First, migrant workers will be included in the local supplementary medical insurance and enjoy the treatment of local supplementary medical insurance.
Two, medical insurance form name adjustment
The original comprehensive medical insurance, hospitalization medical insurance and migrant workers' medical insurance were renamed as the first, second and third files of basic medical insurance respectively.
Third, the adjustment of medical insurance payment structure.
First, the total contribution rate of the first-class insured of basic medical insurance will be reduced from 8.5% to 8.2%, of which the total contribution rate of basic medical insurance will remain unchanged at 8% (6% for units and 2% for individuals), but the contribution rate of local supplementary medical insurance will be adjusted from 0.5% to 0.2%.
Second, the total contribution ratio of the second-class insured of basic medical insurance remains unchanged at 0.8%, but the basic medical insurance is adjusted from 0.6% of the average monthly salary of employees in this city last year to 0.7% (the unit pays 0.5% and the individual pays 0.2%), and the contribution ratio of local supplementary medical insurance is adjusted from 0.2% to 0.1%;
The third is to change the payment method of the third basic medical insurance, from the original fixed payment 12 yuan to 0.55% of the average monthly salary of employees in this city last year, of which individual payment is 0. 1% and unit payment is 0.45% (including 0.4% of basic medical insurance and 0.05% of local supplementary medical insurance).
Third, the old people who have moved into this city and have not received the pension insurance benefits or pensions on a monthly basis will take part in medical insurance instead of the original one-time payment 18, and the payment standard is 165438+ 0.7% of the average monthly salary of employees in this city in the previous year (including basic medical insurance1/kloc-0.5% and local supplementary medical insurance 0.2). People who pay in one lump sum will not change.
Four, adjust the medical insurance payment and enjoy the form of medical insurance when the employees of this city retire.
First, according to the provisions of the National Social Insurance Law, the medical insurance for retirees who receive the employee pension insurance formalities in this city on a monthly basis at the latest or in 2022 (previous year) will no longer be paid by the pension fund, but will be treated free of charge after meeting certain conditions of medical insurance payment period. The payment period is gradually transitioned, that is, from the latest or 2022 (calendar year), the actual payment period of medical insurance in this city is 10 year, and the cumulative payment period is 15 year, and you can enjoy medical insurance benefits for free after retirement; Through the transition of 10 year, by 2024, if the accumulated payment period of retirees reaches 25 years and the actual payment period of this city reaches 15 years, they can enjoy medical insurance benefits for free after retirement; If the payment period is insufficient at the time of retirement, it should continue to pay to the prescribed period.
The second is to stipulate that the form of continuing to enjoy medical insurance benefits after the insured stops paying fees is related to the number of years of paying medical insurance forms. The insured can continue to enjoy the first-class treatment of basic medical insurance after attending the first-class treatment of basic medical insurance in this city for 15 years. Those who have participated in the first-class treatment of basic medical insurance for less than 15 years can stop paying and continue to enjoy the first-class treatment of basic medical insurance, or they can continue to participate in the first-class treatment of basic medical insurance and pay the corresponding medical insurance benefits 15 years.
Third, if the insured person requests to stop paying and continue to enjoy the first-class treatment of basic medical insurance, 60% of the average monthly salary of employees in this city in the previous year will be included in the personal account on a monthly basis, and the expenses will be paid by the serious illness pooling fund.
The fourth is to stipulate the old method for the elderly, and maintain the original practice for retirees who have gone through the formalities of receiving employee pension insurance on a monthly basis before the implementation of the new method.
Five, adjust the basic medical insurance benefits, improve the overall level.
