First, the basic model

In-patient overall planning+outpatient overall planning

Hospital overall planning includes: general hospitalization, medical treatment for major diseases, and normal delivery in hospital; Outpatient co-ordination includes: general outpatient service and large outpatient service for special diseases.

Second, raise funds.

The individual payment of rural residents is not less than 60 yuan per person per year; The central and local governments provide 280 yuan subsidies to participating rural residents every year. The fund-raising standard is not less than 340 yuan per person per year for participating rural residents.

Three. allocation of funds

(a) outpatient co-ordination fund

The outpatient co-ordination fund is used for large outpatient compensation for rural residents' general outpatient service and special diseases. The general outpatient co-ordination fund is extracted from all co-ordination areas according to the local actual situation, and each rural resident is not less than 40 yuan; The withdrawal amount of the large-scale outpatient co-ordination fund for special diseases is determined by each co-ordination area according to local conditions.

(two) the hospitalization fund

The hospitalization fund was established after deducting outpatient co-ordination, general medical expenses and risk funds from the total amount of funds raised in the current year, and was used to participate in the compensation for general hospitalization of rural residents, the compensation for medical treatment of major diseases, and the subsidy for normal delivery. The distribution of general hospitalization compensation, medical compensation for major diseases and the subsidy fund for normal delivery in hospital shall be determined by the overall planning areas according to local conditions.

(3) risk fund

After raising the level of fund-raising, the venture fund should be supplemented to make its scale reach 10% of the total fund in that year.

(4) General medical expenses

General medical expenses are used for compensation of general outpatient clinics at township and village levels, and outpatient co-ordination and zero-difference sales of drugs are implemented. In 20 13 years, the subsidy amount for general medical expenses of the new rural cooperative medical system is determined in principle according to the standard that each participant is not less than 16 yuan. According to the use of funds and the payment of general medical expenses in the previous year and the requirements of document No. The provincial government's 20 1 142, governments at all levels can increase after 20 1 1.

(five) the proportion of hospitalization compensation for drugs listed in the national essential drugs list (equipped and used by primary medical and health institutions) and the non-essential drugs list in Hebei Province increased by 5 percentage points; Increase the proportion of compensation for traditional Chinese medicine (including: Chinese patent medicines, Chinese herbal pieces, Chinese medicine diagnosis and treatment items and Chinese medicine preparations listed in the reimbursement catalogue of the new rural cooperative medical system). The specific compensation measures shall be formulated by the overall planning areas according to the payment capacity of the local new rural cooperative medical fund.

Fourth, compensation for medical expenses.

Outpatient overall compensation

1, general outpatient co-ordination compensation

Outpatient co-ordination compensation is limited to township and village designated medical institutions. There is no deductible for outpatient compensation; Widen the compensation gap between designated medical institutions at township and village levels, and the compensation ratio can generally be set at 45%-50% at village level and 40%-45% at township level; The capping line of annual outpatient compensation for rural residents can be set as 100- 150 yuan. In order to ensure the rational and effective use and safe operation of the outpatient co-ordination fund, counties (cities, districts) that carry out outpatient co-ordination should reform the payment method, establish an index system to control outpatient expenses, implement the total budget of outpatient co-ordination compensation funds, limit the average outpatient expenses in towns and villages, establish an assessment system, link the assessment results with the distribution of compensation funds, effectively strengthen the supervision of designated medical institutions, strictly regulate service behavior, and curb fraud. The compensation scheme for outpatient co-ordination shall be formulated according to local conditions in the co-ordination area.

2. Large outpatient compensation for special diseases

Counties (cities, districts) should reasonably determine the special diseases compensated by the new rural cooperative medical system (generally not less than 15) on the basis of baseline investigation and according to the local data such as the prevalence rate of special diseases, outpatient service rate and annual per capita outpatient expenses, formulate the overall compensation scheme for large-scale outpatient services for special diseases, and reasonably set the deductible line, compensation ratio and capping line.

Special diseases such as radiotherapy and chemotherapy for malignant tumor, leukemia, psychosis and hemophilia shall be compensated with reference to the compensation measures for inpatients.

Types of special diseases (for reference):

High risk of hypertension and above Grade III, rheumatic heart disease, cor pulmonale, myocardial infarction, various chronic heart failure, sequelae of cerebrovascular disease (with serious dysfunction), chronic moderate and severe viral hepatitis, liver cirrhosis, chronic nephritis, diabetes (with serious complications), malignant tumor radiotherapy and chemotherapy, leukemia, hemophilia, aplastic anemia, rheumatoid arthritis (with serious limb dysfunction), systemic lupus erythematosus, epilepsy and chronic nephritis.

