Starting from April 1st, Kunming City and the provincial level have simultaneously implemented outpatient benefits of employee basic medical insurance. By reducing personal account transfers, establishing general outpatient protection, and adopting policy linkage transformation to promote the system to be more efficient It is fair and inclusive, and strives to solve the problems of insufficient personal accounts of insured persons suffering from common diseases and frequently-occurring diseases, and weak bank finances. While many citizens have praised this brand-new medical insurance policy, the specific operational aspects such as how to provide financial support for the whole family and how to reimburse outpatient clinics are the issues that citizens are most concerned about. In this issue of "Spring City Medical Insurance Micro Classroom", Xiaozhang brings you the most complete guide.

1. What is "outpatient medical care"? Generally speaking, outpatient medical care has two meanings. One is to coordinate medical care. The most important change in the outpatient financial system currently implemented is to give full play to the financial role of the coordinating fund to reimburse insured employees for ordinary outpatient expenses within the scope of the medical insurance policy incurred by insured employees in designated service institutions, so that outpatient medical patients can also Can enjoy the reimbursement benefits from the overall planning fund. The second is account economy. After the implementation of "outpatient medical insurance", the personal accounts of insured employees can be used financially by spouses, children, and parents, which improves the efficiency of personal account use. In addition, it is clearly stated that it can be used for individual payments of resident medical insurance and large-amount medical expense subsidies for employees. Personal payments, commercial health reimbursement payments, etc., from another aspect, open the door for insured persons to be included in the multi-level medical security network.

2. Who does the "outpatient medical insurance" policy apply to? All employees participating in the province's normal insurance and paying premiums (including flexible employment insured persons) are covered by the coverage. Employee medical insurance participants in Kunming will be able to enjoy the outpatient financial treatment policy from April 1, 2022.

3. After the implementation of the "Outpatient Medical Benefit", what are the main improvements in the benefits of insured employees? 1. Outpatient medical treatment is guaranteed. Outpatient expenses that are within the scope of the medical insurance policy can be reimbursed by the overall fund; 2. The scope of personal account payment has been expanded. First, the insured can use the personal account to pay related expenses within the scope of the policy together with his spouse, parents, and children; Second, in addition to paying personal expenses that comply with the provisions of the medical insurance policy, it can also be used for personal payments such as medical insurance for urban and rural residents, subsidies for large medical expenses for employees, long-term care insurance, and the purchase of commercial health insurance.

IV. What does the outpatient protection in "outpatient insurance" refer to and what are the specific regulations? (1) Outpatient protection includes: employee medical insurance general outpatient service (including outpatient examination), outpatient chronic disease, Outpatient special diseases, outpatient emergency rescue, national medical insurance negotiated drug outpatient coverage, and day surgery. (2) Specific treatment provisions:

1. General outpatient insured persons who visit ordinary outpatient clinics of designated medical institutions and incur medical expenses within the policy scope that comply with the medical insurance regulations (hereinafter referred to as expenses within the policy scope) shall be included in the general outpatient clinic. Outpatient coverage. For settlement of each general outpatient visit, the minimum payment standard for the cost coordination fund within the scope of the policy is: 30 yuan for first-level and lower designated medical institutions, 60 yuan for second-level designated medical institutions, and 90 yuan for third-level designated medical institutions. On-the-job reimbursement ratio: 60% for first-level and below designated medical institutions, 55% for second-level designated medical institutions, and 50% for third-level designated medical institutions. The payment ratio for retirees is 5 percentage points higher than that for active employees. The annual maximum payment limit is 6,000 yuan, which is calculated separately from the annual hospitalization maximum payment limit. Expenses exceeding 6,000 yuan within the scope of the general outpatient policy will be reimbursed according to the payment ratio of the employee medical insurance hospitalization pooling fund of the medical institution where the patient is treated, and will be calculated together with the maximum annual hospitalization payment limit. (The basic overall fund payment ratios for active employees in primary, secondary, and tertiary medical institutions are 91%, 88%, and 85% respectively; the payment ratios for retirees are 95%, 92%, and 89% respectively, which are within the scope of the policy The subsidy payment ratio for large medical expenses is 90%. The maximum annual hospitalization payment limit is 430,000 yuan)

2. The minimum payment standard for chronic diseases is 300 yuan, and expenses exceeding the minimum payment standard will be reimbursed within the scope of the policy. The proportion is uniformly 80%, and the maximum payment limit for a single disease is 2,000 yuan (of which the maximum payment limit for mental illness is 3,000 yuan). Each additional disease type increases the overall fund payment limit by 1,000 yuan, and the annual maximum payment limit is 5,000 yuan.

3. The minimum reimbursement standard for special diseases is 880 yuan. If the treatment in a designated medical institution at level 2 or above exceeds the minimum payment standard and is within the scope of the policy, the expenses will be based on the hospitalization reimbursement ratio of the medical institution (including chronic renal failure and There is no minimum payment standard for special disease expenses in severe mental illness outpatient clinics, and the reimbursement rate within the scope of the policy is 90%).

