Legal analysis: unified coverage, unified financing policies, unified security benefits, unified medical insurance catalog, unified fixed-point management, and unified fund management.
Legal basis: "Opinions of the State Council on Integrating the Basic Medical Insurance System for Urban and Rural Residents" 2. Integration of basic system policies
(1) Unified coverage.
The coverage of the urban and rural residents’ medical insurance system includes all persons who should be insured (combined) with the existing urban residents’ medical insurance and the new rural cooperative medical insurance, that is, it covers all other urban and rural residents except those who should be insured by the employee basic medical insurance. Migrant workers and people with flexible employment are required to participate in the basic medical insurance for employees in accordance with the law. Those who have difficulty can participate in the urban and rural residents' medical insurance in accordance with local regulations. All localities should improve insurance participation methods, promote insurance coverage when needed, and avoid duplicate insurance participation.
(2) Unify financing policies.
Adhere to multi-channel financing, continue to implement a financing method that mainly combines individual contributions and government subsidies, and encourage collectives, units or other social and economic organizations to provide support or funding. All localities must comprehensively consider the needs of urban and rural residents for medical insurance and critical illness insurance, and reasonably determine unified financing standards for urban and rural areas in accordance with the principle of balancing fund revenue and expenditure. In areas where there is a large gap between the individual payment standards of urban residents' medical insurance and the new rural cooperative medical insurance, differential payment methods can be adopted to gradually transition within 2 to 3 years. The actual per capita financing and individual contributions after integration shall not be lower than the current level. Improve the dynamic adjustment mechanism for financing. On the basis of actuarial balance, we will gradually establish a stable financing mechanism that is consistent with the level of economic and social development and the affordability of all parties. Gradually establish a mechanism to connect individual payment standards with the per capita disposable income of urban and rural residents. Reasonably divide the financing responsibilities of the government and individuals, and while raising government subsidy standards, appropriately increase the proportion of individual contributions.
(3) Unified security benefits.
Follow the principles of moderate security and balanced revenue and expenditure, balance urban and rural security benefits, gradually unify the coverage and payment standards, and provide fair basic medical security for insured persons. Properly handle the special guarantee policies before integration and ensure transition and connection. The Urban and Rural Residents Medical Insurance Fund is mainly used to pay for inpatient and outpatient medical expenses incurred by insured persons. The level of hospitalization insurance will be stabilized, and the payment ratio of hospitalization expenses within the scope of the policy will remain at around 75%. Further improve outpatient coordination, gradually improve the level of outpatient protection, and gradually narrow the gap between the payment ratio within the scope of the policy and the actual payment ratio.
(4) Unified medical insurance catalogue.
Unify the medical insurance drug catalog and medical service item catalog for urban and rural residents, and clarify the scope of payment for drugs and medical services. All provinces (autonomous regions and municipalities) must follow the relevant provisions of the national basic medical insurance drug management and essential drug system, and follow the principles of clinical necessity, safety and effectiveness, reasonable price, appropriate technology, and affordable funds, in the existing urban residents’ medical insurance and new rural cooperative medical care catalogues. On the basis of appropriate consideration of changes in the needs of insured persons, adjustments should be made, with increases and decreases, controlled and expanded, to ensure that the types are basically complete and the overall structure is reasonable. Improve the management methods of the medical insurance catalog and implement hierarchical management and dynamic adjustment.
(5) Unified fixed-point management.
Unify the management methods of designated institutions for urban and rural residents’ medical insurance, strengthen the management of designated service agreements, and establish and improve an assessment and evaluation mechanism and a dynamic access and exit mechanism. Implement the same designated management policy for non-public medical institutions and public medical institutions. In principle, the coordinating regional management agency is responsible for the access, exit and supervision of designated institutions, and the provincial management agency is responsible for formulating the access principles and management measures for designated institutions, and focusing on strengthening the supervision of provincial and municipal designated medical institutions outside the coordinating area. Guidance and supervision.
(6) Unified fund management.
Urban and rural residents’ medical insurance implements the country’s unified fund financial system, accounting system and fund budget and final account management system. Urban and rural residents’ medical insurance funds are included in special fiscal accounts and implemented “two lines of revenue and expenditure” management. The funds are independently accounted for and managed in separate accounts, and no unit or individual is allowed to misappropriate them. Comprehensively promote total payment control in conjunction with fund budget management. The use of the fund follows the principles of determining expenditure based on revenue, balancing revenue and expenditure, and having a slight balance, ensuring that payable expenses are paid in full and in a timely manner, and the balance rate of the fund for the year and the cumulative balance rate are reasonably controlled. Establish and improve fund operation risk early warning mechanisms to prevent fund risks and improve utilization efficiency. Strengthen the internal audit and external supervision of the fund, adhere to the information disclosure system of the fund's revenue and expenditure operations and the medical settlement information of insured persons, and strengthen social supervision, democratic supervision and public opinion supervision.