In order to implement the social insurance law, further improve the basic medical insurance policy for urban workers (hereinafter referred to as "medical insurance") and ensure that the insured enjoy medical insurance benefits according to law, the municipal government has decided to adjust the relevant policies on medical insurance, and the relevant matters are hereby notified as follows:
First, medical insurance implements the system of combining the minimum payment period with the actual payment period.
(a) to participate in medical insurance to implement the payment period system, the payment period includes the deemed payment period and the actual payment period.
(2) Before the start of the medical insurance system in our city on August 1 2000, the insured workers reached the length of service or working years stipulated by the state and the province, which was regarded as the payment period as medical insurance; The actual payment period of medical insurance only refers to the actual payment period of employee medical insurance after August 2000 1.
(three) the insured to enjoy medical insurance benefits for retirees, must also meet the following conditions:
1. Insured persons who have reached the statutory retirement age and gone through retirement formalities are in a state of continuous participation before retirement;
2. Cumulative payment period of medical insurance, 25 years for males and 20 years for females;
3. The actual payment period exceeds 10 years.
Insured persons who meet the provisions of the preceding paragraph will no longer pay the basic medical insurance premium after retirement and enjoy the medical insurance benefits for retirees.
The insured who has gone through the retirement formalities and enjoyed the old-age insurance benefits, but has not reached the above-mentioned prescribed period of time, can enjoy the medical insurance benefits for retirees in accordance with the prescribed payment base and proportion after paying or continuing to pay the prescribed period of time.
(four) the specific measures for the implementation of the payment period shall be formulated by the municipal human resources and social security department.
Two, adjust the proportion of medical insurance units.
(a) the proportion of the insured units to pay the basic medical insurance premium is adjusted from 7% to 9%. The contribution ratio of 2% of the insured remains unchanged.
(2) Persons who have terminated their labor (personnel) relationship with the employer, and other flexible employees who have participated in medical insurance, can pay the basic medical insurance premium at the rate of 1 1% and enjoy the basic medical insurance benefits; You can also pay the basic medical insurance premium at the rate of 6% and enjoy the medical insurance benefits of hospitalization (including family beds), but it is not included in the personal account fund and does not enjoy the outpatient treatment paid by the overall fund. Choose the above insurance form and do not change it within one overall year.
Three, appropriately reduce the proportion of basic medical insurance premiums included in personal accounts, and reduce the funds for outpatient co-ordination.
Pay the basic medical insurance premiums to determine the proportion of individual accounts according to the insured persons of different ages:
1 and the proportion under 35 years old (including 35 years old) was adjusted from 3% to 2.5%;
2. The proportion of people aged over 36 to 45 was adjusted from 3.3% to 2.8%;
3.46 years of age or older (including 46 years of age) retirement ratio was adjusted from 4.2% to 3.7%;
The proportion of retirees under the age of 4.69 is adjusted from 6% to 5%; The proportion of retirees over 70 years old and old workers who participated in revolutionary work before the founding of the People's Republic of China was adjusted from 7% to 6%.
Four, appropriately expand the scope of use of personal account funds.
On the basis of the original specified use (paying the expenses of medical insurance coverage in the self-funded part such as hospitalization, outpatient service, medicine purchase and family sickbed). , co-ordinate the fund Qifubiaozhun costs, and pay my serious illness medical assistance costs, health examination, vaccination and other expenses), personal account fund balance expanded to pay for all quasi-brand drugs outside the medical insurance drug list, but the expenses are not included in the Qifubiaozhun.
Five, adjust the city hospitalization Qifubiaozhun.
(1) Qifubiaozhun for hospitalization in the city: the tertiary medical institution was adjusted from 800 yuan to 900 yuan; Secondary medical institutions were adjusted from 300 yuan to 400 yuan; The qifubiaozhun for first-class medical institutions and community health service institutions 100 yuan remains unchanged. Low-income, poor (refers to the poor workers who hold the "Xuzhou Poor Workers' Card", the same below) and severely disabled people are subject to 50% of the above standards; Retirees under the age of 69 (inclusive) are subject to 65% of the above standards, and retirees over the age of 70 (inclusive) and old workers who participated in revolutionary work before the founding of the People's Republic of China are subject to 50% of the standards.
