In order to further develop the overall function of the basic medical insurance for employees and effectively reduce the burden of outpatient medical expenses for insured employees, in accordance with the unified arrangements of the State Council and the provincial government, combined with the actual situation of our city, our city has promulgated the Implementation Measures for the Economic Security Mechanism of the Basic Medical Insurance for Employees in Huai 'an City, and the relevant contents are now explained as follows.
First, the policy background of establishing the economic security mechanism of * * * outpatient basic medical insurance in Huai 'an.
Establishing and improving the economic security mechanism of medical insurance outpatient service for employees is an important decision made in the Opinions of the Central Committee of the State Council on Deepening the Reform of Medical Security System. In April, 20265438 and February, 65438, the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients and the Implementation Opinions of the General Office of the Provincial Government on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients were successively issued. The main requirements are to strengthen the economic security function of outpatient service, improve the method of calculating and distributing personal accounts, and standardize the scope of use of personal accounts. At the same time, the national guiding opinions and the implementation opinions of Jiangsu Province put forward time limit requirements for establishing and improving the economic security mechanism of employee medical insurance outpatient service.
Two, Huai 'an "implementation measures" to implement the national and provincial requirements of the time schedule.
In order to implement the national and provincial government's guidance on outpatient economic security, the office of the municipal government officially issued the Measures for the Implementation of the Economic Security Mechanism for Outpatients with Basic Medical Insurance for Employees in Huai 'an City, which will be implemented from June 65438+ 10/day in 2023, and the reform task will be completed before the end of 2023, and will be fully implemented from 2024.
Three, Huai 'an Jianli * * * the main contents of the economic security mechanism of medical insurance outpatient service for employees.
Establish a co-ordination system for general outpatient expenses of employee medical insurance
The basic medical insurance for employees, the general outpatient expenses that meet the scope of the basic medical insurance policy in designated medical institutions, which are above the Qifubiaozhun and below the maximum payment limit, shall be paid by the basic medical insurance fund in accordance with the prescribed proportion. In a natural year, the minimum payment standard for compliance medical expenses of general outpatient service is 600 yuan, and the maximum payment limit is 6000 yuan, and the payment limit is not used for outpatient service and hospitalization. The payment ratio of designated medical institutions at the first level and below, at the second level and at the third level was 70%, 65% and 60% respectively, and the retirees increased by 5 percentage points respectively.
Improve the personal account entry method.
From June 5438+1 October1day, 2023, it will be included in the basic medical insurance premiums paid by individuals in the personal accounts of on-the-job employees, and the inclusion standard is 2% of the insured payment base, and all the basic medical insurance premiums paid by the unit will be included in the overall fund; From June 65438+1 October 1 in 2023, the individual accounts of retirees will be included in the monthly quota according to the distribution scale of their individual accounts in 2022, and from June 65438+1October/0/in 2024, the amount of individual accounts of retirees will be uniformly adjusted as the basic pension of Huai 'an in the year when the reform was implemented. For flexible employees who do not receive pensions, the personal account allocation standard remains unchanged. If the insured changes his basic medical insurance relationship to retirement, his personal account will be transferred to the proportion from the month after retirement.
Adjust and optimize the payment scope of personal account.
From June 5438+1 October1in 2023, the personal account funds are mainly used to pay the out-of-pocket expenses of the insured within the policy scope of designated medical institutions. After the reform, the family benefit mechanism of individual account will be established according to the provincial regulations, and family members will benefit from three aspects: first, it can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions; Second, it can be used to pay the expenses borne by the insured himself, his spouse, parents and children in purchasing drugs, medical devices and medical consumables at designated retail pharmacies; Third, it can be used for the insured to participate in personal contributions such as large medical expenses subsidies for employees and long-term care insurance, and to explore personal accounts for spouses, parents and children to participate in the basic medical insurance for urban and rural residents. At the same time, the "Implementation Measures" stipulates that personal accounts shall not be used for public health expenses, physical fitness or health care consumption not covered by basic medical insurance.
Improve the accessibility and convenience of outpatient service.
After the reform, the insured workers can enjoy the corresponding outpatient security treatment in the designated medical institutions of medical insurance in accordance with the corresponding regulations. Relying on the provincial prescription circulation platform, the drug security services provided by qualified designated retail pharmacies will be included in the scope of outpatient security, and the settlement and adjustment of external prescriptions of designated retail pharmacies will be supported. Within the scope of the policy, the payment ratio of the drug cost pooling fund is consistent with that of the designated medical institutions with external prescriptions, and the convenience and accessibility of designated retail pharmacies are fully brought into play.
Adjust and improve the outpatient special disease policy
The province's medical insurance implements a system of outpatient chronic diseases and special diseases, and unifies the scope of outpatient special diseases. For those who are not included in the scope of outpatient special diseases in the province, we will continue to implement the current outpatient special disease treatment policy in our city. For outpatient special diseases whose treatment level is higher than the existing outpatient special disease guarantee level after outpatient co-ordination, the transition will be based on outpatient co-ordination guarantee.
In short, through the new system function transformation, all the basic medical insurance premiums paid by the unit will be included in the overall fund, which will better solve the problem of outpatient security for employees' medical insurance participants, realize the system result of * * * economic security and improve management efficiency.
In the next step, the Municipal Medical Insurance Bureau, in conjunction with the Municipal Finance Bureau and other departments, further combined with the actual situation of our city, will do a good job in policy implementation, classified guarantee and step-by-step implementation, properly handle the policy convergence before and after the reform, further optimize the structure of the employee medical insurance fund, improve the personal account management mechanism, enhance the guarantee function of the medical insurance fund, and strictly follow the requirements of the municipal party Committee and the municipal government, improve the working mechanism, strengthen organizational leadership, ensure the smooth and orderly implementation of policies, and complete various tasks on schedule.