Employees who participate in medical insurance can enjoy reimbursement of general outpatient expenses, which has attracted much attention.
What is the payment limit determined by the general outpatient co-ordination policy?
Can I still enjoy the reimbursement of general outpatient service after enjoying the treatment of special outpatient service?
What are the new changes in personal account entry methods?
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In view of people's concerns, on June 9th, 165438+ Hunan Provincial Medical Security Bureau held a news briefing on "Employee Medical Insurance Outpatient" to introduce the situation and answer questions.
Maximum payment limit of the overall fund: employees 1.500 yuan, retirees 2000 yuan.
Who can enjoy this new policy? Wu, member of the party group and deputy director of the Provincial Medical Security Bureau, introduced,
The general outpatient co-ordination system will cover all insured persons in the province's employee medical insurance.
Employee medical insurance participants in
First-class medical institutions and primary medical and health institutions, outpatient medical expenses within the scope of the policy, there is no Qifubiaozhun, paid by 70%; In secondary medical institutions, outpatient medical expenses within the scope of the policy, Qifubiaozhun 200 yuan, paid at the rate of 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%.
According to the regulations,
In a natural year, the minimum payment standard of each insured person 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.
"According to estimates, the payment limit determined by the current general outpatient co-ordination policy, plus the amount transferred from the personal account, can basically meet the outpatient medical needs of the insured." The overall policy design of the general outpatient service of medical insurance for employees in Wu Shuo and our province reflects that the treatment payment is appropriately tilted 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.
The reporter learned from the news briefing that in the next two months, Huaihua, Yueyang, Zhangjiajie, Yiyang, Yongzhou, Loudi, Xiangxi Tujia and Miao Autonomous Prefecture, Changde and Hengyang in our province will also start this policy one after another. Before the end of the year, our province will comprehensively establish a general outpatient co-ordination system for employee medical insurance.
Reimbursement for special outpatient service and general outpatient service: the amount shall be reimbursed separately, but the same expense shall not be reimbursed repeatedly.
Chronic diseases and special diseases, such as hypertension and diabetes, which are heavily burdened by the masses, have caused considerable burden to patients due to some factors such as long treatment cycle and great damage to health.
The reporter learned that our province will soon introduce the management measures for outpatient treatment of chronic special diseases with employee medical insurance. In order to strengthen standardized management, our province unified the inclusion criteria of chronic diseases and special diseases in outpatient clinics, and clarified the evaluation procedures for the inclusion of chronic diseases and special diseases in medical insurance funds. Outpatient drugs for chronic diseases and special diseases are subject to separate payment management. At present, 43 kinds of diseases are included in the reimbursement scope of chronic diseases and special diseases, and the reimbursement ratio and amount of each disease are determined. Outpatient medical expenses of employees with chronic diseases and special diseases are paid at the rate of 80%, and those of retirees with chronic diseases and special diseases are paid at the rate of 85%.
Then, after the implementation of the employee medical insurance outpatient co-ordination system, can the insured who enjoy the special needs outpatient treatment enjoy the reimbursement of the general outpatient service at the same time?
Yi Xuesi, member of the party group and deputy director of Changsha Medical Security Bureau, introduced,
After the implementation of the medical insurance outpatient co-ordination system, the insured who enjoys the special outpatient treatment can also enjoy the reimbursement treatment of the general outpatient service, but the same expenses are not repeated. The amount of reimbursement for special outpatient service and general outpatient service shall be settled and reimbursed respectively.
He explained that, for example, an insured person enjoys the reimbursement treatment of "hypertension" special outpatient service, and the monthly standard is 260 yuan. In addition to enjoying the special outpatient reimbursement treatment every month, if he goes to the hospital for outpatient treatment due to illness, the relevant medical expenses can be reimbursed according to the outpatient co-ordination policy, which does not conflict with the special outpatient expenses. However, 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 charging method: the charging standard has changed, allowing family members to use each other economically.
The security function is insufficient, the economy is not strong, the illness is not enough, and the illness cannot be used. The effect of reducing the burden of outpatient medical expenses is not obvious enough ... With the development of social economy and the change of personal medical needs, the limitations of personal accounts have gradually become prominent. After entering the era of employee medical insurance "outpatient co-ordination", the way of personal account entry will also usher in a series of changes.
It is reported that from June 65438+ 10/day, 2023, personal accounts will be credited in a new way. Among them,
The basic medical insurance premiums paid by individual employees on the job are all included in personal accounts, and the inclusion standard is 2% of the base of my insured payment; Retirees' personal accounts are credited to 75 yuan/month.
Cities and states with real difficulties can be temporarily determined by 2% of the average basic pension for retirees of enterprises and institutions in this city and state in 202 1 year, but since June 1 day, it must be implemented according to the unified standards of the whole province.
"According to our calculation, after improving the personal account calculation and payment method, about 9 billion yuan will be used to strengthen outpatient security." Wu "calculated an account": "In this way, the money can become a real fund investment, and can be really used for the sick, especially the elderly, and really used for the payment of medical services. Therefore, in terms of the efficiency of the use of funds, it should be said that it is a great activation and improvement. "
The use of personal accounts will also expand. After the reform,
Family members will be allowed to use personal accounts with each other.
However, personal accounts may not be used for expenses not covered by basic medical insurance, such as free medical care, fitness or health care consumption, and health check-ups cannot be included in general outpatient clinics for the time being.
"Outpatient medical expenses within the accidental injury policy can be included in the general outpatient reimbursement of employees. Except in special circumstances. " At the news briefing, Fang Xinwen, member of the party group and deputy director of Xiangtan Medical Insurance Bureau, introduced that the outpatient expenses for accidental injuries and medical expenses for work-related injuries borne by third parties were not included in the scope of overall reimbursement for general outpatient services.
If the insured complains that there is no third-party responsible person, the designated medical institution shall strengthen the identity authentication of the injured person, and after the insured person or his family fills in the Letter of Commitment on No Third-party Liability for Accidental Injury, the outpatient medical expenses will be included in the general outpatient department for overall reimbursement.
Convenience measures: the first batch of 149 designated medical institutions have been recognized at the provincial level, and the outpatient co-ordination expenses are directly settled online.
"In order to facilitate the outpatient medical treatment and expense reimbursement of the insured people, we have continuously simplified and optimized business processes and introduced convenience service measures." Li Wenzong, director of Hunan Medical Maternity Insurance Service Center, introduced,
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.
When the insured goes through the formalities of medical treatment, medicine purchase and medical insurance registration and reimbursement,
Through the direct settlement of outpatient co-ordination expenses, the insured person only needs to pay part of the expenses paid by the individual for medical treatment and medicine purchase.
The part paid by the outpatient co-ordination fund shall be paid by the designated medical institutions and agencies according to the agreement.
There is no need to "run errands" for medical insurance reimbursement of outpatient co-ordination expenses of insured persons.
The registration procedures for outpatient medical treatment, drug purchase and medical insurance in the province have also been cancelled.
When the insured person goes to the designated medical institution across the overall planning area, there is no need to apply for medical registration in different places in advance. He/she only needs to indicate the insured place and the type of medical treatment on his/her own initiative, and he/she can directly settle the medical reimbursement with the medical insurance electronic certificate, resident ID card or social security card.
Source: Hunan Daily Huasheng Online