In terms of establishing and improving the outpatient co-ordination of medical insurance for employees, Nanjing will establish a new outpatient co-ordination policy from June 5438+ 10/June 2023, optimize and integrate the original outpatient co-ordination of medical insurance for employees and the outpatient chronic disease policy, and merge them into a new outpatient co-ordination policy to realize the transformation from basic medical insurance disease protection to cost protection, and improve the fairness and accessibility of outpatient security treatment. After the implementation of the Measures, the level of outpatient treatment will be improved. First, the Qifubiaozhun was abolished, and the original outpatient co-ordination and outpatient chronic disease Qifubiaozhun (ranging from 600 to 2,200 yuan) was abolished. The new outpatient co-ordination policy does not set the minimum payment standard. The second is to raise the upper limit of outpatient expenses. The new outpatient co-ordination fee payment limit covers the original outpatient co-ordination and the original outpatient chronic disease fund payment limit, which is generally improved. The annual outpatient fee limit is increased from the original 3333 yuan10.2 million yuan to10.5 million yuan. The third is to implement cost segmentation guarantee. The higher the outpatient medical expenses, the higher the proportion of overall fund payment; And appropriate to the primary medical institutions and retirees, the cost is below 1 ,000 yuan (inclusive), and the fund payment ratio is 40%-60%; 1000 yuan (excluding)-5,000 yuan (including), and the fund pays 60%-85%; 5000 yuan (excluding)-1.5 million yuan (including), and the fund pays 65%-90%. In addition, Nanjing will also expand the form of outpatient support. Support the external prescription settlement and adjustment of designated retail pharmacies, and include the drug security services provided by qualified designated retail pharmacies into the scope of outpatient security. Within the scope of the policy, the payment ratio of the drug cost pooling fund is consistent with that of the designated medical institutions with external prescriptions, and the convenience and accessibility of designated retail pharmacies are fully brought into play.
After the implementation of the Measures, on the basis of the original four special diseases, such as malignant tumor, dialysis treatment of chronic renal failure, anti-rejection treatment after organ transplantation (including hematopoietic stem cells) and hemophilia, nine new diseases were added, totaling 13. Nine new special diseases are aplastic anemia, systemic lupus erythematosus, intracranial benign tumor, myelofibrosis, motor neuron disease, chronic renal failure without dialysis treatment, tuberculosis, severe mental disorder and AIDS. From 65438+ 10/month 1, the payment limit is cancelled, which is linked to the course of disease. Adjust the annual fund payment ceiling for various diseases. The maximum payment limit of the fund is no longer linked to the course of disease, and is set according to the original maximum payment limit. For example, for outpatient treatment of malignant tumors, the original policy was that the upper limit of outpatient auxiliary examination and medication fund payment was 20,000 yuan/year in 1-3 years, and the upper limit of fund payment was 1 10,000 yuan/year in 4-5 years, and it was 4,000 yuan/year from the sixth year; After the adjustment of malignant tumor diagnosis, the upper limit of outpatient auxiliary examination and drug use fund payment is 20 thousand yuan/year. After the implementation of the Measures, the proportion of medical insurance fund payment will increase. For example, for outpatient treatment of malignant tumors, the original policy was that the proportion of radiotherapy and chemotherapy funds was 92%-96%, and the proportion of auxiliary drug testing funds was 90%-95%; The new policy has been raised to 92%-96%. Systemic lupus erythematosus (SLE), a special disease newly included in outpatient service, originally implemented the outpatient chronic disease policy, and the proportion of fund payment ranged from 60% to 95% according to the nature of the population and medical institutions, and the new policy was uniformly raised to 92% to 96%.
After the implementation of the Measures, the personal account entry policy will also be adjusted. Including, starting from June 5438+ 10, 2023, the basic medical insurance premium paid by individuals in the personal accounts of on-the-job employees shall be included, and the inclusion standard shall be 2% of the insured payment base. From June 5438+ 10, 2023, the personal account of retired (retired) personnel will be transferred to the monthly quota according to the amount allocated in my personal account in February 2022; In 2023, the new retirees in that year will be transferred according to 5.4% of the pension in the month of retirement, which will be included in the quota in that month. If the employee's medical insurance insured person turns to retirement on the job, after going through the relevant formalities, the employee's medical insurance retiree's personal account will be included in the implementation measures from the next month. From June 5438+ 10, 2024, according to the relevant provisions of the state and the province, the policy of calculating and issuing personal accounts for retirees will be adjusted. After the implementation of the Measures, personal account funds will be mainly used to pay out-of-pocket expenses within the policy scope of designated medical institutions and help their family members. There are ten main payment methods.
In addition, starting from June 65438+1 October1,Nanjing will also establish a personal account health incentive mechanism. Those who participate in the medical insurance for employees in Nanjing in a natural year will not be paid from the overall fund (including sporadic reimbursement of medical expenses, excluding outpatient medical expenses, general medical expenses and nucleic acid detection fees paid from the overall fund), and the increase in personal accounts in the following year will be included in 200 yuan, and those who are not paid from the overall fund for two consecutive years will be increased by 100 yuan, with a cumulative increase in 300 yuan. And so on, the highest does not exceed 500 yuan.