According to the Implementation Opinions of the People's Government of Anhui Province on the Health Poverty Alleviation Project (No.68 [2016] of Anhui Province), the Notice of the People's Government of Anhui Province on Implementing 33 livelihood projects in 20 17 (〔2065438〕 10/0] of Anhui Province) and the General Office of the People's Government of Anhui Province.
I. Guiding ideology
Thoroughly implement the spirit of the 18th National Congress of the Communist Party of China and the Third, Fourth, Fifth and Sixth Plenary Sessions of the 18th National Congress, further improve the working mechanism, improve policies and measures, strengthen standardized management, strengthen overall planning and convergence, minimize the burden of medical expenses for people in need, and weave a safety net to protect basic people's livelihood.
II. Objectives and tasks
In 20 17, all the poor people with files and cards will be included in the scope of urban and rural medical assistance, and medical assistance for serious and serious diseases will be carried out in an all-round way to subsidize people in need to participate in insurance. In-patient assistance and outpatient assistance should be provided to effectively alleviate the problem of "expensive medical treatment" for people in need.
Third, the target of assistance
Minimum living security object (hereinafter referred to as "minimum living security object");
(2) Helpless dependents;
(3) Poor people in rural areas (hereinafter referred to as poor people);
(four) the elderly, minors, seriously ill patients and severely disabled people from low-income families (hereinafter referred to as "low-income medical assistance targets");
(five) patients with serious illness in poor families due to illness (referring to family patients with serious difficulties in basic life due to medical expenses exceeding the family's affordability);
(6) Other persons with special difficulties as stipulated by the local government.
Measures for the identification of low-income medical assistance targets, seriously ill patients from poor families due to illness and other people with special difficulties shall be formulated by the people's governments at or above the county level.
Fourth, the scope of assistance.
(1) There are no disease restrictions for low-income objects, destitute dependents and poor people. Medical assistance for low-income medical assistance recipients, seriously ill patients from poor families due to illness, and other people with special difficulties specified by the local government must be seriously ill or chronically ill.
The scope of medical assistance for serious diseases or serious chronic diseases can be determined according to "diseases" or "medical expenses" paid by patients. The main diseases are: severe organ failure (heart, liver, lung, brain, kidney), various malignant tumors such as breast cancer, multidrug-resistant tuberculosis, AIDS opportunistic infection, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, dialysis before and after liver and kidney transplantation, anti-rejection treatment after operation, type I diabetes, hyperthyroidism, cleft lip and palate, severe psychosis, advanced schistosomiasis and other diseases stipulated by the local government. Implement medical assistance for serious and serious diseases for those who still have difficulties after being reimbursed by serious illness insurance. The scope of compliance medical expenses for medical assistance for serious diseases is determined with reference to the relevant provisions of local serious illness insurance.
(2) To provide medical assistance to eligible recipients for medical expenses that they cannot afford after being compensated by urban and rural basic medical insurance, serious illness insurance, various supplementary medical care and commercial insurance (hereinafter referred to as "various insurances") and receiving special medical assistance. For those who have not participated in the urban and rural basic medical insurance for various reasons, the compliance medical expenses shall be calculated and processed according to a certain proportion of the total medical expenses, which shall be reasonably determined by all localities in combination with the actual situation. If it is impossible to distinguish between compliant medical expenses and fixed payment for a single disease, the compliant out-of-pocket expenses shall be determined according to the remaining medical expenses after reimbursement of basic medical insurance and various insurances.
Verb (abbreviation of verb) aid standard
(a) the people's governments at the city and county levels should comprehensively consider the affordability of sick families, personal medical expenses, local financing and other factors, and classify and file to determine the proportion of assistance and the annual maximum assistance limit (capping line). In principle, the proportion of subsistence allowances, destitute dependents and poor people is higher than that of subsistence allowances, and subsistence allowances are higher than other objects. For the same kind of assistance object, the greater the amount of personal expenses, the higher the proportion of assistance.
