since April 1st, Kunming and the provincial level have implemented the basic medical insurance outpatient service. By reducing the personal account transfer, the general outpatient service security has been established, and the policy linkage transformation has been adopted to promote a fairer and more inclusive system, and efforts have been made to solve the problems of insufficient personal accounts of the insured who suffer from common diseases and frequently-occurring diseases, and the * * * aid is not strong. For this brand-new medical insurance policy, many citizens praised it, and the specific operational links such as how to help the whole family and how to reimburse the outpatient service are the most concerned issues of the citizens. In this issue of "Spring City Medical Insurance Micro Classroom", Xiaozhang brings you the most comprehensive strategy.

1. What is "outpatient aid"? Generally speaking, outpatient * * * aid has two meanings, one is to plan as a whole * * * aid. The most important change in the outpatient * * * aid implemented now is to give full play to the role of the overall fund, and reimburse the ordinary outpatient expenses incurred by the insured workers in the designated service institutions within the scope of the medical insurance policy, so that outpatient patients can also enjoy the reimbursement treatment of the overall fund. The second is the account * * * economy. After the implementation of the "outpatient aid", the personal accounts of insured employees can be used by spouses, children and parents, which improves the efficiency of personal accounts. In addition, it is clearly put forward that it can be used for individual contributions of residents' medical insurance, subsidies for large medical expenses of employees, and reimbursement for business health, which opens the door for insured people to be included in multi-level medical security network on the other hand.

second, who are the people to whom the policy of "outpatient aid" applies? The employees' medical insurance insured persons (including flexible employment insured persons) who pay normal insurance premiums in the province are all within the scope of protection. The workers' medical insurance participants in Kunming can enjoy the outpatient treatment policy from April 1, 222.

third, after the implementation of "outpatient * * * aid", what are the main improvements in the treatment of insured employees? 1. Outpatient medical treatment is guaranteed. Outpatient expenses within the scope of medical insurance policy can be reimbursed by the overall fund; 2. The scope of personal account payment is expanded. First, the insured person can use the personal account with his spouse, parents and children to pay related expenses within the scope stipulated by the policy; Second, in addition to paying the expenses borne by individuals within the medical insurance policy, it can also be used for personal contributions such as participating in medical insurance for urban and rural residents, subsidizing large medical expenses for employees, long-term care insurance and purchasing commercial health insurance.

iv. what is the outpatient security in "outpatient assistance" and what are the specific provisions? (1) Outpatient care includes: general outpatient care for employees' medical insurance (including outpatient examination), outpatient chronic diseases, outpatient special diseases, outpatient emergency rescue, outpatient care for drugs negotiated by national medical insurance, and daytime surgery. (II) Specific treatment provisions:

1. The insured persons in the general outpatient clinic visit the general outpatient clinic in designated medical institutions, and the medical expenses within the policy scope that meet the medical insurance provisions (hereinafter referred to as the expenses within the policy scope) are included in the general outpatient security. For the settlement of each general outpatient visit, the minimum payment standard of the overall fund within the policy scope is: 3 yuan, a designated medical institution at or below the first level, 6 yuan, a designated medical institution at the second level, and 9 yuan, a designated medical institution at the third level. On-the-job reimbursement ratio: 6% of designated medical institutions at or below the first level, 55% of designated medical institutions at the second level and 5% of designated medical institutions at the third level. The payment ratio of retirees is 5 percentage points higher than that of employees. The annual maximum payment limit is 6 yuan, which is calculated separately from the annual maximum payment limit for hospitalization. The expenses within the scope of the general outpatient policy of more than 6 yuan shall be reimbursed according to the proportion of the medical insurance hospitalization pooling fund for the employees of the medical institutions, and shall be combined with the annual hospitalization maximum payment limit. (The proportion of employees' basic pooling fund payment in primary, secondary and tertiary medical institutions is 91%, 88% and 85% respectively; Retirees pay 95%, 92% and 89% respectively, and the proportion of large medical expenses within the policy scope is 9%. The maximum annual hospitalization payment is 43, yuan. )

2. The Qifubiaozhun for chronic diseases is 3 yuan, and the reimbursement rate within the policy scope above the Qifubiaozhun is 8%. The maximum payment limit for a single disease is 2, yuan (including the maximum payment limit for mental illness is 3, yuan), and the maximum payment limit for each additional disease is 5, yuan.

3. Qifubiaozhun for special diseases. In 88 yuan, the expenses in the designated medical institutions above the second level and above that exceed the Qifubiaozhun shall be implemented according to the proportion of hospitalization reimbursement of the medical institutions (there is no Qifubiaozhun for outpatient special diseases of chronic renal failure and severe psychosis, and the reimbursement proportion within the policy range is 9%).

