Shanghai Medical Insurance Personal Account Transfer Standard 223:

1. Improve the personal account transfer method.

from July 1, 223, all the basic medical insurance premiums paid by employees will be included in my personal medical account, and the inclusion standard is 2% of my insured payment base, and all the basic medical insurance premiums paid by the unit will be included in the overall fund;

2. Strengthen the function of outpatient service.

Improve the medical insurance outpatient fee guarantee mechanism for employees, and adjust the treatment standard for outpatient and emergency services from July 1, 223;

3. standardize the scope of personal accounts.

Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies. From July 1, 222, the scope of personal accounts will be expanded step by step. Personal accounts can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables in designated retail pharmacies. Explore personal accounts for personal contributions for spouses, parents and children to participate in basic medical insurance for urban and rural residents. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance;

4. Enhance the supplementary guarantee function of local additional funds.

the local supplementary medical insurance premiums paid by the employer are all included in the local supplementary fund and accounted for separately. From January 1, 223, outpatient and emergency medical expenses will be included in the scope of overall fund payment, and will no longer be paid by local additional funds. The local supplementary funds continue to pay all kinds of burden reduction expenses including comprehensive burden reduction of employees' medical insurance, and some medical expenses above the maximum payment limit of the overall fund. Explore the multi-channel financing and supplementary guarantee functions of local additional funds in dealing with population aging;

5. Strengthen supervision and management.

Improve the management and service measures, innovate the system operation mechanism, guide the rational utilization of medical resources, ensure the stable operation of medical insurance funds, and give full play to the security function. Strictly implement the budget management system of medical insurance fund and strengthen the construction of fund audit system and internal control system. Further improve the dynamic management mechanism of the whole process of personal accounts, and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of medical behavior and medical expenses, improve the administrative law enforcement supervision system at the municipal and district levels, continue to carry out special actions to crack down on fraud and insurance fraud, strengthen joint supervision across departments, strengthen social supervision, and accelerate the construction of intelligent supervision system;

6. accelerate the construction of primary medical service system, improve the contract service of family doctors, standardize the long-term prescription management, and guide the insured to seek medical treatment for the first time at the primary level. Improve the payment mechanism that is suitable for outpatient economic security.

strengthen the linkage of "three doctors" and promote the deepening of medical and health system reform. We will continue to deepen the reform of medical insurance payment methods, and promote the payment by disease score (DIP) system and the payment by disease diagnosis (DRG) system under the management of total budget, so as to provide better medical services for the masses and reduce the burden of medical treatment for the masses. Scientifically and reasonably determine the payment standard of medical insurance, and guide the active use of drugs with definite curative effect and reasonable price. Further, eligible "internet plus" medical services will be included in the scope of payment.

The reimbursement methods of medical insurance are as follows:

1. Local reimbursement

If the insured person goes to a local designated medical institution for reimbursement, the medical expenses incurred can be directly settled with the medical insurance card at the time of settlement, and the settlement center will directly calculate the reimbursable amount, and the insured person only needs to pay the self-funded medical expenses, which is very convenient;

2. reimbursement in different places

At present, medical insurance has not been fully networked nationwide. Therefore, when seeing a doctor in a designated medical institution in different places, it is usually necessary for the insured person to advance the expenses by himself, and keep all the documents, and then go to the social security handling center where the insured person is located to handle the reimbursement manually.

to sum up, since 223, the medical insurance settlement system in different places has been officially implemented. For those who live in different places for a long time and go out for medical treatment temporarily across provinces, the medical insurance expenses incurred can be directly reimbursed without going back to the insured place.

Legal basis:

Article 26 of the Social Insurance Law of the People's Republic of China

The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.