Notice on unifying the reimbursement and compensation scheme of 20 10 for the new rural cooperative medical system in the whole city Jining Municipal Health Bureau Jining Municipal Civil Affairs Bureau Jining Municipal Finance Bureau Jining Municipal Agriculture Bureau Wiki Jifufa [2009] No.35 Notice on unifying the reimbursement and compensation scheme of 20 10 for the new rural cooperative medical system in the whole city counties and cities Health Bureaus, Civil Affairs Bureaus, Agriculture Bureaus, Social Development Bureaus and Finance Bureaus of Jining High-tech Zone Management Committee, Jining Beihu Resort Management Committee Office and Finance Branch: In order to fully implement the implementation opinions of the Municipal Party Committee and Municipal Government on further deepening the reform of the medical and health system (J.F. [2009] 17) and the notice of the municipal government on printing and distributing the recent key implementation plan for the reform of the medical and health system (2009-20 1 1) (J.F.) According to the requirements of the Provincial Health Department, The Opinions of the Provincial Civil Affairs Department, the Provincial Department of Finance and the Provincial Department of Agriculture on Consolidating and Developing the New Rural Cooperative Medical System (Lu Wei Nong Wei Fa [2009] No.5), combined with the actual situation of our city, are hereby notified as follows about the unified reimbursement and compensation scheme for the new rural cooperative medical system in 20 10. First, the financing standard is 20 10. In the year, the financing level of the new rural cooperative medical system will be raised to not less than 120 yuan per person per year. Among them, the financial subsidies at all levels will be raised to not less than 100 yuan per person per year, and individual farmers will pay 20 yuan every year. On the basis of the provincial finance (including the central subsidy) subsidizing 45 yuan for each participating farmer in our city, the municipal finance subsidizes 6 yuan for each participating farmer in Yanzhou City, Zoucheng City and Jining High-tech Zone, 10 yuan for each participating farmer in Shizhong District, rencheng district City, Qufu City, Weishan County and Beihu Resort, and surabaya county City, Yutai County, Jinxiang County, Jiaxiang County and Wenshang. The difference is partly made up by the county (city, district) level finance, and the financing level of the new rural cooperative medical system is raised to not less than 150 yuan per person per year at 201year, in which the government subsidies at all levels are not less than 120 yuan, and the individual contributions of farmers are not less than 30 yuan. Encourage qualified places to appropriately raise local financial subsidies and farmers' payment standards according to their own financial resources and farmers' affordability. Second, the compensation model in 20 10, the city continued to implement the model of co-ordination of hospitalization and outpatient service. Outpatient co-ordination fund (including health examination fees, etc.). ) generally does not exceed 35% of the total amount of funds raised in the current year, while the hospital pooling funds and risk funds extracted in that year are generally not less than 65% of the total amount of funds raised in that year. The extraction of risk funds shall be carried out in accordance with the provisions of the document of the Provincial Department of Finance and the Provincial Health Department 18. Three, hospitalization compensation 1, hospitalization deductible line set up four deductible lines, a designated medical institution 100 yuan, two or three designated medical institutions in 500 yuan, 600 yuan designated medical institutions outside the city. The deductible line of hospitalization compensation is deducted within the scope of compensation, and no compensation is paid. Participating farmers are hospitalized in the same hospital, and only one deductible is deducted within one year. 2. The proportion of hospitalization compensation is 65% for first-class designated medical institutions, 55% for second-class designated medical institutions, 45% for third-class designated medical institutions and 35% for provincial-level designated medical institutions. Counties (cities, districts) can float on this basis, but not more than 5%. When calculating the actual compensation amount of participating farmers, deduct the deductible amount from the reportable expenses, and then compensate according to the prescribed compensation ratio. The implementation of security compensation, the actual compensation ratio of hospitalization in medical institutions at or above the county level is not less than 25%. For those who have been hospitalized in designated medical institutions outside the province and have not been referred for the record, they can be compensated according to 60% of the prescribed compensation ratio; Those who have not been referred for medical treatment outside the province or in non-designated medical institutions in the province (except for medical treatment and emergency treatment for migrant workers in the workplace) will not be compensated. 3, to participate in the natural delivery of pregnant women in hospital quota compensation 200 yuan. Cesarean section is still carried out according to the requirements of the management method of "four unifications and four fixings". For the medical expenses incurred by newborns born between the last payment period and the next payment period, their mothers can enjoy the compensation policy of the new rural cooperative medical system. 