Chapter I General Provisions
Article 1 In order to further improve the mutual aid responsibility system of employees' basic medical insurance (hereinafter referred to as employee medical insurance), optimize the use structure of medical insurance funds, improve the use efficiency of medical insurance funds, better solve the outpatient security problem of insured personnel, and effectively reduce their daily medical expenses, According to 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 Notice of the General Office of Shandong Provincial People's Government on Printing and Distributing the Implementation Plan for Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Shandong Province (Lu Zhengban Fa [202 1
The second basic principle. Adhere to the best and do what you can; Insist that everyone is responsible and everyone enjoys it; Adhere to the basic guarantee and make overall plans; Adhere to a smooth transition and maintain policy continuity; Adhere to synergy, improve the outpatient service guarantee mechanism and improve the personal account system, and gradually change; Adhere to local conditions, proceed from reality, and actively explore effective ways to strengthen the outpatient security of employee medical insurance; Adhere to the linkage of systems and simultaneously promote the reform of the security mechanism for residents' outpatient services.
Article 3 These Detailed Rules shall apply to employees and retirees, flexible employees and retirees of various enterprises, institutions, social organizations and private non-enterprise units participating in medical insurance for employees in our city.
Article 4 All relevant departments should cooperate closely to form a joint force to ensure the orderly progress of reform. The municipal medical security administrative department is responsible for the overall coordination of the medical insurance outpatient service for employees in our city. Medical insurance agencies are specifically responsible for the collection, management, treatment review and payment of general outpatient funds; Responsible for establishing a unified and standardized handling business process. The financial department shall cooperate with the supervision and management of the medical insurance fund; The health department is responsible for strengthening the supervision and assessment of medical institutions and promoting the standardized diagnosis and treatment behavior of designated medical institutions; The market supervision department is responsible for strengthening the supervision of drug circulation and cracking down on illegal activities such as drug reselling.
Chapter II General Outpatient Service
Fifth, reform the personal account of employee medical insurance. The basic medical insurance premiums paid by individual employees are all included in my personal account, and the standard is 2% of my insured payment base. From June 5438+ 10, 2023, the basic medical insurance premium paid by the unit will be reduced to 50% of the current standard; The policy of recording individual accounts of retirees remains unchanged. From June 5438+ 10, 2024, the basic medical insurance premiums paid by employees will no longer be included in individual accounts, but will be included in the overall fund; Individual accounts of retirees are allocated by the overall fund according to the quota. For retirees under 70 years old, the quota will be uniformly adjusted to 2% of the average basic pension in 2023, and for retirees over 70 years old, the quota will be uniformly adjusted to 2.5% of the average basic pension in 2023. On-the-job retired employees will be included in personal accounts according to the standards of retirees from the next month. Flexible employees shall enjoy the basic medical insurance benefits for retirees according to the regulations, and the personal account policy shall be implemented with reference to these regulations.
Article 6 In a natural year, the Qifubiaozhun for first-class and below, second-class and third-class medical institutions are 50 yuan, 500 yuan and 700 yuan respectively, and the maximum payment limit for general outpatient medical care is 3,000 yuan; The medical expenses within the scope of the general outpatient policy above the threshold and within the maximum payment limit shall be paid by 60%, 60% and 50% respectively, and the implementation time shall be from June 65, 2023 to 2023 10. From June 5438+ 10, 2024, the maximum payment limit for general outpatient service was raised to 4,000 yuan, and the proportion of retirees increased by 5 percentage points.
Long-term residents in different places seek medical treatment in outpatient clinics, and the reimbursement policy of medical institutions at the same level in our city is implemented. Temporary medical personnel go out for outpatient treatment in other co-ordination areas, and the outpatient medical expenses are paid 10%, and the treatment policy of medical institutions at the same level in our city is implemented.
Seventh general outpatient medical insurance for employees to co-ordinate the implementation of the basic medical insurance drug list, diagnosis and treatment items, medical service facilities and payment standards.
Eighth workers medical insurance general outpatient co-ordination fund will not be paid:
(a) shall be paid by the industrial injury insurance fund;
(2) It shall be borne by a third party;
(three) shall be borne by public health;
(4) Going abroad for medical treatment;
(5) General outpatient medical expenses incurred during hospitalization;
(six) other relevant provisions shall not pay the cost of the project.
