Notice of reimbursement compensation scheme

County Health Bureau, Civil Affairs Bureau, Finance Bureau, Agriculture Bureau, Jining High-tech Zone Management Committee Social Development Bureau, Finance Bureau, Jining Beihu Resort Management Committee Office, Finance Bureau:

In order to fully implement the Implementation Opinions of the Municipal Party Committee and the Municipal Government on Further Deepening the Reform of the Medical and Health System (J.F. [2009] 17) and the Notice of the Municipal Government on Printing and Distributing the Recent Key Implementation Plan for the Reform of the Medical and Health System (J.F. [2009]30) (Opinions of the Provincial Health Department, the Provincial Civil Affairs Department and the Provincial Department of Agriculture on Consolidating and Developing the New Rural Cooperative Medical System)

I. Funding criteria

In 20 10, the fund-raising level of the new rural cooperative medical system was raised to not less than 120 yuan per person per year, among which the financial subsidies at all levels were raised to not less than 100 yuan per person per year, and individual farmers paid 20 yuan annually. On the basis of the provincial finance (including the central subsidy) subsidizing 45 yuan for each participating farmer in our city, the municipal finance subsidizes 6 yuan for each participating farmer in Yanzhou City, Zoucheng City and Jining High-tech Zone, 10 yuan for each participating farmer in Shizhong District, rencheng district City, Qufu City, Weishan County and Beihu Resort, and surabaya county City, Yutai County, Jinxiang County, Jiaxiang County and Wenshang. The difference is partly made up by the county (city, district) level finance, and the financing level of the new rural cooperative medical system is raised to not less than 150 yuan per person per year at 201year, in which the government subsidies at all levels are not less than 120 yuan, and the individual contributions of farmers are not less than 30 yuan. Encourage qualified places to appropriately raise local financial subsidies and farmers' payment standards according to their own financial resources and farmers' affordability.

Second, the compensation mode

20 10 the whole city continues to implement the mode of coordinating hospitalization and outpatient service. Outpatient co-ordination fund (including health examination fees, etc.). ) generally does not exceed 35% of the total amount of funds raised in the current year, while the hospital pooling funds and risk funds extracted in that year are generally not less than 65% of the total amount of funds raised in that year. The extraction of risk funds shall be carried out in accordance with the provisions of the document of the Provincial Department of Finance and the Provincial Health Department 18.

Third, hospitalization compensation.

1, hospitalization deductible line

The establishment of a four-level deductible, a designated medical institution 100 yuan, a designated medical institution in 500 yuan, a designated medical institution in 600 yuan outside the city. The deductible line of hospitalization compensation is deducted within the scope of compensation, and no compensation is paid. Participating farmers are hospitalized in the same hospital, and only one deductible is deducted within one year.

2. Proportion of hospitalization compensation

The proportion of reimbursement and compensation for first-class designated medical institutions is 65%, that for second-class designated medical institutions is 55%, that for third-class designated medical institutions is 45%, and that for provincial-level designated medical institutions is 35%. Counties (cities, districts) can float on this basis, but not more than 5%. When calculating the actual compensation amount of participating farmers, deduct the deductible amount from the reportable expenses, and then compensate according to the prescribed compensation ratio. The implementation of security compensation, the actual compensation ratio of hospitalization in medical institutions at or above the county level is not less than 25%.

For those who have been hospitalized in designated medical institutions outside the province and have not been referred for the record, they can be compensated according to 60% of the prescribed compensation ratio; Those who have not been referred for medical treatment outside the province or in non-designated medical institutions in the province (except for medical treatment and emergency treatment for migrant workers in the workplace) will not be compensated.

3, to participate in the natural delivery of pregnant women in hospital quota compensation 200 yuan. Cesarean section is still carried out according to the requirements of the management method of "four unifications and four fixings". For the medical expenses incurred by newborns born between the last payment period and the next payment period, their mothers can enjoy the compensation policy of the new rural cooperative medical system.

4 hospitalization compensation capping line is 50 thousand yuan, and the hospitalization compensation capping line is calculated according to the actual compensation amount obtained in that year.