4 hospitalization compensation capping line is 50 thousand yuan, and the hospitalization compensation capping line is calculated according to the actual compensation amount obtained in that year. 5, migrant workers and farmers participating in sudden illness can first see a doctor, and inform the new rural cooperative medical institutions in the overall planning area within one week before discharge or by telephone, and the hospitalization expenses will be compensated according to the compensation ratio of local designated medical institutions at the same level with relevant certificates. 6. Significantly increase the proportion of national compensation for essential drugs, and increase the proportion of drug compensation in the list of essential drugs by 10%. Appropriately increase the proportion of compensation for Chinese medicine services, increase the proportion of compensation for Chinese medicine expenses (excluding proprietary Chinese medicines) by 10%, and increase the proportion of compensation for acupuncture and other appropriate Chinese medicine treatment expenses for inpatients by 90%. 7, strengthen departmental cooperation, do a good job in the policy, technology, service management and cost settlement of the new rural cooperative medical care and rural medical assistance system. Establish a unified service platform for the new rural cooperative medical system and rural medical assistance at the county level, realize the information sharing of the two systems, and implement a "one-stop" service for poor farmers to settle the compensation for the new rural cooperative medical system and medical assistance subsidies in medical institutions on the spot after seeking medical treatment, so as to facilitate poor farmers. 4. Non-hospitalization compensation 1. Outpatient compensation is generally compensated in the first-level and village-level designated medical institutions of the new rural cooperative medical system (village-level medical institutions not included in the integrated management of rural health services shall not be used as designated medical institutions of the new rural cooperative medical system). There is no deductible line, and the outpatient expenses are compensated according to the proportion of 20%. The top line of outpatient reimbursement compensation expenses per person per year is 50 yuan, and the actual compensation amount obtained during the year is calculated cumulatively. 2. Compensation for chronic diseases should include the following diseases: hypertension (phase II), heart disease complicated with cardiac insufficiency, cerebral hemorrhage and cerebral infarction recovery period, rheumatoid arthritis, chronic active hepatitis, chronic obstructive emphysema and cor pulmonale, epilepsy, hepatolenticular degeneration, decompensated cirrhosis, diabetes with ineffective diet control, chronic nephritis, Parkinson's disease, systemic lupus erythematosus, intervertebral disc herniation, chronic pelvic inflammatory disease and adnexitis, tuberculosis and schizophrenia. Chronic diseases should be organized by the county-level new rural cooperative medical institutions for expert appraisal or early medical record verification. Patients with chronic diseases voluntarily choose a county-level designated medical institution to treat chronic diseases, and make compensation in the selected county-level designated medical institution or county-level new rural cooperative medical service agency. The deductible line is 200 yuan, and the expenses below the deductible line are compensated according to the proportion of outpatient compensation. The compensation ratio above the deductible line is 40% (nominal compensation ratio), and the annual cumulative ceiling line (compensation income) is 1 1,000 yuan. The funds are paid by the outpatient co-ordination fund. Large outpatient treatment expenses for special diseases such as radiotherapy and chemotherapy for malignant tumor, aplastic anemia, hemophilia and organ transplantation anti-rejection treatment shall be implemented with reference to hospitalization compensation in hospitals at the same level. Patients with special diseases voluntarily choose county-level designated medical institutions for treatment, and make compensation in the selected county-level designated medical institutions or county-level new rural cooperative medical institutions. The deductible line is 400 yuan, and the expenses below the deductible line are compensated according to the proportion of outpatient compensation, while the expenses above the deductible line are compared with the hospitalization compensation in the same hospital. The annual cumulative capping line (compensation income) is 5000 yuan. The expenses for dialysis treatment of chronic renal insufficiency and large-scale outpatient treatment of leukemia are compensated according to the hospitalization in the same hospital, with the deductible line in 400 yuan and the annual cumulative top line (compensation income) of 50,000 yuan. The above funds are paid from the hospitalization fund. 3. Secondary compensation Secondary compensation is not a normal compensation method, and secondary compensation is not advocated. However, in places where there are many fund balances in that year or accumulated fund balances over the years, farmers who received serious illness compensation in that year can generally get secondary compensation, not just a few farmers. At the same time, it is necessary to do a good job in the organization, publicity and publicity of secondary compensation, so as to avoid unnecessary treatment comparison among participating farmers. 