4. Emergency rescue (including pre-hospital emergency rescue) is reimbursed according to the hospitalization treatment according to the level of the medical institution. If you are hospitalized in the same designated medical institution within 3 days after emergency rescue, the minimum payment standard is the same as the hospitalization minimum standard. Combined cumulative calculation. There is no minimum payment standard for pre-hospital emergency rescue expenses incurred in the 120 ambulance, and they are reimbursed according to the hospitalization treatment of first-level medical institutions.

5. Nationally negotiated drugs. Each negotiated drug is paid once a year according to the hospitalization minimum standard of third-level medical institutions (currently 880 yuan). For treatment in second-level and above designated medical institutions, the out-of-pocket expenses are deducted. Expenses within the scope of the policy that exceed the minimum payment standard will be based on the hospitalization reimbursement ratio of the medical institution.

6. The deductible payment standard for day surgery shall be halved according to the hospitalization deductible standard of third-level designated medical institutions; the reimbursement ratio shall be based on the hospitalization payment ratio of designated medical institutions; day surgery for which disease settlement standards have been announced Surgery is paid according to the type of disease.

5. How to reimburse "outpatient medical insurance"? Relying on the "smart medical insurance" platform unifiedly constructed by the province, "one-stop settlement" can be achieved for the outpatient medical expenses incurred by insured employees in designated medical institutions. "That is, after the insured employees seek medical treatment and purchase medicines, through the medical insurance settlement system, they only need to pay the personal burden according to the system prompts to complete the instant reimbursement settlement of the "outpatient financial aid".

6. What impact will the implementation of the “Outpatient Clinic Financial Aid” have on personal accounts? Before the implementation of the “Outpatient Clinic Financial Aid”, personal accounts were transferred to a portion of the individual payment and the unit payment** *Same inclusion (flexible employment personnel are paid by individuals). After the policy is implemented, all basic medical insurance premiums paid by the unit will be included in the overall fund. The personal account of active employees is included in the basic medical insurance premium paid by the individual, specifically: 2% of the insured payment base (including the part of Kunming long-term care insurance payment that should be transferred from the personal account). The personal accounts of retired employees will continue to be transferred according to the existing regulations, and no adjustments will be made for the time being. 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.

7. How to realize "Relative *** Enjoyment" for personal accounts? Insured persons can volunteer through the "Yunnan Medical Insurance" WeChat applet or go to the service hall of Yunnan Provincial Medical Security Bureau (No. 439 Huancheng South Road) Financially bind personal accounts for spouses, parents, and children. The binding persons are divided into authorizers and users. The authorizer is the applicant for financial binding of the personal account. The users are the spouse, parents and children of the authorizer. They are limited to insured persons in Yunnan Province. The specific binding process can be found on the official website of the Yunnan Provincial Medical Security Bureau or the WeChat official account.

8. How to use a personal account to pay the personal payment part of relevant insurance? After realizing the financial binding of personal accounts, the spouses, parents, and children of insured employees participate in the individual basic medical insurance for urban and rural residents. For personal payment of large-amount medical expense subsidies for employees, long-term care insurance, etc., insured employees can apply to use their personal accounts to pay for them through the "Yunnan Medical Insurance" WeChat applet or the service hall of the Yunnan Provincial Medical Security Bureau. When insured employees personally pay large medical expense subsidies and long-term care insurance premiums, they can apply to use their personal accounts to pay through the "Yunnan Medical Insurance" WeChat applet or the service hall of the Yunnan Provincial Medical Security Bureau.

9. Can I enjoy the "outpatient medical treatment" treatment in other places? Yes. All types of insured employees who meet medical insurance regulations in other places can seek medical treatment at designated medical institutions in other places outside the coordination area after registration, and outpatient financial security expenses will be settled online. If online settlement cannot be made when seeking medical treatment, the insured person shall go to the medical insurance agency in the insured place to handle settlement with his or her medical insurance voucher, medical expense invoice, medical record and other materials.

10. Does the “relatives’ benefits” after outpatient medical insurance mean that “one person applies for medical insurance and the whole family enjoys benefits”? Not so. 1. Relatives are limited to the spouse, parents, and children of the insured person, and in principle are limited to the insured persons in Yunnan Province; 2. "Relative *** enjoyment" refers to *** use and *** enjoyment of their personal accounts, only It is used to pay personal expenses that comply with the provisions of the medical insurance policy, to participate in urban and rural residents’ medical insurance, employees’ large medical expense subsidies, long-term care insurance, and purchase of commercial health insurance, etc. It cannot be enjoyed or used exclusively. The insured person himself enjoys the reimbursement from the medical insurance co-ordination fund and the additional benefits and various other security benefits based on his insurance participation. It is particularly important to remind you that if you violate this provision and enjoy the relevant benefits involving the payment of the unified fund, you are suspected of violating the laws and regulations related to medical security, and the relevant departments will deal with your behavior in accordance with the laws and regulations.