5, migrant workers and farmers participating in sudden illness can first see a doctor, and inform the new rural cooperative medical institutions in the overall planning area within one week before discharge or by telephone, and the hospitalization expenses will be compensated according to the compensation ratio of local designated medical institutions at the same level with relevant certificates.

6. Significantly increase the proportion of national compensation for essential drugs, and increase the proportion of drug compensation in the list of essential drugs by 10%. Appropriately increase the proportion of compensation for Chinese medicine services, increase the proportion of compensation for Chinese medicine expenses (excluding proprietary Chinese medicines) by 10%, and increase the proportion of compensation for acupuncture and other appropriate Chinese medicine treatment expenses for inpatients by 90%.

7, strengthen departmental cooperation, do a good job in the policy, technology, service management and cost settlement of the new rural cooperative medical care and rural medical assistance system. Establish a unified service platform for the new rural cooperative medical system and rural medical assistance at the county level, realize information sharing between the two systems, and implement a "one-stop" service for poor farmers to settle compensation and medical assistance subsidies in medical institutions after seeking medical treatment, so as to facilitate poor farmers.

Fourth, non-hospitalization compensation.

1, outpatient compensation

Outpatient co-ordination is generally compensated in the first-level and village-level designated medical institutions of the new rural cooperative medical system (village-level medical institutions that are not included in the integration of rural health service management shall not be used as designated medical institutions of the new rural cooperative medical system), and there is no deductible, and the outpatient expenses are compensated according to the proportion of 20%. The top line for reimbursement of outpatient expenses per person per year is 50 yuan, and the actual compensation amount obtained during the year is calculated cumulatively.

2. Compensation for chronic diseases

It should include the following diseases: hypertension (phase II), heart disease complicated with cardiac insufficiency, cerebral hemorrhage and cerebral infarction recovery period, rheumatoid arthritis, chronic active hepatitis, chronic obstructive emphysema and pulmonary heart disease, epilepsy, hepatolenticular degeneration, decompensated cirrhosis, diabetes with ineffective diet control, chronic nephritis, Parkinson's disease, systemic lupus erythematosus, intervertebral disc herniation, chronic pelvic inflammatory disease and adnexitis, tuberculosis and schizophrenia.

Chronic diseases should be organized by the county-level new rural cooperative medical institutions for expert appraisal or early medical record verification. Patients with chronic diseases voluntarily choose a county-level designated medical institution to treat chronic diseases, and make compensation in the selected county-level designated medical institution or county-level new rural cooperative medical service agency. The deductible line is 200 yuan, and the expenses below the deductible line are compensated according to the proportion of outpatient compensation. The compensation ratio above the deductible line is 40% (nominal compensation ratio), and the annual cumulative ceiling line (compensation income) is 1 1,000 yuan. The funds are paid by the outpatient co-ordination fund.

Large outpatient treatment expenses for special diseases such as radiotherapy and chemotherapy for malignant tumor, aplastic anemia, hemophilia and organ transplantation anti-rejection treatment shall be implemented with reference to hospitalization compensation in hospitals at the same level. Patients with special diseases voluntarily choose county-level designated medical institutions for treatment, and make compensation in the selected county-level designated medical institutions or county-level new rural cooperative medical institutions. The deductible line is 400 yuan, and the expenses below the deductible line are compensated according to the proportion of outpatient compensation, while the expenses above the deductible line are compared with the hospitalization compensation in the same hospital. The annual cumulative capping line (compensation income) is 5000 yuan. The expenses for dialysis treatment of chronic renal insufficiency and large-scale outpatient treatment of leukemia are compensated according to the hospitalization in the same hospital, with the deductible line in 400 yuan and the annual cumulative top line (compensation income) of 50,000 yuan. The above funds are paid from the hospitalization fund.

3. Secondary compensation

Secondary compensation is not a normal way of compensation, and secondary compensation is not advocated. In places where there were many fund balances in those years or accumulated fund balances over the years, farmers who received serious illness compensation in those years generally received secondary compensation, not just a few farmers. At the same time, it is necessary to do a good job in the organization and publicity of secondary compensation to avoid unnecessary treatment comparison among participating farmers.

