Since 1997, the medical insurance system for employees in Nantong has established a security model combining social pooling (that is, pooling funds) and individual accounts. The overall fund guarantees chronic diseases and special diseases (including special drugs for outpatient service) in hospitals and clinics, and personal accounts guarantee common diseases and drug expenses for outpatient service. With the development of social economy, the limitations of personal accounts have gradually become prominent. The main problem is that the overall accumulated balance of personal accounts is more, but the security function is insufficient, mutual assistance is not enough, and personal accounts between family members can not be used sparingly, resulting in inefficient use of medical insurance funds and ineffective burden reduction.
The employee medical insurance fund is divided into two parts: one is the overall fund, which is the "big pool" of the medical insurance fund; Second, the personal account, that is, "the money in the medical insurance card", the economic security of outpatient service can be simply understood as "one big and one small". "Big * * * economy" is to establish a * * * economic security mechanism for outpatient service, realize the system transition without increasing the payment of new units and individuals, reimburse the employees for the regular outpatient service expenses through the overall fund, realize the * * * economic security for all insured employees, better solve the outpatient service security problem of insured personnel, especially the elderly, and reduce the burden of personal medical expenses; "Small * * * assistance" refers to family * * * assistance, which means that personal account funds are shared among specific family members such as spouses, parents and children. After the implementation of outpatient assistance, the sleeping personal account funds in the overall fund were revitalized, mutual assistance was realized, the contradiction between idle personal account funds and insufficient outpatient support was alleviated, the outpatient treatment of sick insured personnel was improved, and personal accounts were alleviated. Moreover, because ordinary outpatient clinics can be reimbursed, it will also reduce the waste of medical insurance funds and medical resources caused by hospitalization reimbursement.
At the same time, the use scope of personal account funds has been further standardized and expanded, which can be used not only to pay the medical expenses incurred by oneself, their spouses, parents and children, and the expenses incurred in purchasing medicines, medical devices and medical consumables at designated retail pharmacies, but also to pay the personal contributions of spouses, parents and children who participate in residents' medical insurance or employee supplementary insurance and long-term care insurance, as well as to buy commercial subsidy insurance guided by the government and connected with basic medical insurance. However, personal accounts may not be used for public health, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance. It should be noted that spouses, parents and children who are authorized to use personal account funds need to participate in the basic medical insurance in Jiangsu Province.
After the reform, the funds included in the individual accounts of on-the-job employees are 2% of their payment base, which is lower than the previous year's level, and the unit contributions will all be included in the employee medical insurance pooling fund; Those who participate in employee medical insurance as flexible employees shall be included in personal accounts according to 2% of their payment base, and the rest of the basic medical insurance premiums shall be included in the employee medical insurance pooling fund. From 2023, personal account funds will be transferred monthly, instead of one-time transfer at the beginning of previous years. In addition, the personal accounts of retirees who enjoy retirement medical insurance benefits will not be adjusted in 2023. In 2024, it will be adjusted from pre-planning at the beginning of the year to monthly liquidation at the end of the year, and the amount of inclusion will be adjusted to 2.5% of the average basic pension in the year when the reform was implemented according to the opinions of the overall planning area.
It should be reminded that, because the treatment level of the new general outpatient co-ordination policy is higher than that of the original chronic disease policy, the original chronic disease of outpatient service is included in the unified protection scope of general outpatient service, and the original chronic disease policies such as hypertension (Grade II and III), diabetes and active hepatitis B are stopped. The current policy of outpatient medication for hypertension and diabetes in residents' medical insurance remains unchanged.