At present, Jiangxi Province has unified the cooperative medical care implementation plan across the province:

There are unified regulations on reimbursement ratios, thresholds and related procedures. The plan is as follows:

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Guiding Opinions on Unifying the Province’s New Rural Cooperative Medical Care Compensation Plan

In order to establish a relatively unified compensation model for the new rural cooperative medical care (hereinafter referred to as the new rural cooperative medical system) in our province and standardize the operation and management of the new rural cooperative medical system, these guiding opinions are specially formulated.

1. Basic Principles

The formulation of the compensation model for each new rural cooperative medical county (district) adheres to the principle of determining expenditure based on revenue, providing appropriate protection, with slight savings; focusing on hospitalization compensation , taking into account the benefits; maintaining relative stability and continuous improvement; fully embodying the basic principle of mutual aid and economy, focusing on overall planning of serious diseases.

2. Strict scope of use of the hospitalization pooling fund

The hospitalization pooling fund can only be used to compensate farmers for hospitalization medical expenses, outpatient serious illness (chronic disease) medical expenses and maternal hospital delivery. It shall not be used for farmers’ health examinations, planned immunization, preventive health care, health education and other public health services and medical assistance.

3. Fund Raising

The annual subsidies from the central finance, provincial finance, municipal finance and county (district) level finance to each participating farmer are 20 yuan and 14 yuan respectively. (17 yuan for nationally designated poverty-stricken counties), 3 yuan (0 yuan for nationally designated poverty-stricken counties) and 3 yuan, and farmers’ self-payment of participation funds is no less than 10 yuan.

IV. Fund Allocation

The New Rural Cooperative Medical Care Fund is divided into three parts, namely risk fund, hospitalization overall fund and outpatient family account fund (hereinafter referred to as family account).

(1) Venture funds. The risk fund is a special reserve fund drawn from the New Rural Cooperative Medical Care Fund and transferred from the balance of the New Rural Cooperative Medical Care Fund to make up for abnormal overexpenditures of the New Rural Cooperative Medical Care Fund. The risk fund is withdrawn by each county (district) at a proportion of 3% of the total amount of the New Rural Cooperative Medical Care Fund raised every year. Counties (districts) with large fund balances can also put 50% of the remaining funds into risk funds. The scale of the venture fund should be maintained at 10% of the total annual funds raised. After reaching the specified scale, no further withdrawals will be made. The management of risk funds is implemented in accordance with the "Risk Fund Management Measures for New Rural Cooperative Medical Care Pilot Counties in Jiangxi Province" (Gancaishe [2004] No. 124).

(2) Hospitalization overall fund. All central and local financial subsidies to participating farmers will be included in the hospitalization overall fund, and no less than 20% of farmers' self-paid funds will be included in the hospitalization overall fund. The hospitalization pooling fund is used to compensate participating farmers whose reimbursable hospitalization expenses reach the minimum standard, to compensate for outpatient serious illnesses (chronic diseases) specified by each county (district), and to receive fixed compensation for hospital delivery.

(3) Family account. After the farmers' self-payments are included in the overall fund, the remainder belongs to the participating farmers' own family accounts. Subsidy funds from the central and local governments to participating farmers shall not be included in the family accounts. Family accounts are used jointly by family members, and the amount in the family account can be used up at one time. The balance of the current year can be transferred to the next year for use. Compensation for outpatient expenses shall not exceed the total funds in the family account. The funds accumulated in the family account shall not be used to offset the self-payment of farmers' participation funds in the next year.

5. Compensation model

Our province implements the model of "outpatient family account compensation, inpatient reimbursement in proportion, and outpatient serious illness (chronic disease) compensation".

VI. Compensation setting

(1) Hospitalization deductible

Four-level deductibles are set up. The deductible is 100 yuan for designated medical institutions at the township level and 100 yuan at the county level. The fee for designated medical institutions is 300 yuan, the fee for designated medical institutions outside the county (district) is 600 yuan, and the fee for non-designated medical institutions outside the county (district) is 800 yuan. The minimum payment line shall not be less than 100 yuan. Below the deductible line is the portion paid by the individual. If you are hospitalized multiple times for the same disease during the year, only one deductible will be calculated. If you are continuously transferred to another hospital for treatment of the same disease, only the hospital with the highest level will be calculated once.

