Starting next year, the medical insurance for employees in our city will greatly increase the "capping line" for the use of pooling funds and lower the threshold for the use of pooling funds. It is expected that from February 1 2023, the specific measures for the use of family personal accounts will be implemented, allowing the money in personal medical insurance cards to pay for the medical expenses of spouses, parents and children.
Implement the "implementation plan"
To be insured
Provide a number of reform "dividends"
Ten Questions and Ten Answers on the Economic Security Policy of Medical Insurance Outpatient Service for Employees
Let's have a look!
1
ask
What are the deployment requirements of the state and the province for establishing and improving the economic security mechanism for employees' basic medical insurance outpatient service?
answer
In April last year, the General Office of the State Council issued the Guiding Opinions on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients (Guo Ban Fa [202 1] 14, hereinafter referred to as the Guiding Opinions), and the National Medical Insurance Bureau issued the Three-year Action Plan for Establishing and Perfecting the Economic Security Mechanism for Employees' Medical Insurance Outpatients (20265438). In February, 2002 1,1,the general office of the provincial government issued the Implementation Opinions on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients (Su Zhengban [202 1]108, hereinafter referred to as the Implementation Opinions). The main spirit is to adjust the overall fund and personal account structure in about three years, and the increased overall fund will be mainly used for outpatient medical insurance, so as to improve the outpatient treatment of insured persons, promote the transformation of employee medical insurance outpatient insurance from individual accumulation guarantee mode to social mutual medical insurance mode, and reduce the burden of outpatient medical expenses of the masses, especially retirees.
2
ask
What is the time schedule of Wuxi's implementation plan to implement the national and provincial deployment requirements?
answer
According to the requirements of national guidance and provincial implementation opinions, our city has issued an implementation plan to improve the ongoing outpatient co-ordination policy. The "Implementation Plan" of our city has been implemented since June 65438+ 10/day, 2023. At that time, the overall treatment level of outpatient service will be improved and the personal accounts of on-the-job employees will be adjusted. The policy of adjusting individual accounts of retirees will be reformed according to provincial regulations at the end of 2023, and will be implemented from June 65438+ 10/0/2024.
three
ask
What kind of outpatient co-ordination treatment can employees' medical insurance participants enjoy after the reform?
answer
The outpatient service covers the medical insurance of all insured employees as a whole, and the general outpatient expenses that exceed the Qifubiaozhun incurred by the insured in the designated medical institutions that meet the scope of the basic medical insurance policy are included in the payment scope of the outpatient service pooling fund. The first is to adjust the deductible standard (deductible line). From June 5438+1 October1day, 2023, the annual minimum payment standards for working and retired personnel will be adjusted to 500 yuan and 300 yuan respectively (the minimum deductible can be paid by personal account). The second is to set the proportion of medical insurance payment for different levels of medical institutions. From the original first visit to community medical institutions, the proportion of in-service and retirees' fund payment was 70% and 85% respectively, and it was adjusted to community health service institutions, and the proportion of in-service and retirees' outpatient co-ordination fund payment was 80% and 90% respectively; For medical treatment in primary and secondary medical institutions, the proportion of on-the-job and retirees' outpatient co-ordination fund payment is 75% and 85% respectively; In tertiary medical institutions, the proportion of in-service and retirees' outpatient co-ordination fund payment is 60% and 70% respectively. In the designated retail pharmacies and designated outpatient departments (the) and other policies within the scope of medical expenses (excluding prescriptions outside the prescription circulation platform), the overall fund payment ratio shall be implemented with reference to the payment ratio of tertiary medical institutions. The third is to raise the maximum payment limit (capping line). Within one year, the original fund paid 5,000 yuan and 6,000 yuan to the employees and retirees respectively, and the maximum payment limit of medical expenses within the policy scope was raised to12,000 yuan (among which the limit of compliance medical expenses paid by various funds in designated retail pharmacies and designated outpatient clinics was tentatively set at 2,000 yuan). The fourth is to optimize the payment order of medical insurance fund. From the original need to run out of personal account funds first, and then enter the outpatient department for overall protection, it is adjusted to: after reaching the "deductible line", you can use the overall fund. The use of funds has changed from individual account, deductible line and overall fund to deductible line and overall fund. At the same time, with the gradual adjustment of individual accounts and the enhancement of the affordability of the overall fund, the overall treatment of outpatient service will be gradually improved.
four
ask
How to improve the method of personal account calculation and payment?
answer
From June 5438+1 October1day, 2023, it will be included in the monthly basic medical insurance premiums paid by individuals in the personal accounts of on-the-job employees, and the inclusion standard is 2% of the insured payment base, and all the basic medical insurance premiums paid by the unit will be included in the overall fund; From June 65438+1 October1day in 2023, the personal accounts of retirees will be transferred according to the personal account allocation amount in 2022. From June 5438+1 October1in 2024, the specific calculation method and standard for adjusting the individual account amount of retirees to the average level of basic pension in Wuxi in 2023 will be determined by the municipal medical insurance department according to the provincial regulations.
