policy interpretation of the measures for the implementation of the * * * economic security mechanism for workers' basic medical insurance outpatient service in Huai 'an

In order to further develop the function of co-ordination of workers' basic medical insurance and effectively reduce the burden of medical expenses for workers' medical insurance insured outpatients, according to the unified arrangements of the State Council and the provincial government, combined with the actual situation of our city, our city issued the measures for the implementation of the * * * economic security mechanism for workers' basic medical insurance outpatient service in Huai 'an, and now we interpret the relevant contents as follows.

1. Policy background of establishing * * * economic security mechanism for workers' basic medical insurance outpatient service in Huai 'an

Establishing and improving the * * * economic security mechanism for workers' medical insurance outpatient service is a major decision made in "Opinions of Central the State Council on Deepening the Reform of Medical Security System". In April and December, 221, the Guiding Opinions of General Office of the State Council on Establishing and Perfecting the Security Mechanism for Employees' Basic Medical Insurance Outpatients and the Implementation Opinions of General Office of the Provincial Government on Establishing and Perfecting the Security Mechanism for Employees' Basic Medical Insurance Outpatients were successively issued. The main requirements are to enhance the security function of outpatient clinics, improve the method of counting personal accounts, standardize the scope of use of personal accounts, and implement personal accounts for families. At the same time, the National Guiding Opinions and the Implementation Opinions of Jiangsu Province put forward the time limit requirements for establishing and improving the economic security mechanism of medical insurance outpatient service for employees.

II. Implementation Measures for Huai 'an

In order to implement the national and provincial government's guidance on outpatient * * * economic security, the municipal government office officially issued the Implementation Measures for the outpatient * * economic security mechanism of basic medical insurance for employees in Huai 'an, which will be implemented on January 1, 223, and the reform task will be completed by the end of 223.

III. Main contents of medical insurance outpatient service in Huai 'an Jianli

Establishment of a co-ordination system for general outpatient expenses of medical insurance for employees

The general outpatient expenses incurred by employees in designated medical institutions that meet the scope of basic medical insurance policies shall be paid by the basic medical insurance co-ordination fund in accordance with the prescribed proportion. In a natural year, the minimum payment standard for compliance medical expenses of general outpatient service is 6 yuan, with the maximum payment limit of 6, yuan, and outpatient service and hospitalization do not use the payment limit. The payment proportion of the first-class and below, second-class and third-class designated medical institutions was 7%, 65% and 6% respectively, and the retirees increased by 5 percentage points respectively.

Improve the method of personal account entry

From January 1, 223, the basic medical insurance premium paid by the individual in the personal account of on-the-job employees will be included, and the inclusion standard will be 2% of the base of the insured payment, and all the basic medical insurance premiums paid by the unit will be included in the overall fund; From January 1, 223, retirees' personal accounts will be included in the monthly quota according to the allocation scale of their personal accounts in 222. From January 1, 224, the amount of retirees' personal accounts will be uniformly adjusted to 2.5% of the average level of basic pensions in Huai' an in the year when the reform was implemented according to the opinions. For flexible employees who do not receive pensions, the personal account allocation standard remains unchanged. The insured person shall change his/her personal account into the proportion from the second month of retirement when he/she changes his/her basic medical insurance relationship to retirement.

Adjust and optimize the payment scope of personal account

Since January 1, 223, 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, a personal account family benefit mechanism will be established according to the provincial regulations, and family members will benefit from it in three aspects: first, it can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions; Second, it can be used to pay for the expenses borne by the insured himself, his spouse, parents and children to buy medicines, medical devices and medical consumables at designated retail pharmacies; Third, it can be used for the insured to participate in personal contributions such as large medical expenses subsidies for employees and long-term care insurance, and explore personal accounts for the personal contributions of spouses, parents and children to participate in basic medical insurance for urban and rural residents. At the same time, the "Implementation Measures" stipulates that personal accounts shall not be used for public health expenses, physical fitness or health care consumption, which are not covered by the basic medical insurance.

Enhance the accessibility and convenience of outpatient service

After the reform, the insured workers can enjoy the corresponding outpatient service in the designated medical institutions of medical insurance according to the corresponding regulations. Relying on the provincial prescription circulation platform, the drug security services provided by qualified designated retail pharmacies will be included in the scope of outpatient security, and the settlement and dispensing of external prescriptions in designated retail pharmacies will be supported. The payment ratio of drug expenses pooling funds within the policy scope is consistent with that of designated medical institutions with external prescriptions, giving full play to the convenience and accessibility of designated retail pharmacies.

adjust and improve the outpatient special disease policy

implement the system of chronic diseases and special diseases in outpatient medical insurance for employees in the whole province, and unify the scope of special diseases in outpatient. For those who are not included in the scope of outpatient special diseases in the province, continue to implement the current outpatient special disease treatment policy in our city. For outpatient special diseases whose treatment level is higher than the existing outpatient special disease protection level after outpatient co-ordination, the transition will be based on outpatient co-ordination protection.

in short, through the new system function transformation, all the basic medical insurance premiums paid by the unit will be included in the overall fund, which will better solve the problem of outpatient security for employees' medical insurance participants and achieve the system result of * * * economic security and improving management efficiency.

In the next step, the Municipal Medical Insurance Bureau, together with the Municipal Finance Bureau and other departments, will further combine the actual situation of our city, do a good job in implementing policies in a classified and step-by-step manner, properly handle the policy convergence before and after the reform, further optimize the structure of employee medical insurance funds, improve the personal account management mechanism, enhance the security function of medical insurance funds, strictly follow the requirements of the municipal party committee and municipal government, improve the working mechanism, strengthen organizational leadership, ensure the smooth and orderly implementation of policies, and complete various tasks on schedule.