(2) Hospitalization compensation ratio

Medical institutions at the same level only set one compensation ratio. It is 60% for designated medical institutions at the township level, 50% for designated medical institutions at the county level, 40% for designated medical institutions outside the county (district), and 30% for non-designated medical institutions outside the county (district). Each county (district) can fluctuate by 5% on this basis for county-level designated medical institutions and hospitals outside the county.

In principle, the hospitalization compensation ratio of township-level designated medical institutions is higher than that of county-level designated medical institutions, and that of county-level designated medical institutions is higher than that of medical institutions outside the county. The difference in hospitalization compensation ratios at all levels must be controlled within 10%. When calculating the actual compensation amount for participating farmers, the deductible amount is deducted from the deductible amount, and then the compensation is based on the prescribed compensation ratio.

(3) Hospitalization compensation ceiling line

The hospitalization compensation ceiling line is 15,000 yuan, which is calculated based on the cumulative amount of compensation actually received during the year.

(4) Implementing the minimum compensation amount for hospitalization

After the hospitalization medical expenses of participating farmers reach the deductible, the minimum compensation amount for farmers shall not be less than 30 yuan. The minimum compensation amount for participating farmers shall be no less than 30 yuan. If you are hospitalized, you can only enjoy the minimum compensation once.

(5) Others

1. Insist on the agricultural population to participate in the New Rural Cooperative Medical System on a household basis. After the prescribed fee deadline, farmers who request to participate will no longer be accepted.

2. Each county (district) should include some serious diseases (chronic diseases) that can be treated in outpatient clinics into the scope of compensation of the overall fund. The specific selection of diseases, compensation procedures and compensation standards shall be referred to our "About "Guiding Opinions on Adjusting the Implementation Plan of New Rural Cooperative Medical Care in Pilot Counties" (Ganhe Medical Office [2004] No. 8) and "Compensation Regulations on Including Outpatient Serious Illnesses (Chronic Diseases) into the Compensation Scope of the New Rural Cooperative Medical Care Fund" are implemented.

3. Participating farmers do not need to go through transfer procedures when seeking medical treatment at designated medical institutions in the county (district) or going to the designated medical institutions in neighboring counties for hospitalization; in addition, those who seek medical treatment outside the county (district) must go to the county agricultural medical bureau. Go through the transfer procedures; for emergencies and for farmers working in other places who are hospitalized locally for illness, they must notify the county (district) Agricultural Medical Bureau within 7 working days, otherwise no compensation will be given.

4. Participating farmers will receive a fixed compensation of 150 yuan for hospital delivery in designated medical institutions. Surgical and obstetric complications and complications will be based on hospitalization compensation standards.

5. When traditional Chinese medicine and traditional Chinese medicine techniques are used to treat diseases in designated medical institutions, the compensation rate for medical institutions of the same level is 10% higher than for Western medicine treatment.

6. For participating farmers who have participated in commercial insurance, if they need both commercial insurance compensation and New Rural Cooperative Medical System compensation after discharge, the participating farmers can submit the original hospitalization invoice to the commercial insurance company to complete the compensation procedures. The Agricultural Medical Bureau The participating farmers will be compensated using a copy of the invoice and the original compensation list from the commercial insurance company marked "checked with the original" and stamped with the official seal. The Agricultural Medical Bureau should sign cooperation agreements with various commercial insurance companies in the county (district), establish a good information exchange mechanism, and regularly check the copies of invoices with the originals to ensure the authenticity of the copies.

7. If a farmer who participates in an emergency is hospitalized immediately after an outpatient examination, the outpatient examination and treatment expenses on that day can be included in the compensation scope of the overall fund. During the hospitalization period, due to the need of the illness, he goes to a higher-level hospital for examination, and the examination expenses incurred It is calculated according to the corresponding compensation ratio at the inspection hospital level and included in the scope of compensation.

8. The diagnostic and treatment projects that are not covered by the overall fund and partially paid by the overall fund shall be implemented in accordance with the "Scope of Diagnostic and Treatment Projects and Medical Service Facilities that are not covered by the Jiangxi New Rural Cooperative Medical Care Fund and are partially paid by the Jiangxi Province New Rural Cooperative Medical Coordination Fund."

7. Materials that should be brought when applying for compensation

(1) After being hospitalized, participating farmers should bring the New Rural Cooperative Medical System Certificate, hospitalization invoice, discharge summary, household register, expense list, and transfer certificate and other information required by local regulations to go to the designated location to complete the compensation procedures.