Chapter III Chronic Diseases and Special Diseases in Outpatients
Ninth workers suffering from provincial and municipal basic medical insurance outpatient medical expenses of chronic diseases and special diseases, included in the scope of payment of chronic diseases and special diseases. The scope and treatment standard of chronic diseases and special diseases in outpatient department of workers are dynamically adjusted according to the progress of personal account reform. The specific plan shall be formulated separately by the Municipal medical insurance bureau in conjunction with the Municipal Finance Bureau.
Tenth, according to the fund's affordability and the level of general outpatient support, explore the establishment of a conversion mechanism for outpatient support, and promote the transition of some chronic diseases and special diseases from disease support to cost support.
Article 11 For some drugs that are clinically necessary, expensive, irreplaceable, suitable for outpatient treatment and not included in the scope of outpatient chronic diseases and special diseases, a separate drug payment policy shall be formulated with reference to the treatment methods of outpatient chronic diseases and special diseases. Day surgery and day ward shall be settled with reference to hospitalization medical insurance benefits.
Article 12 Support the settlement and adjustment of prescriptions outside designated retail pharmacies, bring the outpatient drug guarantee services for chronic diseases and special diseases provided by qualified designated retail pharmacies into the scope of outpatient service for employees, implement a unified reimbursement ratio with designated medical institutions, and combine the annual Qifubiaozhun with the annual maximum payment limit. The qualified "internet plus" medical service will be included in the scope of medical insurance payment, and the online payment channel for chronic disease follow-up medical insurance will be opened through the medium of medical insurance electronic certificate, so as to realize online registration, online follow-up, online prescription dressing change, prescription circulation, medical insurance payment, drug distribution and other service functions.
Chapter IV Medical Management
Thirteenth strict management of the use of personal accounts, personal accounts are mainly used to pay the insured's out-of-pocket expenses in designated medical institutions or designated retail pharmacies, and can also be used to pay the following expenses:
(a) medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions;
(two) the expenses incurred by the insured and their spouses, parents and children in purchasing drugs, medical devices and medical consumables at designated retail pharmacies;
(three) spouses, parents and children to participate in the basic medical insurance for urban and rural residents, long-term care insurance, government-guided commercial supplementary medical insurance and other personal contributions.
Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance.
Fourteenth outpatient co-ordinate the implementation of contract management, the implementation of grass-roots first diagnosis, two-way referral system. The insured in the designated medical institutions for medical treatment, should be issued by my medical insurance electronic certificate or social security card and other insurance certificates; The attending doctor should carefully check the identity to ensure that the witnesses are consistent.
Fifteenth improve the outpatient payment mechanism, general outpatient, outpatient chronic diseases and special diseases to implement a multi-payment method based on head payment, supplemented by disease payment.
Article 16 Improve the assessment methods of designated medical institutions for medical insurance, establish a statistical analysis system for outpatient expenses, regularly monitor abnormal indicators such as rapid growth of medical expenses, high per capita expenses, high proportion of patients' own expenses, high proportion of examination expenses, excessive use of off-catalogue items, and guide designated medical institutions to standardize diagnosis and treatment services. Incorporate outpatient medical services into the agreement management system of designated medical insurance institutions, quantify the contents of the agreement, strengthen daily assessment, link the assessment results with the year-end liquidation of medical insurance, renewal and termination of the agreement, and encourage medical institutions to strengthen self-management.
Article 17 Strictly supervise the medical insurance fund, focusing on investigating and dealing with illegal acts such as impersonation, fictitious medical services, forging medical documents or bills, falsely recording the expenses of drugs, consumables, diagnosis and treatment items and medical service facilities, "increasing the price during operation", exaggerating the condition or curative effect, forcing patients to accept medical treatment and consumption, overtreatment, and overdose.
Chapter V Supplementary Provisions
Eighteenth improve the security mechanism of residents' medical insurance outpatient service, and steadily improve the security level of residents' general outpatient service. By 2024, the reimbursement amount of general outpatient service will be increased by about 50% on the existing basis. We will steadily improve the level of outpatient chronic diseases and special diseases. In 2024, the proportion of outpatient chronic diseases and special diseases will be no less than 65%.
Nineteenth staff outpatient economic security mechanism has new provisions, from its provisions.
Article 20 These Detailed Rules shall come into force on June 65438+1 October1day, 2023, and shall be valid until February 3, 2027. If the original policy content of our city is inconsistent with the provisions of these rules, these rules shall prevail.