and reimbursement procedures of the insured are simplified, and the outpatient co-ordination expenses are directly settled through the Internet. The insured person only needs to pay part of the expenses paid by the individual for medical treatment and drug purchase, which belongs to the part paid by the outpatient co-ordination fund. Designated medical institutions and agencies pay according to the agreement, and the outpatient co-ordination expenses reimbursed by the insured medical insurance need not be "funded and run errands".

The medical insurance registration procedures for cross-regional outpatient treatment and drug purchase in the province were cancelled. When the insured goes to designated medical institutions across regions for medical treatment, it is not necessary to register for medical treatment in different places in advance, and only need to indicate the insured place and the type of medical treatment actively, so that the medical reimbursement and drug purchase expenses can be directly settled with the medical insurance electronic certificate, resident ID card or social security card.

In order to implement the "last mile" of outpatient co-ordination policy, designated medical institutions actively open up internal blocking points in hospitals, open and expand outpatient co-ordination settlement windows, formulate internal settlement process systems in hospitals, speed up the transformation of hospital information systems, realize real-time settlement of outpatient expenses, and facilitate the insured people to seek medical treatment.

Experience: "mutual aid" reimbursement, 1300 yuan only needs to pay 778 yuan for medical expenses.

Recently, citizen Cao Qinghe (pseudonym) came to the outpatient department of Hunan Cancer Hospital for treatment due to abdominal discomfort.

The attending doctor issued the corresponding examination. When Cao Qinghe settled accounts, he found that the total cost was 1300 yuan, and he only had to pay 778 yuan. From June 65438+1 October1,Hunan Cancer Hospital began to implement the policy of medical insurance outpatient mutual aid, and general outpatient expenses can be included in medical insurance reimbursement.

How exactly is it reimbursed? In a natural year, the accumulative qifubiaozhun for co-ordination of outpatient service for employees shall not exceed that of 300 yuan, with the maximum payment limit of 2,000 yuan for employees 1.500 yuan and retirees. Take a tertiary designated hospital as an example: Qifubiaozhun is 300 yuan, and the employee medical insurance fund is reimbursed at 60%. Total outpatient expenses 1300 yuan, of which the out-of-pocket ratio is 10%( 130 yuan). Then, the reimbursement amount of this outpatient service = (1300-130-300) × 60% = 522 yuan (300 yuan is the deductible line, so the accumulated 300 yuan is not deducted every year).

The scope of co-ordination payment for workers' outpatient service is consistent with the basic medical insurance, that is, the list of basic medical insurance drugs, the list of medical service items and the list of medical consumables stipulated by the state and the province, and those outside the scope of payment for basic medical insurance will not be paid.

After the outpatient doctor issues the doctor's advice, the insured person will settle in the special outpatient window with the medical insurance electronic certificate, ID card or social security card, and the insured person only needs to pay the self-funded part. Insured persons do not enjoy outpatient co-ordination and chronic special disease treatment during hospitalization; Medical expenses have been paid for the "dual-channel" management of drug treatment and outpatient treatment of chronic diseases and special diseases, but the outpatient treatment of employees will not be paid; Outpatient medical expenses for accidental injuries borne by third parties are not included in the scope of medical insurance reimbursement.

expand

Can the insured employees who are accidentally injured be included in the general outpatient reimbursement when they seek medical treatment in the outpatient department?

Outpatient medical expenses in the accident insurance policy can be included in the reimbursement of general outpatient service, but there are several special circumstances that are not included in the reimbursement of general outpatient service. In the first case, there is an accidental injury outpatient fee borne by a third person; The second situation is the outpatient medical expenses caused by work-related injuries.

In practice, if the insured complains that there is no third-party responsible person, the designated medical institutions should strengthen the identity authentication of the injured person, and combine the actual situation such as the consultation and the insured's condition. After the insured or his family members fill in the Letter of Commitment on No Third Party Liability for Accidental Injuries, the outpatient medical expenses will be included in the general outpatient reimbursement.

Can the medical examination expenses be included in the general outpatient department for overall reimbursement?

Health examination can not be included in the general outpatient service for the time being. The establishment of general outpatient co-ordination of medical insurance for employees aims to reduce the burden of outpatient treatment expenses caused by diseases of insured employees. Physical examination is a physical examination of the subject through medical means and methods to understand the health status of the subject, which mainly plays the role of disease prevention and control. In addition, the List of National and Provincial Medical Insurance Benefits also clearly stipulates that "physical fitness, health care consumption and health examination" are not covered by the medical insurance fund.

Medical insurance can be reimbursed as follows:

1, drug reimbursement for basic medical insurance

There are two kinds of drugs within the scope of reimbursement, one is Class A and the other is Class B. Class A drugs are the most basic drugs that we can guarantee clinical treatment. Class B drugs are adjusted by each region according to its own situation.

2, the basic medical insurance treatment project reimbursement

The basic medical insurance diagnosis and treatment project must meet three conditions: it must be safe and effective, and the cost is appropriate; The price department has set the charging standard; Treatment in designated medical institutions.

3. Reimbursement of basic medical service facilities.

Legal basis;

Article 23 of People's Republic of China (PRC) Social Insurance Law

Employees should participate in the basic medical insurance for employees, and employers and employees should jointly pay the basic medical insurance premiums in accordance with state regulations.

Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.