(2) Participating farmers should bring their New Rural Cooperative Medical System certificate when seeking outpatient treatment at designated medical institutions within the county, and the designated medical institutions will directly exempt outpatient medical consultation fees.

(3) Participating farmers who suffer from serious outpatient diseases (chronic diseases) must bring their new rural cooperative medical certificate, household registration book, and certificate of serious outpatient diseases (chronic diseases) issued by the Agricultural Medical Bureau within the specified time (usually in December). Outpatient medical records, outpatient invoices and lists must be submitted to designated locations for compensation procedures.

8. Compensation Procedure

Participating farmers are hospitalized in designated medical institutions at the county (district) level. After discharge, they go through the compensation procedures at the New Rural Cooperative Medical System compensation window, and the designated medical institutions will The medical expenses incurred will be reviewed and the amount of compensation due will be advanced according to the standards stipulated in the implementation plan.

For hospitalization in a designated medical institution in a township (town) or in a hospital outside the county (district), if the hospitalization fee is within 2,000 yuan, the agricultural medical office where the registered farmer is registered shall be responsible for reviewing the medical expenses incurred and complying with the provisions of the implementation plan. The amount that should be compensated will be paid to farmers according to the standard. If the hospitalization medical expenses are more than 2,000 yuan (including 2,000 yuan) or there are questions about the hospitalization information, the Agricultural Medical Office will report it to the Agricultural Medical Bureau for review. The Agricultural Medical Office will pay the subsidy according to the standards stipulated in the implementation plan. The amount is paid to the farmer within 20 working days.

9. Compensation plan approval process

The compensation plans of each new rural cooperative medical system county (district) need to be submitted to the municipal joint medical office for preliminary review, and then the municipal joint medical office will submit them to the provincial cooperative medical office. The review by the medical office will be finalized by the county (district) government. Once the plan is determined, it is generally not appropriate to make new adjustments during the year. If the plan does need to be adjusted, it must be approved by the municipal and provincial joint medical offices in advance before implementation.

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The following expenses are not within the scope of Jiangxi Provincial Cooperative Medical Care reimbursement:

1. Diagnosis and treatment items for which expenses are not paid

1. Registration fee, consultation fee, house call fee, remote diagnosis and treatment fee, home hospital bed fee, etc.

2. Self-invited special care fees, door-to-door service fees, high-quality priority fees and other special medical service fees, as well as expedited examination and treatment fees, roll-call surgery surcharges, etc.

3. Medical record production fee, disease certificate fee, computer query and management fee, various bill production fees, magnetic card fees, etc.

(2) Non-disease treatment items

1. Various beauty treatments such as freckles, acne, warts, acne, freckle removal, pigmentation and hair loss (including alopecia areata), gray hair, Mole removal, ear piercing, saddle nose, breast augmentation, single eyelid to double eyelid, massage and beauty treatments, etc.

2. Various plastic surgery, orthopedics (except for sequelae of poliomyelitis) and treatment of physiological defects such as body odor removal, stuttering correction, strabismus correction, "O" shaped legs, "X" shaped legs, refractive errors , vision correction and other surgical projects.

3. Diabetes decision support system, sleep breathing monitoring system, trace element detection, bone density measurement, human body information diagnosis, computer selection of the best pregnancy period, fetal gender and fetal development examination and other diagnostic and treatment items.

4. Various diagnosis and treatment projects for weight loss, weight gain, height gain, bodybuilding, and smoking cessation.

5. Various preventive and health-care diagnosis and treatment (except perinatal health care) and other items.

6. Various medical consultations (including psychological consultation, health consultation, dietary consultation, disease consultation), various predictions (including stroke prediction, health prediction, disease prediction), various identifications (forensic identification, Work injury identification, medical identification, paternity identification), health guidance and other projects.

(3) Diagnostic and treatment equipment and medical materials

1. Inspections using large medical equipment such as positron emission tomography device PET, electron beam CT, ophthalmic excimer laser therapy instrument treatment program.

2. Glasses, prosthetic eyes, dentures, prosthetic limbs, hearing aids, brain-boosting equipment, leather (steel) vests, steel waistbands, steel necks, stomach supports, kidney supports, scrotal supports, pessaries, crutches , wheelchairs, deformed insoles, medicated pillows, medicated pads, hot compress bags, tourniquets, infusion nets, cremasteric belts, hernia belts, knee braces, artificial anal bags and other equipment.

