1. Background of the introduction: Establishing and improving the financial security mechanism for employee medical insurance outpatient clinics is a clear task arrangement proposed by the country and our province to deepen the reform of the medical security system.

The employee medical insurance system was established in 1999 and implements a model that combines overall funds and personal accounts. "The overall fund covers inpatient and outpatient chronic diseases and special diseases (hereinafter collectively referred to as outpatient chronic diseases), and individual accounts cover outpatient minor illnesses."

The personal accounts of employee medical insurance have played an active role in promoting the transition from the publicly funded labor insurance medical system to the social medical insurance system.

With the development of the economy and society, the people's demand for medical security continues to increase, and limitations such as insufficient personal account protection functions and poor economic efficiency have gradually become apparent.

On April 13, 2021, the General Office of the State Council issued the "Guiding Opinions", requiring all provincial people's governments to make overall arrangements, make scientific decisions, and issue implementation measures in a timely manner in accordance with the requirements of the "Guiding Opinions."

In accordance with the work deployment, our province comprehensively benchmarked and compared the national "Guiding Opinions" and carefully sorted out the province's establishment and improvement of the financial security mechanism for employee medical insurance outpatient services item by item. On the basis of summarizing practical experience, extensively listening to opinions, and repeated research and demonstration

, the Provincial Government Office issued the "Implementation Opinions".

2. Main content The "Implementation Opinions" propose specific measures for our province to establish and improve the outpatient financial security mechanism from six aspects.

(1) Establish a general outpatient coordination system for employee medical insurance.

On the basis of doing a good job in providing medical protection for outpatient chronic and special diseases such as hypertension and diabetes that carry a heavy burden on the public, general outpatient expenses for frequently-occurring and common diseases will be included in the payment scope of the employee medical insurance pooling fund.

General outpatient clinics cover all insured persons in employee medical insurance.

The minimum payment standard is set on a case-by-case basis, and in principle does not exceed 50 yuan per time. There is no minimum payment standard for grassroots designated medical institutions.

The annual maximum payment limit for ordinary outpatient services for active employees is about 1,500 yuan, and the maximum annual payment limit for retirees is about 2,000 yuan. The general outpatient service payment limit is not included in the annual maximum payment limit for the employee medical insurance pooling fund.

General outpatient medical expenses within the scope of the policy above the minimum payment standard and below the maximum payment limit shall be paid by the employee medical insurance coordinating fund on a proportional basis. According to regulations, the payment ratio for medical treatment in third-level designated medical institutions shall not be less than 50%.

The payment ratio for medical treatment in designated medical institutions below is not less than 55%, and the payment ratio for retirees is 10 percentage points higher than that of active employees; after the insured person signs a family doctor contract, the general outpatient medical expenses incurred in the contracted primary medical institution will be

The payment ratio is increased by 5 percentage points based on the above.

Specific standards are determined by each coordinating region based on the affordability of the medical insurance fund.

(2) Improve the accounting method for personal accounts.

The basic medical insurance premiums paid by individual employees are included in their personal accounts, and the basic medical insurance premiums paid by the unit are all included in the overall planning fund; the individual accounts of retirees are transferred from the overall planning fund on a monthly fixed basis, and the amount of transfer is determined by each overall planning region according to the implementation of the reform

The basic pension is determined by about 2% of the monthly average level of the previous year.

After adjusting the overall pooling fund and individual account structures, the increased pooling fund is mainly used for outpatient financial security and to improve the outpatient benefits of insured persons.

The adjustments to the crediting methods for employee medical insurance personal accounts will be implemented simultaneously with the coordination of general outpatient clinics.

(3) Standardize the scope of use of personal accounts.

Personal account funds are mainly used to pay out-of-pocket expenses incurred by insured persons within the scope of the policy at designated medical institutions.

It can be used to pay the personally borne medical expenses incurred by the insured person, his spouse, parents, and children for medical treatment in designated medical institutions, as well as the personally borne expenses incurred by purchasing drugs, medical equipment, and medical consumables at designated retail pharmacies.

It can be used to pay individual contributions for spouses, parents, and children to participate in the basic medical insurance for urban and rural residents or to participate in large-scale medical expense subsidies for employees.

It shall not be used for expenditures such as public health expenses, sports fitness or health care consumption that are not covered by basic medical insurance.

(4) Strengthen policy coordination.

Gradually improve outpatient chronic and special disease protection policies and measures, formulate a province-wide outpatient chronic and special disease catalog, and unify the disease identification standards.

Each coordinating region can gradually expand the scope of outpatient chronic and special diseases paid by the coordinating fund based on the affordability of the medical insurance fund.

While implementing the employee medical insurance general outpatient co-ordination system, strengthen the connection with the hospitalization fee payment policy, appropriately adjust the employee medical insurance inpatient deductible payment standards in conjunction with the annual maximum payment limit for outpatient services, and appropriately widen the gap in the hospitalization deductible standards of medical institutions at different levels.

Simultaneously improve the outpatient coordination of basic medical insurance for urban and rural residents and gradually improve the level of protection.

(5) Improve the payment mechanism that is compatible with outpatient financial security.

Primary medical services can be paid on a per-capita basis, and we should actively explore the combination of capitation payment and chronic disease management; for qualified outpatient special diseases such as day surgeries and dominant diseases of traditional Chinese medicine, payment by disease type or grouping related to disease diagnosis can be implemented

; Outpatient fees that are not suitable for package payment can be paid on a per-item basis.

(6) Strengthen supervision and management.

Establish and improve a supervision and management mechanism that is compatible with outpatient financial security, guide the rational use of medical resources, ensure the stable operation of medical insurance funds, and give full play to the security function.

Establish a dynamic management mechanism for the entire process of personal accounts, and strengthen the review of personal account usage, settlement and other aspects.

Strengthen the supervision of medical behaviors and medical expenses to ensure the safe, efficient and rational use of funds.