There is no deductible line for medical assistance for low-income households, destitute dependents and poor people; The deductible line of medical assistance for low-income recipients can be reasonably determined; For patients with serious illness from poor families due to illness, a medical assistance deductible line is set up, and the self-funded expenses above the deductible line are given assistance in proportion within the annual maximum relief limit.
For low-income households and destitute support personnel, within the annual assistance limit, the proportion of self-funded assistance for compliance hospitalization shall not be less than 70%, and the proportion of assistance for destitute support personnel may be appropriately increased. The proportion of medical assistance for the poor and the way of fund settlement shall be implemented in accordance with the Implementation Plan of Comprehensive Medical Security System for the Rural Poor in Anhui Province (Wanfa [2016] No.22).
0- 14 (including 14) children with acute leukemia and congenital heart disease in rural areas shall be provided with medical assistance in accordance with the notice of the former provincial health department and other departments on printing and distributing the implementation plan (version 20 10) for carrying out the pilot work of paying for major diseases in Anhui Province to improve the level of medical security (Anhui Weinong [2065438+])
(two) after the above insurance compensation (including security compensation) or medical assistance, the remaining personal medical expenses are still high, and all localities will give assistance again according to the needs of the recipients and the financing of medical assistance.
Assistance mode of intransitive verbs
(a) funding participation. Subsidize low-income households, destitute dependents, poor people and low-income medical assistance recipients to participate in local rural cooperative medical care or medical insurance for urban residents. Among them, subsistence allowances, destitute dependents and poor people pay all the insurance funds on their behalf; For other relief objects, according to local conditions, part or all of the insured funds will be paid on behalf of them. In that year, the enrollment and insurance work for the next year should be completed in time.
(two) the implementation of hospitalization assistance. For patients with serious and serious diseases and serious chronic diseases among the recipients, pre-medical, in-medical or post-medical assistance shall be implemented as appropriate. For serious diseases with clear clinical diagnosis and treatment path, assistance can be given by paying by disease type.
(3) Standardize outpatient assistance. Focus on medical assistance recipients who need long-term medication for chronic diseases, long-term outpatient treatment for serious diseases, and high medical expenses at their own expense. The health and family planning department has defined the path of diagnosis and treatment and the diseases that can be treated through outpatient service, and can carry out outpatient assistance by paying for a single disease.
Seven, apply for assistance, examination and approval procedures
(a) the implementation of designated medical institutions for immediate settlement of medical assistance expenses. All localities should determine the designated medical institutions for medical assistance in accordance with the principles of openness, equality and competition within the designated medical institutions for local basic medical insurance. In principle, the scope of medication and diagnosis and treatment items of medical assistance for serious diseases shall be implemented with reference to the relevant provisions of basic medical insurance for urban and rural residents and serious illness insurance. For medical assistance objects that really need to go to higher medical institutions or cross-county hospitals, referral or filing procedures should be performed according to regulations. Designated medical institutions should cancel the hospitalization deposit of the relief object, and implement preferential relief for medical expenses (registration fee, inspection fee, inspection fee, medicine fee, hospitalization bed fee, etc.). ). Medical aid agencies should promptly confirm the aid recipients and ensure that the needy people are hospitalized in time.
Medical assistance and basic medical insurance, serious illness insurance for urban and rural residents, comprehensive medical insurance for the poor, emergency medical assistance for diseases, commercial insurance and other information management platforms are interconnected and share information. Relevant departments provide relevant data timely and accurately, and realize "one-stop" information exchange and instant settlement.
(II) Low-income residents, destitute dependents and low-income medical assistance objects go to designated medical institutions for medical treatment with relevant certificates and supporting materials, and the medical expenses incurred are paid by the medical assistance fund, and the designated medical institutions or insurance agencies pay in advance according to the agreement, and the assistance objects only need to pay the conceited part. The advance payment of designated medical institutions or insurance institutions shall be settled regularly by the civil affairs department according to the facts. The urban and rural medical assistance fund does not settle the medical expenses incurred by not using drugs, making diagnosis and providing medical services according to regulations.