For special diseases, individuals shall fill in a written application, and the appraisal team of designated medical institutions at the county level designated by the health administrative department at the county level shall identify and issue a diagnosis certificate, which shall be reported to the health administrative department at the county level for examination and confirmation, and the new rural cooperative medical system agency at the county level shall register. Patients with special diseases shall be reimbursed for medical expenses with outpatient medical records, prescriptions and charging vouchers of designated medical institutions of the new rural cooperative medical system.

(2) Hospitalization compensation

The overall compensation scheme for hospitalization of the new rural cooperative medical system is formulated by the counties (cities, districts) that carry out the new rural cooperative medical system. The general requirements are: to make full use of the fund to ensure that the participating rural residents benefit to the maximum extent; Within the scope of the policy, the proportion of hospitalization expenses is about 75%.

1, general hospitalization compensation

(1) Deductible (RMB)

Town level 100- 150

County level 300-400

Municipal 800- 1200

Provincial level 1500

Outside the province level 3 and above 3000-4000

note:

(1) If the same rural resident is hospitalized again due to different diseases in the same year, the deductible should be deducted again (except for diseases that require multiple hospitalizations such as malignant tumors).

(2) If the insured rural residents are transferred from the superior medical institution to the lower medical institution for continuous hospitalization due to the same disease, the hospitalization deductible line of the lower medical institution shall not be deducted when calculating the hospitalization compensation expenses of the lower medical institution; If the hospitalization from a lower medical institution is transferred to a higher medical institution for further hospitalization, the deductible expenses of the lower medical institution shall be deducted from the deductible of the higher medical institution when calculating the hospitalization compensation expenses.

(2) Compensation ratio

85%-90% at the township level

70%-80% at county level

Municipal 60%-68%

Provincial 55%

Outside the province level 3 and above 45%-55%

note:

① Participating rural residents can independently choose the designated medical institutions of the new rural cooperative medical system in the overall planning area. Because of illness need referral, designated medical institutions should handle the referral procedures in time, patients or their families according to local regulations to the county-level new rural cooperative medical institutions for approval and filing. Due to special reasons such as urgency, danger and severity of illness, patients or their families can't go through the referral filing formalities in time, and should report to the participating institutions of the new rural cooperative medical system in time and go through the relevant formalities within the prescribed time limit.

The participants live in different places, and the medical expenses incurred in the designated medical institutions of the new rural cooperative medical system agreed in different places shall be compensated according to the provisions of the new rural cooperative medical system.

(3) If the newborn is not within the payment time limit at birth, it will enjoy the treatment of the new rural cooperative medical system with its participating parents, and the compensation expenses incurred will be merged with their parents 1. Newborns are exempted from the participation fee of the year, which is not included in the number of participants in the year, and governments at all levels do not provide additional subsidies.

④ Under any of the following circumstances, the new rural cooperative medical system shall compensate according to the compensation scheme based on the actual payment of rural residents:

First, the medical services received are subsidized by special funds;

Two. The medical services received are reduced or exempted by medical institutions.

(3) the capping line

The capping line is 90,000 yuan per person per year. The annual cumulative calculation of the capping line includes hospitalization compensation, hospitalization subsidy for normal delivery, general outpatient co-ordination compensation, large outpatient compensation for special diseases and secondary compensation for serious diseases. Medical compensation for major diseases shall be calculated separately.

2. Medical treatment of major diseases

Medical treatment of congenital heart disease, leukemia, female cervical cancer, breast cancer, severe mental illness, renal dialysis of end-stage renal disease, multidrug-resistant tuberculosis, opportunistic infection of AIDS, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, type I diabetes, hyperthyroidism, cleft lip and palate, etc. Should be carried out according to the implementation plan issued by the provincial health department.

3, normal delivery hospital delivery allowance

On the basis of the national hospital delivery subsidy program, the new rural cooperative medical system is subsidized according to the standard of each case in 300 yuan.

(3) Secondary compensation

In order to make full use of the new rural cooperative medical fund and ensure the maximum benefit of rural residents, counties (cities, districts) whose overall fund balance (including risk funds) exceeds 15% or whose accumulated fund balance exceeds 25% over the years should formulate a secondary compensation plan according to the balance, and give secondary compensation to rural residents who were hospitalized or/and had a large number of outpatient clinics for special diseases in that year. Through the second compensation, the utilization rate of the overall fund reached more than 85% in that year, and the balance rate of the overall fund was controlled within 25% over the years.

(4) critical illness insurance compensation.

Shijiazhuang, Tangshan and other pilot cities exploring the implementation of serious illness insurance for urban and rural residents should do a good job in effectively connecting the basic medical insurance with the serious illness insurance policy and expense settlement, strengthen the monitoring of medical expenses, and properly formulate the compensation ratio of medical expenses according to the requirements of the Implementation Opinions on Developing Serious Illness Insurance for Urban and Rural Residents (No.64 [2013]) jointly issued by the provincial development and Reform Commission and other six departments to ensure the normal operation of the fund.

