I. Background and basis for the promulgation of the Measures
The medical insurance for employees was established from 1998, and the security mode of combining social pooling with individual accounts was implemented. The overall fund guarantees the expenses of chronic diseases and special diseases in hospitalization and outpatient service, and the personal account guarantees the expenses of common diseases and medicines in outpatient service. Personal account has played an active role in promoting the transition from public labor insurance medical system to social medical insurance system. With the development of social economy, the enhancement of people's health awareness, the change of medical treatment behavior, the change of disease spectrum and the arrival of an aging society, personal accounts have been unable to meet the needs of social development under the new economic normal, and their limitations have gradually become prominent. The main problems are insufficient security function and economy, and the effect of reducing the burden is not obvious.
At the national and provincial levels, the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients (Guo Ban Fa [202 1] 14) and the Implementation Measures for Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Sichuan Province (Chuan Ban Fa [2022] No.85) have been promulgated one after another, clearly improving the personal security.
Second, the significance of the promulgation of the Measures
Establishing and improving the economic security mechanism of medical insurance outpatient service for employees is a task deployment clearly put forward by the state and the province to deepen the reform of medical security system. This reform is conducive to enhancing the risk protection function of the medical insurance fund, returning to the origin of mutual assistance of social insurance, promoting the cooperative protection between family and society, giving full play to the strategic purchasing role of the medical insurance fund, optimizing the allocation of primary medical resources, improving the ability of primary medical services, guiding the masses to seek medical treatment at the primary level, and promoting the linkage of the three hospitals. According to the relevant requirements of the state and the province, the promulgation of the Measures is of great significance for promoting the fairness and sustainability of the system and giving play to * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *.
Three, the meaning of medical insurance outpatient * * * economic security mechanism
"* * * * economy" is also called "law of large numbers", which means to put everyone's money together and give it to people with risky events (diseases). * * * Same as the medical insurance outpatient service guarantee mechanism for employees. Simply put, in the past, the outpatient expenses of employees' medical insurance participants were mainly guaranteed by "personal accounts". Now, on the basis of personal accounts, they can also be guaranteed by "personal accounts". * * * The economic security for workers' outpatient service mainly includes general outpatient medical insurance for workers (hereinafter referred to as overall medical insurance for workers), drug security for workers' "two diseases" outpatient service and special outpatient disease security.
Fourth, the significance of personal account reform of employee medical insurance
First, in the past, the medical expenses incurred by insured employees in outpatient clinics could only be paid by personal accounts or cash, and they could not be reimbursed as a whole, so the medical security was insufficient; Second, the accumulated balance of personal accounts is large. From the perspective of macro big data, the accumulation of funds in personal accounts of employee medical insurance has increased year by year, and a large amount of funds in personal accounts are idle, which cannot be used for the overall economic security of medical expenses of insured patients; Third, there is no direct source of funds for the establishment of outpatient co-ordination, which should not be solved by raising the medical insurance rate.
Therefore, in accordance with the guidance of the state, the provincial government explicitly requires the reform of the personal account inclusion method, reduce the inclusion quota, and incorporate all the funds reduced by personal accounts into the overall fund management to ensure the operation of the outpatient co-ordination system.
Five, after the reform of employee medical insurance personal account changes
First, the method of calculating and distributing personal accounts has changed. On-the-job employees (including flexible employees) personal accounts are included in 2% of their insurance payment base, and the basic medical insurance premiums paid by the unit are all included in the overall fund; Retirees' personal accounts are allocated by the overall fund according to the quota, and the amount allocated is 2.8% of the average level of the city's basic pension in 2022. Individual construction coordinators do not establish individual accounts. After adjusting the overall fund and personal account structure, the amount included in personal account has decreased, and the increased overall fund is mainly used for outpatient economic security to improve the outpatient reimbursement treatment of insured persons.
For example, the payment base of an on-the-job employee is 80,000 yuan/year, and after the implementation of the new policy, the amount transferred to personal account is 80,000× 2% =1600 yuan/year (1333.3 yuan/month). If the average pension in our city is 46,500 yuan/year in 2022, after the implementation of the new policy, the personal account amount of retirees will be 46,500× 2.8% =1302 yuan/year (1008.5 yuan/month).
Second, the scope of personal accounts has changed. After the reform, the use of personal accounts has been further broadened, and personal accounts have benefited family members. The scope of use of personal accounts proposed in the Measures is: "It is mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies, and the personal contributions related to medical security such as basic medical insurance, supplementary medical insurance, serious illness insurance and long-term care insurance for urban and rural residents carried out by the government. Personal accounts shall not be used for public health expenses, sports and fitness, health care consumption, health checks and other expenses not covered by basic medical insurance. "
Six, enjoy the conditions of medical insurance outpatient co-ordination and protection treatment.
Those who participate in employee medical insurance and enjoy the treatment period can enjoy the overall protection treatment of employee medical insurance outpatient service according to the regulations.
