Policy Interpretation of Fushun City's Implementation Plan for Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients

According to the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance (Guo Ban Fa [202 1] 14) and the Implementation Opinions of the General Office of Liaoning Provincial People's Government on Establishing and Perfecting the Outpatient Security Mechanism of Employees' Basic Medical Insurance (Liao Zhengban Fa [202 1] 39), the implementation plan is now explained as follows.

I. Background and basis

200 1, the city established the basic medical insurance for urban workers. At present, the premium is paid by the insured units and individuals according to the "7.5+2" model (retirees no longer pay), and personal accounts are set up. The proportion of personal account allocation is: 2.5% for those under 45 years old (inclusive); 3.0% from 46 to 55 years old; From 56 to 69 years old, it decreased by 4.0%; 4.8% of people over 70 years old (inclusive), which is higher than the individual contribution rate, indicating that some pooled funds are included in individual accounts. In 20021year, the funds allocated by the overall fund to individual accounts accounted for 52% of the total collection income. At the same time, the pressure of increasing income is increasing, and a large amount of funds raised are deposited in personal accounts, which can not play the role of mutual assistance in medical insurance. In 20021year, the general office of the State Council and the general office of the provincial government issued documents one after another, demanding the establishment of an overall medical insurance system for employees' general outpatient clinics this year, and simultaneously promoting the reform of individual accounts.

Second, the formulation process

Based on the scientific analysis of the data of medical treatment and drug purchase of employees' medical insurance participants in recent three years, combined with the bearing capacity of the medical insurance fund of employees in our city, and in accordance with the principle of "fixed income and expenditure, balance of payments and slight balance", the data model of outpatient economic security system in our city is calculated, and the outpatient economic reform plan of our city is formed. Comments have been sought from the public and relevant departments, and submitted to the executive meeting of the municipal government for deliberation and approval after the legality review.

Third, the main content

The main changes of this reform:

The first is to reduce the transfer of personal accounts. The individual accounts of employees who enjoy the treatment of unified accounts are included in 2% of their insurance payment base, and the basic medical insurance premiums paid by employers are all included in the overall fund; The individual account of retirees who enjoy the treatment of unified account and combined account shall be included in the quota by the overall fund, and the quota shall be included in 2% of the average basic pension of retirees in 2022 (when our city reformed), and calculated according to 60 yuan/month.

The second is to establish a general clinic as a whole. Previously, the employee medical insurance system was centered on hospitalization, and the outpatient support was relatively weak, limited to personal accounts and limited outpatient chronic diseases and special diseases, and the burden of outpatient medical expenses was heavy. After the reform, the general outpatient expenses can be reimbursed by the medical insurance co-ordination fund, the Qifubiaozhun is not lower than that of 400 yuan in principle, the maximum payment limit is not lower than 5,000 yuan in principle, and the proportion of fund payment within the policy scope is not lower than 50%, and retirees are appropriately inclined to reduce the burden of outpatient expenses of insured workers.

The third is to expand the use of personal accounts. Previously, personal accounts could only pay the medical expenses of employees themselves. After the reform, it will be extended to cover the medical expenses of employees' spouses, parents and children.

Fourth, the treatment of chronic diseases and special diseases in some outpatient clinics will be steadily transitioned. In this reform, some outpatient chronic diseases and special diseases with long treatment cycle and heavy cost burden are retained, and at the same time, outpatient chronic diseases and special diseases with frequently-occurring diseases and common diseases such as hypertension and diabetes are included in the scope of general outpatient care, so as to realize the transition of outpatient medical expenses from disease protection to cost protection.

Fourth, work highlights

This reform is a major system adjustment since the establishment of the employee medical insurance system, involving the vital interests of 850,000 insured persons in our city. Through the reform of employees' personal medical insurance account, we can raise funds for the outpatient medical expenses of the insured, enhance the economy of outpatient medical insurance, improve the efficiency of fund use, correspondingly improve the accessibility of outpatient medical services, and reduce the burden of outpatient medical expenses of the masses, especially the elderly with high prevalence.