Counties (cities, districts) of the new rural cooperative medical system as a whole compensation scheme shall be submitted to the Municipal Health Bureau, Finance Bureau for examination and approval, promulgated and implemented after the approval of the people's government at the county level, and reported to the Provincial Health Department and the Department of Finance for the record.

CC: Provincial New Rural Cooperative Medical Management Center.

Issued by the Health Department Office of Hebei Province on 20 13 10 3 1.

For the second reimbursement, there are generally the following situations:

First, because the compensation scheme of the new rural cooperative medical system in this area is too conservative and the fund balance of the new rural cooperative medical system is too much, general provincial departments have documents stipulating that the fund balance to be controlled by the new rural cooperative medical system in that year should not exceed 15%, and in some places it is 20%. If it is exceeded, secondary compensation must be implemented, mainly for patients with major diseases with high hospitalization expenses and low reimbursement outside the county, and individual cases may involve the county level. Whether the conditions for the second reimbursement are met depends on whether the first reimbursement amount is met. Therefore, in this case, the second reimbursement is not available to every participating patient.

The second is the second reimbursement for serious illness assistance. At present, most areas have implemented serious illness relief policies. In other words, some common diseases with high cost and heavy family burden will be included in the scope of serious illness relief, such as congenital heart disease, leukemia and most cancers. This policy subsidizes the new rural cooperative medical system by 70%, and the civil affairs department bears 20%, and the total reimbursement ratio reaches 90%. Some farmers call 20% of the reimbursement from the civil affairs department as secondary reimbursement, which is basically available in all provinces and autonomous regions.

Third, the special care recipients of civil affairs (minimum living allowance, five guarantees, and military special care) were hospitalized after participating in the new rural cooperative medical system. After the reimbursement of the new rural cooperative medical system, civil affairs can compensate more, but not much. The highest capping line here is only 5000 yuan.

Extended reading:

Reimbursement scope of new rural cooperative medical system

1, outpatient compensation:

(1) village clinics and village center clinics are reimbursed 60%, and the prescription drug fee limit for each visit 10 yuan, and the prescription drug fee limit for temporary rehydration for doctors in health centers is 50 yuan.

(2) Reimbursement for medical treatment in town health centers is 40%. The limit of examination fee and operation fee for each visit is 50 yuan, and the limit of prescription drug fee is 100 yuan.

(3) The reimbursement for medical treatment in secondary hospitals is 30%, and the limit of each examination fee and operation fee is 50 yuan, and the limit of prescription drug fee is 200 yuan.

(4) 20% reimbursement for medical treatment in tertiary hospitals, with the limit of each examination fee and operation fee in 50 yuan and the limit of prescription drug fee in 200 yuan.

(5) The prescription attached to the invoice of traditional Chinese medicine is limited to 1 yuan.

(6) The annual compensation limit for rural cooperative medical clinics is 5,000 yuan.

2, hospitalization compensation

(1) Reimbursement scope:

A. Drug expenses: auxiliary examination: the expenses for ECG, X-ray fluoroscopy, radiography, laboratory tests, physical therapy, acupuncture, CT and nuclear magnetic resonance are limited to 200 yuan; Surgical expenses (refer to the national standard, reimbursement exceeding 1000 yuan 1000 yuan).

B, the elderly over 60 years old are hospitalized in Xingta Town Health Center, and the daily treatment and nursing expenses are compensated 10 yuan, with the limit of 200 yuan.

(2) Reimbursement ratio: town hospitals reimburse 60%; 40% reimbursement for secondary hospitals; Third-level hospitals are reimbursed 30%.

3. Compensation for serious illness

(1) town risk fund compensation: where the medical expenses of inpatients participating in rural cooperative medical insurance exceed 5,000 yuan at one time or throughout the year, they should be compensated by stages, that is, 5001-kloc-0/0000 yuan will be compensated by 65%,10001-.

(2) The annual compensation limit for hemodialysis, radiotherapy and chemotherapy in the town-level cooperative medical system inpatient and uremia clinic is1.65,438+0.000 yuan.

The following are not included in the scope of reimbursement of rural cooperative medical insurance:

1. Medical treatment at one's own expense (no designated hospital or referral form), drugs purchased at one's own expense, drugs that cannot be reimbursed according to the regulations of public medical care and medical expenses that do not meet the requirements of family planning;

2, outpatient treatment fees, visits, hospitalization fees, meals, escort fees, nutrition fees, blood transfusion fees (except for family blood storage, according to the relevant provisions of reimbursement), heating and cooling fees, ambulance fees, allowances and other expenses;

3. Medical expenses for car accidents, fights, suicides, alcoholism, industrial accidents and medical accidents;

4. Orthopedics, plastic surgery, dental implants, artificial limbs, organ transplantation, roll call surgery fees, consulting fees, etc.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.