According to incomplete statistics, at present, Jiangsu, Hunan, Sichuan, Hebei, Henan, Anhui, Beijing, Shanghai, Inner Mongolia, Shandong and other places have begun to gradually adjust the bookkeeping methods and standards of personal accounts for employees and retired employees.
Recently, many retirees have raised questions: When the medical insurance benefits of employees in Shandong Province are adjusted in 2023, will the personal account standard of retirees be lowered?
According to public reports, on June 5, 2022, Shandong Province issued the Notice on Printing and Distributing the Implementation Plan for Establishing and Improving the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Shandong Province. According to document No.22 of Lu Zhengban [2021], the notice of implementation plan specifies seven aspects:
First, in cities that have not yet carried out general outpatient co-ordination, it is necessary to comprehensively establish a general outpatient co-ordination system covering all employees' medical insurance participants before the end of 2022, and ensure the basic outpatient medical needs of the people in a fair and inclusive manner; Cities that have carried out general outpatient co-ordination should further refine and improve policies and standardize outpatient security management measures.
In other words, cities in Shandong Province that have not yet established outpatient co-ordination reimbursement will include outpatient expenses in the scope of reimbursement for employees' outpatient services before the end of 2022. That is to say, from 2023, all employees' general outpatient services in Shandong Province will be included in the scope of reimbursement.
Second, the Qifubiaozhun for general outpatient service of employees was calculated cumulatively in the current year, which was not higher than 2% of the average wage of employees in full-caliber urban units in the province. Different levels of medical institutions should set different qifubiaozhun Within the scope of the policy, the payment ratio is not less than 50% for employees, and retirees are determined by an average of 5 percentage points higher than employees.
In other words, the deductible standard for general outpatient treatment of employees is lowered and set as a unified standard.
For a simple example, according to the Announcement on the Average Wage of Employees in Full-caliber Urban Units in Shandong Province issued by the People's Government of Shandong Province, it is clear that the average wage of employees in full-caliber urban units in Shandong Province in 20021year is 79,597 yuan, so the deductible standard for general outpatient service for employees will not exceed 79,597× 0.02 =1591.94 yuan.
At the same time, it should be noted that the reimbursement rate for the part of on-the-job employees whose general outpatient expenses exceed the deductible line is not less than 50%, while the reimbursement rate for retired employees will be 5% higher than that for on-the-job employees, which means that the reimbursement rate for retired employees whose outpatient expenses exceed the deductible line will start from 55%.
Third, before the end of 2022, formulate a unified catalogue of basic diseases in outpatient clinics for chronic diseases and special diseases in the province, unify the names and identification standards of basic diseases, and unify some diseases with long treatment cycle, great health damage and heavy cost burden into the outpatient scope of chronic diseases and special diseases and make dynamic adjustments.
That is to say, from 2023, Shandong Province will be included in the reimbursement scope of chronic diseases and special diseases in outpatient clinics according to the unified catalogue of chronic diseases and special diseases in the province, which is expected to include dozens of chronic diseases and special diseases such as hypertension, chronic cardiac insufficiency, coronary heart disease and diabetes.
Fourth, support the external prescription settlement and adjustment of designated retail pharmacies, include the drug security services provided by qualified designated retail pharmacies into the scope of outpatient security, implement a unified outpatient reimbursement policy with designated medical institutions, and combine the annual Qifubiaozhun with the annual maximum payment limit.
In other words, Shandong Province will gradually implement the cost of purchasing drugs from retail pharmacies to the coverage of medical insurance clinics for employees, which is also a precedent in the country and is good for both on-the-job employees and retired employees.
Fifth, the basic medical insurance premiums paid by individual employees are all included in my personal account, and the standard is controlled in principle at 2% of my insurance payment base. Before the end of 2022, the basic medical insurance premium paid by the unit will be included in the personal accounts of on-the-job employees, which will be reduced to 50% of the current standard; The policy of recording individual accounts of retirees remains unchanged.
From June 5438+ 10, 2024, the basic medical insurance premiums paid by employees will no longer be included in individual accounts, but will be included in the overall fund; Individual accounts of retirees are allocated by the overall fund according to the quota. For retirees under 70 years old, the payment amount will be adjusted to 2% of the average basic pension in the overall planning area in 2023, and for retirees over 70 years old, the payment amount will be adjusted to 2.5% of the average basic pension in the overall planning area in 2023.
