Document number: Tianjin Renshefa [2015] No.38.

Issue date: 20 15-03- 14

Notice on printing and distributing the main points of Tianjin medical insurance and maternity insurance

County Human Resources and Social Security Bureau, Municipal Social Insurance Fund Management Center, Municipal Medical Insurance Supervision and Inspection Institute, and all relevant units:

The main points of Tianjin medical insurance and maternity insurance are hereby printed and distributed to you, please implement them carefully.

March 1 1

Key points of medical insurance and maternity insurance in Tianjin

The general requirements of medical insurance and maternity insurance in the city are: under the guidance of the spirit of the Third and Fourth Plenary Sessions of the 18th CPC Central Committee, fully implement the deployment of the city's human social security work conference, persist in reform and innovation and administration according to law, persist in safeguarding and improving people's livelihood, improve the system, strengthen refined management, optimize the handling process, lay a solid foundation for development, and promote the sustainable development of medical insurance and maternity insurance.

First, deepen the reform of the medical insurance payment system around the fund balance.

We will continue to fully and accurately implement the measures for the management of total medical insurance, adhere to fairness, openness and transparency, adhere to total control, and do a good job in fund liquidation and fund disbursement. Establish a medical insurance total management assessment system. Formulate the assessment methods of diabetes door-to-door identification center and the management methods of diabetes door-to-door head payment assessment. Focus on designated medical institutions at the grassroots level, and gradually promote the door-to-door payment system for diabetic patients. Accelerate the formulation of the per capita payment method for other diseases, and promote one when it is mature.

Two, comprehensively sort out the basic medical insurance system for employees, and implement the requirements of administration according to law.

Organize the medical insurance department to systematically sort out the existing employee medical insurance related policies from three aspects: policy, handling and supervision, improve the employee medical insurance policy system according to the Social Insurance Law and the Tianjin Basic Medical Insurance Regulations, and formulate corresponding implementation rules and handling management measures.

Third, cooperate with deepening medical reform and do a good job in medical insurance management and service.

Introduce medical insurance supporting policies to support the reform of public hospitals in Binhai New Area. To meet the requirements of drug price reform, we will study and introduce policies and measures to improve the payment standard of medical insurance drugs. In accordance with the unified deployment of the city, promote the settlement of medical insurance network in village clinics.

Four, accelerate the standardization of "two sets of three eyes" and improve the level of refined management.

Study and learn from the bidding model to adjust and improve the management methods of new designated medical service institutions. Develop the network management system of medical insurance "two fixed" and realize the normal management of "two fixed" information. To explore the application of medical insurance drug coding system in medical insurance supervision and drug use evaluation. Began to develop a coding system for diagnosis and treatment projects. Formulate the access catalogue of medical consumables and develop the coding system. Formulate the management catalogue of hospital preparations and Chinese herbal pieces.

Five, improve the supervision service mode, and promote the maintenance of medical order.

Upgrade the real-time monitoring system of medical insurance to realize both behavior supervision and cost trend monitoring. So that the mobile terminal of on-site law enforcement can realize the organic combination of network monitoring and on-site supervision. Realize real-time monitoring of medical expenses of medical (work-related injury) insurance hospitalization. Explore the real-time monitoring of credit card medical treatment in village clinics. Continue to carry out special medical insurance inspection and realize the integration of "technical defense network, legal defense network and group defense network". Implement the requirements of Ministry of Human Resources and Social Security and the Ministry of Public Security on strengthening the investigation and transfer of social insurance fraud cases, and establish a case transfer mechanism. Start the pilot work of dismantling and selling outpatient drugs.

Six, fully realize the daily upload of hospitalization expenses and intelligent audit of medical expenses, and optimize the audit mode.

Take the daily upload fee list as the basis for the discharge settlement of insured patients, pay close attention to the quality of uploaded data, and formulate and maintain the audit rule base. Study the accounting method of inter-annual hospitalization expenses to realize one-time settlement and one-time audit of inter-annual hospitalization expenses.

Seven, the implementation of remote medical settlement requirements, accelerate the construction of information platform.

According to the major strategic deployment of Beijing-Tianjin-Hebei coordinated development and the requirements of Ministry of Human Resources and Social Security and other departments to do a good job in the settlement of medical expenses in different places, we will study the settlement platform for medical treatment in different places with Beijing and Hebei, improve the management policy and operation mechanism of medical treatment settlement in different places, and research and develop an information management system.

Eight, improve the maternity insurance system, improve management efficiency.

Implement a new payment method for maternity medical expenses, from fixed payment to production times. The standard is 3,800 yuan for employees and 2,280 yuan for residents. At the same time, according to the maternity insurance benefits of employees, the reimbursement level of maternity insurance for residents will be adjusted from 50% to 60%. Study the socialized distribution policy of maternity allowance. Further improve the policy system of maternity insurance for urban and rural residents, and make preparations for improving the legislative level of maternity insurance.