(a) to improve the basic medical insurance level 2 and 3 insured outpatient co-ordination fund maximum payment limit, from the original maximum 800 yuan to 1000 yuan;
(two) the structural adjustment of outpatient treatment of serious illness. First, the number of diseases that can enjoy the treatment of serious outpatient diseases has been increased, and the specialized outpatient treatment of hemophilia, aplastic anemia, thalassemia and intracranial benign tumors has been included in the scope of serious outpatient diseases; The second is to stipulate that the proportion of outpatient treatment for serious diseases is linked to the number of years of continuous insurance. If the continuous insured period is less than 12 months, less than 36 months, and more than 36 months, the proportion of medical insurance fund payment is 60%, 75%, and 90% respectively. The original has been approved for outpatient illness, maintain the original payment ratio unchanged;
(3) Reduce the minimum balance requirement of personal accounts for family expenses, and change the minimum balance requirement of personal accounts for family expenses from 5% of the average monthly salary of employees in the previous year to 5% of the average annual salary of employees in the previous year, which is only 60% of the original;
(4) The hospitalization deductible line of medical institutions outside the city has been adjusted from 400 yuan to 400 yuan, which has been referred or filed according to regulations, and 1.000 yuan has not been referred or filed;
(5) Reduce the self-payment ratio of self-referral personnel. For those who go to designated medical institutions outside the city and non-designated medical institutions outside the city for medical treatment, the proportion of fund payment for medical insurance reimbursement is adjusted from 20% and 40% to 90% and 70% respectively according to the payment standards stipulated in the new measures, and the proportion of individual self-payment is reduced by about 10%.
Six, improve the local supplementary medical insurance benefits, adjust the maximum payment limit.
(a) to increase the proportion of payment from the local supplementary medical insurance fund to the serious illness clinic from the original 80% to the highest 90%;
(two) to improve the proportion of local supplementary medical insurance funds for hospitalization of insured persons who have gone through retirement procedures, from 90% to 95%;
(three) the basic medical expenses and local supplementary medical expenses of the insured exceed the payment limit of the local supplementary medical insurance fund, and the local supplementary medical insurance fund pays 50%;
(four) to give local supplementary medical insurance benefits to those who have been insured for less than 6 months, and the payment limit is 6,543,800 yuan;
(five) for more than 72 months, the local supplementary medical insurance fund has no payment limit, and the maximum payment limit is changed to 6,543,800 yuan.
Seven, the employer fails to participate in medical insurance for employees, can apply for payment. In order to solve the problem of interruption of insurance due to the employer, the employer is allowed to pay medical insurance for no more than two years, and the years after payment can be calculated together, but the medical expenses incurred before payment are borne by the employer, and the new medical expenses incurred after payment are paid by the medical insurance fund.
VIII. Adjustment of social insurance management
First, it simplifies the referral process of the insured outside the city and does not require the insured to go to the municipal social security agency. All procedures only need to be handled in the designated hospital, and the designated hospital will report to the social security agency after approval;
Second, insured persons who have reached the statutory retirement age and have not received pension insurance benefits in this city should conduct fingerprint verification regularly every year to avoid fund losses;
Third, strengthen the management of the insured's medical treatment behavior, and increase the punishment. Once the insured's illegal behaviors such as lending social security cards for their own use and buying and selling drugs are verified, the social security card bookkeeping function will be stopped for 3 months to 12 months, and all medical expenses incurred during the suspension of social security cards will be reimbursed and the treatment paid by the medical insurance pooling fund will be paid by half;
Fourth, it stipulates that the insured loses his social security card and stipulates that the insured should report the loss in time. If the insured does not report the loss, his social security card will be fraudulently used, and the loss of personal account will be borne by himself.
Fifth, it is clearly stipulated that medical institutions, pharmaceutical business units, units or individuals cheat insurance. In addition to ordering the refund of the defrauded medical insurance fund, a fine of 5 times the amount defrauded was imposed according to the provisions of the National Social Insurance Law; At the same time, the dishonest behavior of units or individuals in violation of medical insurance regulations will be included in the city's credit evaluation system. If doctors in designated medical institutions violate the regulations and cause losses to the medical insurance fund, the municipal social insurance institution may refuse to provide medical insurance services.
Nine, about the connection with the maternity insurance system
The transitional provisions of maternity medical insurance benefits stipulate that before the promulgation of maternity insurance regulations, the relevant provisions of maternity medical insurance will still be implemented according to the relevant provisions of medical insurance.