Important reminder: On June 5438+1 October1day, 2023, the personal accounts of medical insurance for employees and flexible employees will no longer be unified and funded.
On-the-job employees and freelancers who choose to withhold and pay the monthly medical insurance premium will automatically inject capital every month, usually after 15 of the current month and at the latest on the 6th of the next month, which is normal during this time period; Freelancers who choose to pay by hand on a monthly basis will generally receive the payment within 7 working days after the payment is successful.
rise
individual
example
son
Through two cases, what changes have taken place in personal accounts and outpatient co-ordination in 2023:
Case 1: Zhao, a 35-year-old employee, has a monthly payment base of 5,000 yuan (assuming the three-year base remains unchanged); The annual outpatient medical expenses are about 3,000 yuan, and the drugs are Class A (that is, the full guarantee expenses in the medical insurance catalogue, excluding self-funded and self-care expenses); The balance of personal account in February 2002165438 was 0 yuan.
2022: June 65438+1October 65438+1October 0, 2022, and the personal account investment is 5000* 12*3%= 1800 yuan.
The annual medical expenses are 3000 yuan. Go through the formalities of outpatient co-ordination in community health center.
Spent 1000 in the first half of the year, all paid from personal accounts.
In the second half of the year, I spent 2,000 yuan in the community hospital, of which the personal account cost was 800 yuan, and the rest was reimbursed by 1.200-840 = 360 yuan.
Of the 3,000 yuan, the personal account shall pay 1.800 yuan, and the cash shall be paid to 360 yuan, and the personal burden shall be 2 1.60 yuan.
2023: 5000*2%= 100 yuan will be injected every month in 2023; Total for the whole year 1200 yuan.
The annual medical expenses are 3000 yuan, and they are also treated in community hospitals.
The expenses in the first half of the year are 1 000 yuan, of which the deductible line in 500 yuan is borne by the individual (which can be paid by the individual account), and the rest are reimbursed by the 500 yuan clinic as a whole, and the personal expenses are 500-400 yuan =1000 yuan.
In the second half of the year, 2,000 yuan is needed, 2,000 * yuan is reimbursed as a whole by the outpatient department, and the personal expenditure is 2,000-1600 = 400 yuan.
Of the 3000 yuan, the individual * * * bears 1000 yuan. If there is a balance in the personal account, it can be paid by personal account or by personal cash.
Case 2: Liu, a retired employee, is 6 1 year old, with a 22-year retirement salary of 4,000 yuan (assuming that the retirement salary will remain unchanged for three years), and the annual outpatient medical expenses are about10,000 yuan, and the drugs are Class A (that is, the full guarantee expenses in the medical insurance catalogue, excluding self-funded and self-care expenses); The balance of personal account in February 2002165438 was 0 yuan.
2022: June 65438+1October 65438+1October 0, 2022, and the personal account investment is 4000* 12*7%=3360 yuan.
The annual medical expenses are 10000 yuan. Go through the formalities of outpatient co-ordination in community health center.
In the first half of the year, it cost 4,000 yuan, personal account paid 3,360 yuan, outpatient department reimbursed 640* yuan as a whole, and personal payment was 640-544=96 yuan.
In the second half of the year, I spent 6000 yuan in community hospitals, including 6000 * yuan for outpatient reimbursement, and 6000-5 100 = 900 yuan.
10000 yuan, of which 3,360 yuan was paid by personal account, 996 yuan was paid by personal cash, and 4,356 yuan was paid by personal account.
2023: June 65438 +20231October 0, a one-time capital injection of 4000* 12*7%=3360 yuan.
The annual medical expenses 10000 yuan, all of which were treated in community hospitals.
In the first half of the year, it costs 4,000 yuan, of which the deductible line in 300 yuan is borne by individuals (personal account is ok), and the remaining 3,700 yuan is reimbursed by the outpatient department as a whole, 3,700 * yuan, and the personal expenditure is 3,700-3,330 = 370 yuan.
In the second half of the year, 6,000 yuan is needed, 6,000 * yuan is reimbursed as a whole by the outpatient department, and the personal expenditure is 6,000-5,400 = 600 yuan.
10000 yuan, the individual * * bears 1270 yuan, which can be paid by personal account. After payment, there is still a balance of 2090 yuan in the personal account.
It can be seen that through the coordinated reform of individual account and outpatient co-ordination policy, the medical insurance treatment level of general outpatient insured personnel has been significantly improved.
five
ask
How to adjust the treatment of chronic diseases and special diseases in outpatient department after reform?
answer
According to the unified outpatient chronic diseases and special diseases (hereinafter referred to as chronic diseases and special diseases) system in the province, our city will gradually standardize the scope and guarantee treatment of chronic diseases and special diseases in our city. We will continue to improve the outpatient economic security mechanism, and guide the outpatient chronic disease security to gradually transition to outpatient overall security by improving the general outpatient security benefits of employees' medical insurance.