Nine, to carry out medical insurance policy evaluation, evaluation system performance.

Explore the establishment of medical insurance policy evaluation and effect evaluation mechanism, focusing on the evaluation of the implementation effect of medical insurance fund budget management, diabetes head payment, maternity insurance and medical insurance drugs. Establish a statistical analysis software system suitable for policy evaluation. Through evaluation, explore the establishment of a medical insurance decision-making mechanism with expert argumentation, public participation and risk assessment.

Ten, innovative insurance payment methods, improve the coverage of medical maternity insurance.

Explore the national insurance registration system, and actively promote online payment for urban and rural residents on the basis of online payment for employees. Do a good job in urban and rural residents, especially students and children's insurance in advance. By the end of the year, the number of medical insurance participants should reach10.25 million, and the participation rate should be stabilized at over 95%. The number of people participating in maternity insurance should reach 7.79 million.

Eleven, the implementation of new financing standards, improve the ability of fund support.

Starting this year, the employer's medical insurance rate will be adjusted from 10% to1%,and the rate of civil servants and management units with reference to the civil service law will be adjusted from 9% to 1 1%; The personal rate of enterprises in difficulty and urban areas was adjusted from 7.3% to 8%. The per capita government subsidy of the insured residents increased 150 yuan, reaching 670 yuan, and the level of individual contributions increased at the same time 10 yuan. Students and children are from 70 yuan, and adult residents are from 90 yuan, 320 yuan and 620 yuan. According to the national and municipal arrangements, timely study and determine the funding standards for residents' medical insurance.

Twelve, enhance the management ability of residents' medical insurance, improve management efficiency.

Some opinions on implementing the measures for the administration of residents' medical insurance. Strengthen the construction of student medical insurance service center and improve the service level. Standardize the management of social security cards in student medical insurance centers. Improve the efficiency of reimbursement of medical expenses for students. In line with the reform of public hospitals, the scope of outpatient and emergency medical treatment for urban and rural residents will be expanded to secondary hospitals that carry out the reform of public hospitals.

Thirteen, strengthen the management of residents' serious illness insurance and accidental injury additional insurance, and standardize the handling services.

Do a good job in the liquidation of residents' serious illness insurance and accidental injury additional insurance funds. Further improve the convergence of residents' serious illness insurance, basic medical insurance and medical assistance system, and guide underwriting commercial insurance companies to do a good job in handling services. Integrate and standardize the management of accidental injury insurance for students and children, and sign an entrustment management agreement with the company that underwrites additional accidental injury insurance. Focus on serious diseases and implement a special rescue mechanism for serious illness insurance.

Fourteen, improve the Medicaid and medical assistance policies, do a good job of convergence.

Re-formulate the measures for Medicaid for civil servants. We will continue to do a good job in urban and rural medical assistance and medical subsidies for special care recipients, and improve the connection and "one-stop" service with the basic medical insurance and residents' serious illness insurance system. Cooperate with civil affairs to do a good job in medical assistance for people with special difficulties once every six months.

Fifteen, promote the overall management of units in Tianjin, the implementation of municipal planning.

In conjunction with the municipal finance and SASAC, formulate measures for the implementation of medical insurance for enterprises in some industries into the overall management of the city.

Sixteen, increase publicity and training and scientific research, improve the level of public opinion and scientific decision-making.

Under the guidance of the Bureau's Propaganda Department, the new policies, new measures and key tasks were thoroughly and systematically publicized by using the media platform of the Medical Insurance Research Association. Continue to do a good job in the research of medical insurance topics such as elderly care insurance and medical insurance integrity management mechanism.

Seventeen, to do a good job in the proposal reply, to ensure the quality of handling.

Complete the replies to the suggestions and proposals of the deputies to the NPC and CPPCC on time and with good quality, ensure the telephone communication between the organizer and the individual organizer, and ensure the satisfaction rate of 100%. Hold a special meeting on medical insurance proposal attended by some representatives in due course.

Eighteen, give play to the functions of the county human resources and social security departments, and do a good job in the management of primary medical insurance.

Do a good job in the management, publicity and training of residents' insurance. Based on the residents' medical insurance service center, we will explore adding medical insurance supervision and inspection functions in some districts and counties.

Nineteen, from the nuances, do a good job of routine basic work.

Do a good job in maintaining the information of synonyms of "two definitions" and drug list. Do a good job in the verification of employers with difficulties in paying fees to ensure that the medical insurance benefits of retirees are not affected. Do a good job in adjusting the employer's medical insurance payment rate from "serious illness" to "unified account combination". Establish a regular meeting system for handling letters and visits by multiple departments to resolve conflicts in time.