(III) When applying for medical assistance, seriously ill patients from poor families due to illness and other persons with special difficulties as stipulated by the local government shall submit a written application to the social assistance service window of the township (street) where the household registration is located with relevant documents and certification materials, and issue this year's diagnosis medical records and necessary medical history certification materials. Villages and towns (streets) should send people to investigate and audit within 5 working days after receiving the application; After receiving the application materials, the civil affairs department at the county level shall complete the examination and approval within 5 working days. After receiving the approval form from the civil affairs department at the same level, the financial department at the county level will inject relief funds into its designated financial institutions within 3 working days and implement socialized distribution. In case of sudden major diseases, it should be handled in a special way and examined and approved in time. If it does not meet the conditions for assistance, it shall explain the reasons in writing and notify the applicant.
(four) standardize the medical assistance ledger, establish a rescue roster with accurate information and perfect data, and grasp the income and expenditure of the medical assistance fund in real time. To strengthen the management of medical assistance files, it is necessary to establish and improve paper files on the basis of electronic files, and ensure that the relevant documents provided by designated medical institutions in personal assistance files are complete.
Eight. Fund raising management
(a) medical assistance funds are raised through financial arrangements, special lottery public welfare funds, social donations and other channels. City and county finance according to the number of relief objects, relief standards, the growth of medical expenses and financial subsidies at higher levels, scientifically calculate the demand for funds, and fully arrange the financial medical assistance funds at the same level. The gap in the implementation process is made up by the finance at the same level in time.
(two) the financial departments at all levels of urban and rural medical assistance funds to implement separate accounting, earmarking. The aid recipients shall participate in the medical assistance funds of local basic medical insurance and designated medical institutions, which shall be paid in advance by the civil affairs department in consultation with the financial department at the same level, and the financial department shall regularly allocate the funds to the special accounts of basic medical insurance and designated medical institutions, and notify the agencies to handle relevant procedures for them. The remaining medical assistance funds shall be examined and approved by the civil affairs department according to the prescribed procedures, and the applicant shall be notified in writing in time to obtain relevant documents from relevant financial institutions.
(three) all localities should adhere to the principle of "living within our means, the annual balance", the implementation of timely assistance to the relief object. For areas where the balance of funds in the current year exceeds 10% of the total annual relief fund, our province will reduce the subsidy amount of the medical relief fund in the next year.
(4) The financial and civil affairs departments at all levels should strengthen the management of the use of funds, and severely deal with such violations as false reporting, embezzlement, misappropriation and waste in accordance with relevant laws and regulations. Those who deliberately fabricate false information to defraud higher-level subsidy funds shall be ordered to immediately correct, deduct and stop issuing higher-level subsidy funds, and the responsibilities of relevant units and personnel shall be investigated according to regulations.
Nine. safeguard measure
(a) a clear division of responsibilities. Medical assistance work adheres to the principle of territorial management and implements the responsibility system of the people's governments at the city and county levels. The civil affairs department is responsible for and takes the lead in organizing the implementation. Health and family planning, human resources security, poverty alleviation and other departments are responsible for doing a good job in the insured work of the recipients, and the health and family planning departments strengthen supervision and management of medical institutions. The financial department is responsible for the collection, use, supervision and inspection of medical assistance funds.
(2) Strengthen coordination and cooperation. All departments should strengthen the connection between various rescue systems and insurance systems, improve "one-stop" management services, and do a good job in the connection between serious illness insurance and medical assistance systems. Realize the sharing of personnel information, medical information and medical expenses information between different medical security systems, improve the management service level and facilitate the needy people.
(3) Strengthen supervision and assessment. Establish and improve the performance evaluation system of urban and rural medical assistance, increase the supervision and inspection of urban and rural medical assistance, strengthen social supervision, and enhance the binding force and transparency of work. We will improve the accountability mechanism and severely investigate and punish illegal acts such as misappropriation, false reporting and impersonation of urban and rural medical assistance funds. ;