Seven, employee medical insurance outpatient co-ordination reimbursement scope and standards.
The general outpatient expenses incurred by the insured workers in designated medical institutions, all medical expenses that meet the outpatient medication, examination and diagnosis in the basic medical insurance catalogue, are included in the reimbursement scope of the employee medical insurance outpatient co-ordination fund.
Eight, the meaning and amount of employee medical insurance outpatient co-ordination deductible.
Qifubiaozhun refers to the medical expenses actually incurred by the insured in designated medical institutions that fall within the scope of the policy. The medical insurance fund bears part of it before paying it in accordance with the prescribed proportion. The amount of medical expenses paid by the individual first is the deductible line for the medical insurance fund to pay the medical expenses of the insured, and the medical expenses below the deductible line are borne by the individual. The "Measures" stipulate that the on-the-job employees in the deductible line of medical expenses for employees' medical insurance clinics are 200 yuan and the retirees are 150 yuan; In a natural year, as long as the out-of-pocket expenses of active employees exceed 200 yuan and those of retired employees exceed 150 yuan within the policy scope, the excess can be reimbursed in proportion. The deductible is only paid once in a natural year, and the deductible is not calculated repeatedly every time you see a doctor.
Nine, after the implementation of the overall medical insurance policy for employees, the proportion of reimbursement for insured employees in designated medical institutions and in qualified designated retail pharmacies.
(1) The standard of overall treatment for employees' medical insurance outpatient service is: 200 yuan, an employee from the year of payment, and 150 yuan; Three designated medical institutions and retail pharmacies pay 50%, and two and below designated medical institutions pay 60%. Retirees will be increased by 10 percentage point on the basis of the above corresponding payment ratio. The formulation of policies has given retirees a certain policy inclination.
For example, the total expenses incurred by retired workers in the outpatient service of secondary designated medical institutions are 600 yuan, of which the medical expenses within the policy scope are 500 yuan, and the expenses within the non-policy scope are 100 yuan (the fund will not reimburse them). Within the scope of the policy, after deducting the deductible line 150 yuan from 500 yuan, the remaining 350 yuan will be reimbursed by 70%, and the reimbursement amount from the employee outpatient co-ordination fund will be (500 yuan).
(II) When the insured employees seek medical treatment or purchase medicines in designated medical institutions in other areas outside our city, the deductible line, reimbursement ratio and fund payment limit of the employee medical insurance outpatient service are consistent with that of the insured place (Yibin City).
Ten, employee medical insurance outpatient co-ordinate the annual payment limit
The annual payment limits for incumbents and retirees are 1.200 yuan and 1.600 yuan respectively.
The annual payment limit of outpatient co-ordination refers to the amount that the employee medical insurance fund can reimburse the insured at most in a natural year. After exceeding the annual payment limit, all medical expenses shall be borne by the insured himself.
Eleven, employee health insurance outpatient hypertension and diabetes.
Patients with hypertension and diabetes who participate in employee medical insurance and take medication (hereinafter referred to as "two diseases") are included in the scope of outpatient economic security, and patients with "two diseases" who meet the standards of outpatient special diseases are included in the scope of outpatient special diseases management, and the outpatient special diseases policy is implemented; Those who fail to meet the outpatient special disease standards, after being diagnosed as patients with two diseases by designated medical institutions according to the diagnosis and treatment norms and filed, the insured can enjoy medical insurance for two diseases, and the identification standards, medication scope, guaranteed treatment and management services are consistent with the medical insurance for urban and rural residents (the medical expenses for lowering blood pressure and blood sugar of patients with two diseases in designated medical institutions are reimbursed within the policy scope). The annual payment limit for hypertension is 200 yuan/person-year, and that for diabetes is 300 yuan/person-year. At the same time, the maximum payment limits of hypertension and diabetes are calculated together, and the expenses of hypertension drugs in 200 yuan and diabetes drugs in 300 yuan are reimbursed the most), which will be implemented from June 5438+ 10/day, 2023. The outpatient special disease policy and the "two diseases" outpatient drug guarantee policy shall not be enjoyed repeatedly.
Twelve, voluntary application to provide medical insurance outpatient co-ordination of drug security services pharmacy conditions.
Designated retail pharmacies with compliant qualifications, standardized management, good reputation, reasonable layout, docking of purchase, sale and storage management system and medical insurance system, electronic traceability of drugs sold, drug prices not higher than the online prices of similar products on the platform of centralized procurement of medical devices and medical price supervision in Sichuan Province, and supporting external prescription settlement and adjustment may voluntarily apply for providing medical insurance outpatient services for employees.
Those who have applied to become designated retail pharmacies of medical insurance but have not applied for outpatient co-ordination of medical insurance for employees will not affect their service of using employees' personal accounts.
Thirteen. Comparison of differences between old and new policies
Fourteen Implementation time
It will take effect from June 65438+1 October1day, 2023, and the validity period is 5 years.