(2) The Qifubiaozhun for hospitalization in secondary and tertiary medical institutions for many times in a co-ordination year is reduced by 100 yuan in turn, but the minimum for tertiary medical institutions is not lower than that for 300 yuan, and the minimum for secondary medical institutions is not lower than that for 200 yuan.
(III) For the insured who enjoy the treatment of specific outpatient items, the accumulative Qifubiaozhun for outpatient and inpatient services in the whole city in the same overall year shall not exceed 10% of the average wage of employees in non-private units in cities and towns in our city in the previous year.
(four) the minimum living security, poverty and severe disabilities should apply for registration, and the medical insurance agency shall conduct an annual audit.
Six, the adjustment of outpatient co-ordination (including general outpatient service, some chronic diseases, the same below), the implementation of outpatient co-ordination, outpatient specific projects to choose designated units for medical treatment, drug purchase management.
(a) the scope of outpatient co-ordination fund payment. The outpatient co-ordination fund mainly pays medical insurance class A drugs (including essential drugs), general medical expenses and other medical expenses that meet the requirements, as well as the expenses of Chinese herbal pieces within the scope of medical insurance payment.
(2) The outpatient co-ordination deductible line in a co-ordination year is 1.500 yuan. Minimum living security, extremely poor and severely disabled persons shall be implemented by 50%; Retirees under the age of 69 (inclusive), retirees over the age of 70 (inclusive) and old workers who participated in revolutionary work before the founding of the People's Republic of China are subject to 65% and 50% chronic diseases respectively.
(three) outpatient co-ordination, outpatient specific projects for medical treatment temporarily designated unit management. The insured should choose 1 designated primary medical institutions, 1 designated secondary or tertiary hospitals and 1 designated retail pharmacies to purchase medicines. Insured persons who enjoy specific outpatient programs can only choose 1 designated medical institutions for medical treatment. Once the designated unit is selected, it shall not be changed as a whole within one year in principle. If the designated units are not selected according to the regulations, the expenses incurred will not accumulate the outpatient Qifubiaozhun, and they will not enjoy the outpatient treatment paid by the overall fund.
In the selected designated units and Class A pharmacies, the expenses incurred are included in the outpatient co-ordination Qifubiaozhun.
When the expenses for medical treatment and drug purchase exceed the outpatient co-ordination Qifubiaozhun in the overall year, only the medical expenses that continue to occur in the selected designated medical institutions and Class A pharmacies can be subsidized by the outpatient co-ordination fund according to the regulations.
Except for medical treatment, emergency treatment and first aid in Chinese medical institutions designated by specialist clinics and medical insurance, the expenses for medical treatment and drug purchase in other designated units other than the choice can only be paid by personal account funds, which are not included in the outpatient co-ordination Qifubiaozhun, and the co-ordination fund will not be paid.
According to the spirit of the Opinions of the Provincial Health Department and other six departments on Establishing Up-and-Down Linkage, Division of Labor and Cooperation Mechanism between Public Hospitals and Urban and Rural Grassroots Medical and Health Institutions (Su Weiyi [2011] No.70), the municipal health department will take the lead in establishing the diagnosis and treatment mode of "first diagnosis, graded medical care, quick and slow referral, and two-way referral" as soon as possible. Grassroots medical and health institutions should be established with superior hospitals. With the two-way referral,
(4) The scope of outpatient drugs for chronic diseases is increased by Class A drugs for medical insurance on the basis of the original drugs for chronic diseases.
(5) The outpatient co-ordination fund shall subsidize the expenses incurred by the insured in the basic medical and health institutions (including love hospitals) that implement zero-difference sales of essential drugs that exceed the Qifubiaozhun; In other primary medical institutions and Class A retail pharmacies, 70% subsidies will be given; In secondary hospitals, the subsidy is 60%; In tertiary hospitals, the subsidy is 50%. For retirees under the age of 69 (inclusive), retirees over the age of 70 (inclusive) and old workers who participated in revolutionary work before the founding of the People's Republic of China, the subsidy ratio will be increased by 5 and 10 percentage point respectively.