4. If the participating farmers participate in commercial medical insurance or meet other preferential policies at the same time, they should first implement commercial insurance compensation or preferential policies, and then compensate the total medical expenses of the participating farmers according to the compensation provisions of the new rural cooperative medical system.

Five, continue to implement the "city card" system.

In order to further facilitate the participating farmers to go to the designated medical institutions of the new rural cooperative medical system at all levels in the city for medical reimbursement, we will continue to implement the "one card system for the whole city". The designated medical institutions of the new rural cooperative medical system at the city, county (city, district) and township levels announced by the Municipal Health Bureau will recognize each other in this city, and all participating farmers who go to the designated medical institutions of the new rural cooperative medical system at all levels in Jining will no longer go through the referral procedures. Participating farmers are hospitalized in the new rural cooperative medical institutions recognized by each other and enjoy the reimbursement and compensation ratio of designated medical institutions at the same level as stipulated by participating farmers.

Sixth, define the scope of participation.

In accordance with the provisions of the notice of the general office of the provincial government on comprehensively promoting the pilot work of the new rural cooperative medical system (Lu Zhengban made [2007]1No.), the coverage of the new rural cooperative medical system and urban residents' medical insurance should be clarified to avoid repeated participation. Strictly implement the principle that the new rural cooperative medical system takes households as the unit, and the participants should be registered as agricultural household registration residents. Whether the place where the household registration system is reformed is a rural resident can be defined according to the family planning policy, the veterans resettlement policy and the urban minimum living security policy enjoyed by their families. Primary and middle school students and preschool children with rural household registration should join the new rural cooperative medical system with their parents.

Seven, strengthen supervision and management, to ensure standardized operation.

Strict implementation of the new rural cooperative medical system basic drug list, diagnosis and treatment project list, guiding principles of antibiotic use and other relevant regulations, reasonable examination and treatment, gradual medication, reasonable compatibility, no drug abuse, no prescription. Discharged patients should follow the prescription. Generally, the discharge dosage for acute diseases is less than 7 days, and that for chronic diseases is less than 15 days. The system of mutual recognition of inspection results of medical institutions shall be implemented. If the superior hospital has inspected and issued an inspection result report, the lower hospital shall recognize it, and the inspection result report issued by the hospital at the same level shall recognize each other to avoid repeated inspection. The off-list drugs and medical treatment notification system shall be implemented, and the proportion of off-list drugs in the total medical expenses shall not be higher than 5%, 10%, 15% and 20% respectively in the village and the first, second and third-level designated medical institutions. The supervision departments of the new rural cooperative medical system at all levels should implement the notification and warning system of the average hospitalization medical expenses, and regularly announce the medical expenses of the designated medical institutions of the new rural cooperative medical system to the public in an appropriate way. County (city, district) new rural cooperative medical management departments and designated medical institutions at all levels should formulate specific measures, strengthen the audit management of medical expenses, put an end to illegal expenditures of the new rural cooperative medical fund, and cancel the qualification of the new rural cooperative medical designated medical institutions in violation of the regulations on the management of the new rural cooperative medical system, and severely deal with the relevant responsible persons in accordance with relevant regulations.

Eight. Relevant explanation

1, the unified reimbursement and compensation scheme for the whole city has been implemented since 20 10 1.

2, in the city to continue to implement the new rural cooperative medical system "four unified, four fixed" and "four in one" management approach.

3, counties and urban areas at least once every six months to organize the supervision and inspection of the members of the new rural cooperative medical supervision committee, to ensure the safety of funds.

4. Matters not covered in this notice shall be implemented in accordance with the Opinions of the Provincial Health Department, the Provincial Civil Affairs Department, the Provincial Department of Finance and the Provincial Department of Agriculture on Consolidating and Developing the New Rural Cooperative Medical System (Lu Wei Nong Wei Fa [2009] No.5).

200913 February