That is to say, starting from June 5438+1 October1day, the inclusion standard of individual medical insurance accounts for on-the-job employees in Shandong Province will be cancelled, which means that the inclusion standard of individual medical insurance accounts for on-the-job employees will be lowered.
At the same time, from June 5438+1 October1day in 2024, retired employees will also be included according to the average level of basic pensions in the previous year, and will no longer be included in a certain proportion based on individual basic pensions.
For a simple example, according to public information, the monthly per capita pension of enterprise retirees in Shandong Province in 202 1 year is about 3,647 yuan. Taking Jinan City as an example, the personal account funds of medical insurance for retirees who enjoy the basic medical insurance benefits of Jinan City are included according to 4% of their monthly basic pension, with a guaranteed upper limit (10 yuan after deducting the large amount of medical assistance 8 yuan and outpatient co-ordination expenses), which is divided into the following parts according to the number of years.
Under the age of 60, if the monthly remittance amount is lower than that of 50 yuan, it will be included in 50 yuan, with a maximum of 170 yuan;
If the monthly transfer amount over 60 years old and under 70 years old is lower than that in 60 yuan, it will be included in 60 yuan, with a maximum of 190 yuan;
If the monthly remittance amount over 70 years old and under 80 years old is lower than that of 70 yuan, it will be included in 70 yuan, and the maximum amount will not exceed that of 220 yuan;
If the monthly transfer amount is lower than that of 80 yuan, it will be included in 80 yuan, and the maximum amount will not exceed that of 220 yuan;
If the monthly transfer amount over 90 years old is lower than that of 90 yuan, it will be transferred to 90 yuan, and the maximum amount will not exceed that of 220 yuan.
Suppose a retired employee in Jinan is 68 years old and the monthly basic pension is 6,000 yuan in 2023, then the monthly transfer amount of personal medical insurance account is about 6,000× 0.04 = 240 yuan. According to the policy of guaranteed bottom and capped top, the amount pre-transferred to the individual medical insurance account of retired employees every month is 190 yuan.
If the average monthly basic pension in Shandong Province is 3,647 yuan in 2023, the monthly transfer amount of individual medical insurance account for retirees in 2024 will be adjusted to 3,647× 0.02 = 72.94 yuan.
On the other hand, if the monthly basic pension of retirees is 1.500 yuan in 2023, the corresponding amount transferred to personal medical insurance account in 2023 is 60 yuan, and the amount transferred to personal medical insurance account in 2024 is 72.94 yuan.
In other words, since 2024, the standard of individual medical insurance accounts for retired employees will be unified and implemented according to 2% and 2.5% of the average basic pension in 2023. Then, for retired workers with higher basic pension, the personal medical insurance account will be reduced, while for retired workers with lower basic pension, the personal medical insurance account will be increased.
Six, employee medical insurance personal account funds are mainly used to pay the insured in the designated medical institutions within the scope of the policy of out-of-pocket expenses. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies, and the personal contributions of spouses, parents and children in basic medical insurance for residents, long-term care insurance and government-guided inclusive commercial medical insurance.
That is to say, family members who participate in medical insurance in the same overall planning area of Shandong Province can enjoy the use of personal account balance of employee medical insurance, but the scope of use is limited to three generations of immediate family members.
Seventh, the outpatient service should be brought into the agreement management of designated medical insurance institutions, and the statistical analysis system of outpatient service expenses should be established. Accelerate the national pilot of inter-provincial online settlement of outpatient chronic diseases and special diseases, and realize inter-provincial online settlement of outpatient chronic diseases and special diseases in all areas of the province before the end of 2022.
In other words, since 2023, on-the-job employees and retired employees can also enjoy outpatient reimbursement for chronic diseases and special diseases in different places.
Finally, it should be noted that according to the Notice on Further Standardizing the Payment of Basic Medical Insurance and Payment of Benefits issued by Lu Medical Insurance [2021] No.54, the cumulative minimum payment period for insured employees to enjoy the basic medical insurance benefits for retirees shall be implemented as 30 years for male employees and 25 years for female employees in the overall planning area. If the required period is not reached, it will be put in place before the end of 2025.
Based on the above situation, the personal account standard of medical insurance for on-the-job employees in Shandong Province has been gradually lowered since 2022, while the new standards and measures for personal account of medical insurance for retired employees have been implemented since 2024, and are included according to a unified base and proportion.