In order to further improve the efficiency of the use of medical insurance funds and simultaneously promote the improvement of other medical insurance benefits in our city. First, increase the proportion of employees' hospitalization reimbursement; The second is to improve the medical insurance payment policy for medical materials; The third is to establish and improve subsidies for large medical expenses for employees. Relevant programs will be implemented simultaneously from 2023, and will be pushed after the introduction of specific policies. Please continue to pay attention to the official account of "Wuxi Medical Insurance" WeChat.
six
ask
What does a personal account mean to family members?
answer
Personal account funds are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions. After the reform, personal accounts can help family members in three aspects: first, they can be used to pay medical expenses incurred by insured persons and their spouses, parents and children in designated medical institutions; Second, it can be used to pay the expenses borne by the insured and their spouses, parents and children to buy medicines, medical devices and medical consumables in designated retail pharmacies. The scope of medical devices and medical consumables shall be uniformly formulated by the province; Third, it can be used for the insured to participate in large medical expenses subsidies (or serious illness insurance), long-term care insurance and other personal contributions, and explore personal accounts for spouses, parents and children to participate in the basic medical insurance for urban and rural residents. It is expected that from February 1 2023, the specific measures for the use of family personal accounts will be implemented.
seven
ask
What are the benefits of the reform for the insured and what are the special guarantees for the elderly retirees?
answer
The reform of outpatient economic security mechanism comprehensively considers the implementation of the strategy to deal with the aging population, and adopts three measures to improve the security level of retirees. First, it is clear that the overall outpatient treatment can be appropriately tilted towards retirees, which is mainly reflected in the fact that the deductible is lower than that of the on-the-job employee 200 yuan, and the payment ratio is higher than that of the on-the-job employee 10 percentage point. Second, personal accounts can help families. When the personal accounts of elderly retirees are not enough, the personal accounts of children who participate in employee medical insurance can be used to help families reduce the burden of medical expenses for the elderly. The third is to improve the outpatient special disease policy, and unify the city's outpatient special disease policy in accordance with the requirements of the Provincial Medical Insurance Bureau on unifying the basic medical insurance outpatient special disease policy.
eight
ask
What measures have been taken to strengthen the use of personal accounts and outpatient medical management?
answer
On the one hand, the "Implementation Plan" clarifies that personal accounts may not be used for public health expenses, sports and fitness or health care consumption, and other expenses that are not covered by the basic medical insurance; On the other hand, the "Implementation Plan" clarifies that the supervision of medical insurance funds should be strengthened, outpatient medical expenses should be included in the unified intelligent monitoring scope of medical insurance funds in the province, and laws and regulations such as the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds" should be strictly enforced to prevent personal accounts from being cashed out and used beyond the scope.
nine
ask
What measures does the reform take to improve the accessibility of medical services for the insured?
answer
First, support the external prescription settlement and adjustment of designated retail pharmacies, bring the drug guarantee services provided by qualified designated retail pharmacies into the scope of outpatient protection, and establish a prescription circulation platform. The proportion of drug expenses within the scope of the policy is consistent with that of designated medical institutions with external prescriptions, giving full play to the convenience and accessibility of designated retail pharmacies. Before the prescription circulation platform is deployed and has the implementation conditions, the proportion of fund payment of qualified designated retail pharmacies shall be implemented in accordance with the proportion of tertiary medical institutions. The second is to establish and improve the "dual-channel" drug use guarantee mechanism of national negotiated drugs, actively promote the landing of negotiated drugs, do a good job in linking the separate payment of drug expenses with the outpatient co-ordination policy, and explore the inclusion of qualified "internet plus" medical services in the scope of protection. Third, by promoting the construction of primary medical service system, improving the contract service of family doctors, and standardizing the management of long prescriptions, we will guide non-emergency insured personnel to seek medical treatment for the first time in primary medical and health institutions.
10
ask
How does the reform of outpatient payment method adapt to the requirements of the reform of outpatient economic security mechanism?
answer
The "Implementation Plan" clarifies that the total budget management of outpatient co-ordination fund should be improved, and the payment mode reform of outpatient medical insurance that is compatible with the outpatient economic security mechanism should be deepened. According to the characteristics of outpatient medical service, innovate the policy and management of medical insurance payment. Explore the payment method of per capita payment for outpatient service in primary medical institutions; For outpatient chronic diseases, actively explore the combination of per capita payment and chronic disease management; For daytime surgery and eligible outpatient special diseases, payment shall be made according to the disease type or according to the population related to disease diagnosis; For outpatient expenses that are not suitable for package payment, they can be paid by project.