(six) in a co-ordination year, the maximum subsidy limit of the general outpatient co-ordination fund is 1200 yuan. On this basis, the number of chronic diseases in tertiary outpatient service increased to 1.500 yuan, 2,000 yuan in secondary outpatient service and 2,500 yuan in primary outpatient service.
Seven, adjust the civil service Medicaid approach
(a) the standard for raising Medicaid funds for civil servants is still 4% of the total wages of employees and retirees in the previous year. The civil servants' Medicaid funds raised are transferred to personal accounts on a monthly basis according to the standard of 1% of the salary base, which can be used for outpatient treatment and can be carried forward; The rest of the subsidy funds are used for outpatient chronic diseases, outpatient specific projects, hospitalization and other medical subsidies.
(two) the medical expenses of chronic diseases in civil servants' outpatient clinics are subsidized by the basic medical insurance outpatient co-ordination fund, and the medical expenses incurred after reaching the maximum subsidy limit are re-subsidized by the civil servants' subsidy fund; The scope of payment, proportion and limit of subsidy are the same as the basic medical insurance outpatient co-ordination.
(three) Medicaid for specific items of civil servants' hospitalization and outpatient service is still implemented according to the original provisions.
Eight, to further improve the medical expenses settlement and medical insurance drug payment management measures.
(1) Designated medical institutions shall appropriately increase the total amount of special control and settle accounts at the end of the year in accordance with the Diagnostic Criteria for Critical Emergency Inpatients in Jiangsu Province; Through the implementation of clinical pathway management by the health department, the payment for single disease in hospital is actively promoted.
(two) on the basis of ensuring the basic medical needs, set the highest payment limit standard for drugs with the same dosage form and specifications in the medical insurance drug list; For drugs that mainly play an auxiliary therapeutic role in class B drugs, the proportion of personal advance payment should be appropriately increased, and the proportion of payment should be opened with other class B drugs.
The specific measures shall be formulated by the municipal human resources and social security department in conjunction with the municipal health and finance departments.
Nine, the establishment of medical subsidy mechanism for seriously ill patients and vulnerable groups.
Every year, according to the budget growth of the medical insurance fund, special funds are reserved for Medicaid for seriously ill patients and low-income, poor and severely disabled people in that year. The specific plan shall be formulated by the municipal human resources and social security department in conjunction with the financial department.
Ten, the establishment of uninsured medical insurance fund to participate in the incentive mechanism.
For the insured who have not used the medical insurance fund during the overall planning year, you can choose one of the following incentives:
1. If the accumulated personal account of the insured exceeds 1000 yuan, a "exclusive card" can be applied in the following year. The part of the personal account that exceeds 1000 yuan can be used to pay individuals or relatives to see a doctor at a designated medical institution and buy medicines at a designated retail pharmacy, and can also be used for fitness consumption.
The transfer standard of exclusive card is: personal account 100 1 yuan to 2,000 yuan, and you can apply for transfer to 500 yuan at most; 200 1 yuan to 5000 yuan, the highest application can be transferred to 1000 yuan; 500 1 yuan to 10000 yuan, and the maximum application can be transferred to 2000 yuan; 1000 1 yuan or more, the maximum application can be transferred to 3000 yuan.
2, do not choose to apply for the "exclusive card" of the insured, the following year from the overall fund into their personal account 50 yuan, used to pay for serious illness medical assistance.
Application method of "exclusive card": if there is an employer, I will apply for it and the employer will handle it uniformly; If an individual is insured, he/she shall apply and the agency shall go through the relevant formalities.
XI。 Supplementary Provisions (1) This circular shall be implemented as of 20 12 1. If the provisions of the previous documents are inconsistent with this notice, this notice shall prevail.
(two) counties (cities), tongshan district according to local conditions, can refer to this notice.
(3) The municipal administrative department of human resources and social security shall be responsible for the interpretation of this notice.
20 1 1 year1February 22nd