3. Various household inspection and testing instruments (devices), treatment instruments (devices), physiotherapy instruments (devices), massagers, magnetic therapy supplies and other treatment equipment.

4. Disposable medical materials that cannot be charged separately according to the provincial price department.

(4) Treatment Project Category

1. Human organ sources or tissue sources for various types of organ or tissue transplantation and related operations to obtain organ sources and tissue sources, etc.

2. Other organ or tissue transplantation except kidney, cornea, skin, blood vessel, bone, and bone marrow transplantation.

3. Diagnosis and treatment items such as microwave (radio frequency) treatment for prostatic hyperplasia, helium-neon laser intravascular irradiation (blood therapy), new analgesia technology after anesthesia and surgery (analgesic bed), endoscopic retrograde appendography, etc.

4. Dental dentures, dental implants, teeth cleaning, correction of irregular dentition, yellow and black teeth, missing teeth, stained teeth, baked magnetic teeth and other diagnostic and treatment items.

5. Qigong therapy, music therapy, hypnotherapy, magnet therapy, water bar therapy, oxygen bar therapy, posture therapy, psychotherapy and suggestion therapy (except for mental patients), dietary therapy, nutritional therapy and other auxiliary services treatment program.

6. Diagnosis and treatment items for various infertility (pregnancy) diseases and sexual dysfunction.

7. Scientific research, teaching, and clinically verified diagnosis and treatment projects in various places.

(5) Others

1. Diagnosis and treatment items caused by fighting, brawling, alcoholism, self-injury, suicide, drug rehabilitation, sexually transmitted diseases, medical accidents and other liability accidents .

2. All medical expenses incurred while going abroad and during the trip.

3. Medical expenses for diagnosis and treatment incurred by refusing to be discharged from the hospital as prescribed by the doctor and being hospitalized in bed.

4. Diagnosis and treatment items that are not included in price policy management.

2. Diagnostic and treatment items for partial payment

(1) Diagnostic and treatment equipment and medical materials

1. Application of γ-knife, χ-knife, χ -Ray computed tomography equipment (ct), cardiac and angiography x-ray machines (including digital subtraction equipment), magnetic resonance imaging equipment (mri), single photon emission electronic computer scanning equipment (spect), color multi- Large medical instruments such as Pulometer, medical linear accelerator, color B-ultrasound, and brain topography are used for examination, treatment, and projects.

2. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy projects.

3. Disposable medical materials that can be charged separately as stipulated by the provincial price department.

(2) Treatment items: 1. Hemodialysis and peritoneal dialysis treatment items.

2. Kidney, cornea, skin, blood vessel, bone and bone marrow transplant surgery projects.

3. Artificial organs and bodies for internal replacement such as cardiac pacemakers, artificial valves, artificial joints, intraocular lenses, various stents, various staplers, various catheters, implanted drug delivery devices, etc. Built-in placement materials and installation or placement of surgical items.

4. Surgical projects such as cardiac bypass, cardiac catheter balloon dilatation, and cardiac radiofrequency ablation.

5. Coronary angiography, cardiac laser drilling, T lymphocyte reinfusion method in tumor biological therapy, tumor thermal therapy and other diagnostic and treatment items.

6. Various microwave, spectrum, far-infrared and other auxiliary treatment projects.

3. Scope of medical service facilities that are not eligible for payment

(1) Transportation expenses for medical treatment (referral).

(2) Air conditioning fees, heating fees, TV fees, telephone fees, electric stove fees, refrigerator fees, food incubator fees, compensation for damage to public property, water, electricity, gas and other fees.

(3) Accompanying fees, nursing fees, bathing fees, medicated bath fees, disinfection fees, haircut fees, washing fees, etc.

(4) Outpatient decoction fees and traditional Chinese medicine processing fees.

(5) Fees for cultural and entertainment activities, newspapers and magazines, and fitness activities.

(6) Meal expenses.

(7) Flowers and flower arrangements.

(8) The cost of disposable items such as sanitary tableware, wash basins, cups, toilet paper, sheets, pillowcases, bed towels, and diapers.

(9) The cost of daily necessities such as soap water, garbage bags, mosquito killers, etc.

(10) Medical institutions increase the charging standards of medical service facilities or set their own charging items.

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Issues that need attention

1. Go through relevant procedures and collect relevant bill information as required

2. Pay attention to the cooperative medical drug catalog when taking medication. Drugs outside the catalog are important factors affecting reimbursement.