4. Emergency rescue (including pre-hospital emergency rescue) shall be reimbursed according to the level of the medical institution to be treated, and if the patient is hospitalized in the same designated medical institution within 3 days after emergency rescue, the Qifubiaozhun and hospitalization Qifubiaozhun shall be combined and calculated cumulatively. The pre-hospital emergency rescue expenses incurred in the 12 ambulance are reimbursed according to the hospitalization treatment of the first-class medical institution without setting the minimum threshold.

5. National negotiated drugs Each negotiated drug is paid once a year according to the hospitalization qifubiaozhun of tertiary medical institutions (currently in 88 yuan), and the expenses beyond the qifubiaozhun after deducting the first out-of-pocket expenses in designated medical institutions at level 2 and above are implemented according to the proportion of hospitalization reimbursement of medical institutions.

6. Qifubiaozhun for daytime operation is halved according to Qifubiaozhun for hospitalization in tertiary designated medical institutions; The proportion of reimbursement shall be implemented according to the proportion of hospitalization payment of designated medical institutions; Day surgery with published disease settlement standard is paid by disease.

5. how to reimburse "outpatient aid"? Relying on the unified "smart medical insurance" platform in the whole province, the outpatient medical expenses incurred by insured employees in designated medical institutions can be settled in one stop, that is, after the insured employees purchase medicines, they can complete the immediate reimbursement settlement of "outpatient medical assistance" only by paying the personal burden according to the system prompts through the medical insurance settlement system.

VI. What is the impact on personal accounts after the implementation of "outpatient aid"? Before the implementation of "outpatient * * * aid", the individual account was included in the individual account and part of it was paid by the unit (flexible employees were paid by individuals). After the implementation of the policy, the basic medical insurance premiums paid by the unit were all included in the overall fund. Personal accounts of on-the-job employees are included in the basic medical insurance premium paid by individuals, specifically: 2% of the base of my insurance payment (including the part that should be included in the payment of Kunming long-term care insurance). Personal accounts of retired employees will continue to be included in accordance with existing regulations, and will not be adjusted for the time being. After adjusting the overall fund and personal account structure, the increased overall fund is mainly used for outpatient economic security and improving the outpatient treatment of the insured.

VII. How can personal accounts be enjoyed by relatives? Insured persons can voluntarily bind their spouses, parents and children through the "Yunnan Medical Insurance" WeChat applet or to the service hall of Yunnan Medical Security Bureau (No.439 Huancheng South Road). The binding personnel are divided into the authorizer and the user. The authorizer is the applicant for personal account binding, and the user is the spouse, parents and children of the authorizer, which is limited to the insured in Yunnan Province. The specific binding process can be found in official website of Yunnan Medical Security Bureau or WeChat WeChat official account.

VIII. How to use personal account to pay the personal contribution of relevant insurance? After realizing the * * * economic binding of personal accounts, the spouses, parents and children of the insured employees can participate in personal contributions such as basic medical insurance for urban and rural residents, large medical expenses subsidies for employees, long-term care insurance, etc. The insured employees can apply for using their personal accounts to pay for them through the "Yunnan Medical Insurance" WeChat applet or the service hall of Yunnan Medical Security Bureau. When the insured employees pay large medical expenses subsidies and long-term care insurance fees, they can apply for using their personal accounts to pay through the "Yunnan Medical Insurance" WeChat applet or the service hall of Yunnan Medical Insurance Bureau.

9. Can I enjoy the "out-patient" treatment for medical treatment in different places? Can enjoy. All kinds of employees who meet the requirements of medical insurance for medical treatment in different places can go to designated medical institutions in different places outside the overall planning area for medical treatment after filing, and the outpatient economic security expenses will be settled online. If the medical treatment fails to be settled online, the insured person shall go to the medical insurance agency of the insured place for settlement with his medical insurance voucher, medical expense invoice, medical record and other materials.

X. Does "relatives * * * enjoy" after the outpatient service * * * mean that "one person runs medical insurance and the whole family enjoys treatment"? That's not true. 1. Relatives are limited to the spouses, parents and children of the insured, and in principle limited to the insured in Yunnan Province; 2. "Relatives * * * enjoy" refers to * * * using and * * enjoying their personal accounts, which are only used to pay the expenses borne by individuals within the medical insurance policy, personal contributions for participating in medical insurance for urban and rural residents, large medical expenses subsidies for employees, long-term care insurance and purchasing commercial health insurance, and cannot be reimbursed by the medical insurance pooling fund enjoyed by the insured person himself or on the basis of his participation. In particular, it is important to note that if you use * * * to enjoy the relevant treatment related to the payment of the overall fund in violation of this regulation, it is suspected of violating the relevant laws and regulations on medical security, and the relevant departments will deal with its behavior in accordance with laws and regulations.