Starting from April 1st, Kunming City and the provincial level will simultaneously implement the employee basic medical insurance outpatient service. By reducing personal account transfers, establishing general outpatient protection, adopting policy linkage transformation to promote a fairer and more inclusive system, and focusing on solving patients' problems.

Issues such as insufficient personal accounts of insured persons with common diseases and frequently-occurring diseases and weak bank finances.

While many citizens have praised this brand-new medical insurance policy, the specific operational aspects such as how to provide financial support for the whole family and how to reimburse outpatient clinics are the issues that citizens are most concerned about.

In this issue of "Spring City Medical Insurance Micro Classroom", Xiaozhang brings you the most complete guide.

1. What is "outpatient medical care"? Generally speaking, outpatient medical care has two meanings. One is the overall coordination of medical care.

The most important change in the outpatient financial system currently implemented is to give full play to the financial role of the coordinating fund to reimburse insured employees for ordinary outpatient expenses within the scope of the medical insurance policy incurred by insured employees in designated service institutions, so that outpatient medical patients can also

You can enjoy the reimbursement benefits from the overall planning fund.

The second is account economy.

After the implementation of "outpatient medical insurance", the personal accounts of insured employees can be used financially by spouses, children, and parents, which improves the efficiency of personal account use. In addition, it is clearly stated that it can be used for individual contributions to resident medical insurance and large-amount medical expense subsidies for employees.

Personal payments, commercial health reimbursement payments, etc., from another aspect, open the door for insured persons to be included in the multi-level medical security network.

2. Who does the "outpatient medical insurance" policy apply to? All employees insured by the province's normal insurance and payment (including those insured by flexible employment) are covered by the coverage.

Employee medical insurance participants in Kunming will be able to enjoy the outpatient financial treatment policy from April 1, 2022.

3. After the implementation of the "outpatient welfare", what are the main improvements to the benefits of insured employees? 1. Outpatient medical treatment is guaranteed.

Outpatient expenses that are within the scope of the medical insurance policy can be reimbursed by the overall fund; 2. The scope of personal account payment has been expanded. First, the insured can use the personal account to pay related expenses within the scope of the policy together with his spouse, parents, and children;

Second, in addition to paying personal expenses that comply with the provisions of the medical insurance policy, it can also be used for personal payments such as medical insurance for urban and rural residents, subsidies for large medical expenses for employees, long-term care insurance, and the purchase of commercial health insurance.

4. What does outpatient protection in "outpatient insurance" refer to, and what are the specific regulations? (1) Outpatient protection includes: employee medical insurance general outpatient services (including outpatient examinations), outpatient chronic diseases, outpatient special diseases, and outpatient emergency rescue

, National medical insurance negotiates drug outpatient coverage and day surgery.

(2) Specific treatment provisions: 1. General outpatient services: Insured persons who visit general outpatient clinics at designated medical institutions and incur medical expenses within the scope of the policy that comply with the medical insurance regulations (hereinafter referred to as expenses within the policy scope) will be included in the general outpatient coverage.

For settlement of each general outpatient visit, the minimum payment standard for the cost coordination fund within the scope of the policy is: 30 yuan for first-level and lower designated medical institutions, 60 yuan for second-level designated medical institutions, and 90 yuan for third-level designated medical institutions.

On-the-job reimbursement ratio: 60% for first-level and below designated medical institutions, 55% for second-level designated medical institutions, and 50% for third-level designated medical institutions.

The payment ratio for retirees is 5 percentage points higher than that for active employees.

The annual maximum payment limit is 6,000 yuan, which is calculated separately from the annual hospitalization maximum payment limit.

Expenses exceeding 6,000 yuan within the scope of the general outpatient policy will be reimbursed according to the payment ratio of the employee medical insurance hospitalization pooling fund of the medical institution where the patient is treated, and will be calculated together with the maximum annual hospitalization payment limit.

(The basic overall fund payment ratios for active employees in primary, secondary and tertiary medical institutions are 91%, 88% and 85% respectively; the payment ratios for retirees are 95%, 92% and 89% respectively, which is within the scope of the policy

The subsidy payment ratio for large medical expenses is 90%. The maximum annual hospitalization payment limit is 430,000 yuan.) 2. The minimum payment standard for chronic diseases is 300 yuan, and the reimbursement ratio for expenses above the minimum payment standard is uniformly 80%.

The maximum payment limit for disease types is 2,000 yuan (of which the maximum payment limit for mental illness is 3,000 yuan). Each additional disease type increases the overall fund payment limit by 1,000 yuan, and the annual maximum payment limit is 5,000 yuan.

3. The minimum reimbursement standard for special diseases is 880 yuan. If the treatment in a designated medical institution at level 2 or above exceeds the minimum payment standard and is within the scope of the policy, the expenses will be based on the inpatient reimbursement ratio of the medical institution (including special disease expenses for chronic renal failure and severe mental illness outpatient services).

There is no minimum payment standard, and the reimbursement rate within the scope of the policy is 90%).