4. If the participating farmers participate in commercial medical insurance or meet other preferential policies at the same time, they should first implement commercial insurance compensation or preferential policies, and then compensate the total medical expenses of the participating farmers according to the compensation provisions of the new rural cooperative medical system. V. Continue to implement the "one-card system in the city" In order to further facilitate the participating farmers to go to the designated medical institutions of the new rural cooperative medical system at all levels in the city for medical reimbursement, continue to implement the "one-card system in the city", and the designated medical institutions of the new rural cooperative medical system announced by the Municipal Health Bureau recognize each other in this city. Where the participating farmers go to the designated medical institutions of the new rural cooperative medical system at all levels in Jining City for medical treatment, they will no longer go through the referral procedures. Participating farmers are hospitalized in the new rural cooperative medical institutions recognized by each other and enjoy the reimbursement and compensation ratio of designated medical institutions at the same level as stipulated by participating farmers. Six, clear the scope of insurance in accordance with the provisions of the general office of the provincial government "on comprehensively promoting the new rural cooperative medical system pilot work notice" (Lu Zhengban made [2007]1No.), clearly define the coverage of the new rural cooperative medical system and medical insurance for urban residents, to avoid repeated insurance (insurance). Strictly implement the principle that the new rural cooperative medical system takes households as the unit, and the participants should be registered as agricultural household registration residents. Whether the place where the household registration system is reformed is a rural resident can be defined according to the family planning policy, the veterans resettlement policy and the urban minimum living security policy enjoyed by their families. Primary and middle school students and preschool children with rural household registration should join the new rural cooperative medical system with their parents. Seven, strengthen supervision and management, to ensure standardized operation, strict implementation of the new rural cooperative medical system basic drug list, diagnosis and treatment items list and guiding principles of antibiotic use and other relevant provisions, reasonable inspection, reasonable treatment, gradient medication, reasonable compatibility, no drug abuse, no prescription. Discharged patients should follow the prescription. Generally, the discharge dosage for acute diseases is less than 7 days, and that for chronic diseases is less than 15 days. The system of mutual recognition of inspection results of medical institutions shall be implemented. If the superior hospital has inspected and issued an inspection result report, the lower hospital shall recognize it, and the inspection result report issued by the hospital at the same level shall recognize each other to avoid repeated inspection. The off-list drugs and medical treatment notification system shall be implemented, and the proportion of off-list drugs in the total medical expenses shall not be higher than 5%, 10%, 15% and 20% respectively in the village and the first, second and third-level designated medical institutions. The supervision departments of the new rural cooperative medical system at all levels should implement the notification and warning system of the average hospitalization medical expenses, and regularly announce the medical expenses of the designated medical institutions of the new rural cooperative medical system to the public in an appropriate way. County (city, district) new rural cooperative medical management departments and designated medical institutions at all levels should formulate specific measures, strengthen the audit management of medical expenses, put an end to illegal expenditures of the new rural cooperative medical fund, and cancel the qualification of the new rural cooperative medical designated medical institutions in violation of the regulations on the management of the new rural cooperative medical system, and severely deal with the relevant responsible persons in accordance with relevant regulations. Eight. Description 1. 20 10 to 1 Implement the unified reimbursement and compensation scheme of the whole city. 2, in the city to continue to implement the new rural cooperative medical system "four unified, four fixed" and "four in one" management approach. 3, counties and urban areas at least once every six months to organize the supervision and inspection of the members of the new rural cooperative medical supervision committee, to ensure the safety of funds. 4. Matters not covered in this notice shall be implemented in accordance with the Opinions of the Provincial Health Department, the Provincial Civil Affairs Department, the Provincial Department of Finance and the Provincial Department of Agriculture on Consolidating and Developing the New Rural Cooperative Medical System (Lu Wei Nong Wei Fa [2009] No.5). 200913 February

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