First, the implementation of the new rural cooperative medical system financing standards
From 20 12, the financing standard of the new rural cooperative medical system has been raised to not less than that of 290 yuan per person per year. Among them, governments at all levels will raise the subsidy standard of the new rural cooperative medical system to 240 yuan per person per year, and the provincial finance will give graded subsidies according to the financial situation of various places; Individual contributions are not less than 50 yuan per person per year. Where the economic conditions are better and the medical expenses are higher, the government subsidies and individual payment standards will be appropriately raised. All co-ordination areas should strengthen the management of participation and conscientiously do a good job in the collection of individual participation fees. 2065438+At the end of February 2002, the county-level health administrative department shall determine the number of participants. After the number of participants is determined, it shall not be changed in principle during the year. The financial departments at all levels shall calculate and allocate subsidy funds according to the determined number of participants.
Two, standardize the new rural cooperative medical fund allocation
The new rural cooperative medical fund is composed of inpatient pooling fund, outpatient pooling fund and risk fund. After deducting the risk fund from the total fund-raising of the new rural cooperative medical system, in principle, the hospitalization co-ordination is charged at 245 yuan per capita (including the hospitalization co-ordination fund 230 yuan, the supplementary compensation fund for large medical expenses of major diseases 15 yuan) and the outpatient co-ordination fund 45 yuan per capita (including the general outpatient co-ordination fund 35 yuan and the outpatient special disease co-ordination fund 10 yuan), and all localities can make appropriate adjustments according to the actual situation.
According to the provisions, the supplementary compensation fund for large medical expenses for major diseases will be withdrawn, and it will not continue to be withdrawn if it reaches the annual 15 yuan standard (including the balance over the years).
Strict fund compensation scope. The new rural cooperative medical fund can only be used to compensate the medical expenses of participating farmers. For the special compensation items stipulated by the relevant national and provincial policies, the national special subsidy policy shall be implemented first, and the rest medical expenses shall be compensated according to the reimbursement regulations of the new rural cooperative medical system. Items included in free treatment are not included in the compensation scope of the new rural cooperative medical fund.
Third, adjust the overall compensation scheme of the new rural cooperative medical system.
(A) adjust the overall compensation scheme for hospitalization
In principle, the deductible line of hospitalization compensation for the new rural cooperative medical system is 300 ~ 400 yuan and 600 ~ 1000 yuan at or above the county level respectively, and all localities can choose appropriately within this range. There is no deductible line at the township level.
The capping line is the highest compensation that participating farmers can get for one or more hospitalizations in a guaranteed year. It should be no less than 80,000 yuan in 20 12 years, and in some places, it should not exceed 654.38+10,000 yuan in principle.
After raising the financing standard of the new rural cooperative medical system, the reimbursement rate of medical institutions at township level, county level and above increased by 5 percentage points compared with 20 1 1, reaching 15 percentage points. According to the hospitalization rate and "reimbursable expenses each time" in the overall planning areas in recent years (the product of the two is "per capita reimbursable expenses"), the provincial technical expert steering group of the new rural cooperative medical system divides all localities into three grades, and all localities should choose the corresponding grades according to the per capita reimbursable expenses range of counties (cities, districts). In principle, the proportion of hospitalization compensation in designated medical institutions at or above the county level is 75% ~ 80% and 45% ~ 65% respectively; Segmentation of township-level hospitalization compensation: that is, the proportion of compensation below 500 yuan (including 500 yuan) and beyond 500 yuan is 60% ~ 95%. The specific salary reference scheme is as follows:
20 12 Reference Scheme for Compensation of New Rural Cooperative Medical System
Reimburseable expenses per capita (yuan) General outpatient compensation and hospitalization compensation (subsection compensation)
Township medical institutions medical institutions at or above the county level
≤500 yuan > 500 yuan
Compensation proportion capping line compensation proportion compensation proportion compensation proportion compensation proportion compensation proportion compensation proportion.
174~29260%40060%95%80%~85%60%~65%
293~33660%40060%95%80%~85%55%~60%
337~46660%40060%90%75~80%%45%~55%
(two) adjust the major illness hospitalization large medical expenses compensation scheme.
Adhere to all districts and cities as a whole to carry out supplementary compensation for large medical expenses incurred in hospitalization for major diseases, and the new rural cooperative medical management centers in all districts and cities coordinate the management of supplementary compensation for hospitalization for major diseases, and the county-level new rural cooperative medical agencies handle supplementary compensation services for participating farmers.
Improve the supplementary compensation scheme for large hospitalization medical expenses for major diseases. According to the operation of the serious illness fund and the improvement of the overall compensation ratio, the overall planning areas can appropriately adjust the deductible and compensation ratio. The deductible of 20 12 years can be reduced to 1- 1.5 million yuan, and the compensation ratio is 70%-80%. Districts and cities with lower medical expenses can further reduce the deductible according to the actual operation of the fund, improve the level of protection, and effectively solve the economic burden of patients with higher medical expenses. In an overall planning area, all participants enjoy the same reimbursement treatment.
(3) Appropriately improve the level of outpatient special disease protection.
Continue to improve the compensation scheme for special outpatient diseases, improve the level of protection, guide patients to seek medical treatment reasonably, and ease the pressure of hospitalization. On the basis of "fixed diseases", "fixed drugs" and "fixed diagnosis and treatment items", the outpatient expenses of hypertension, diabetes and severe mental illness are compensated by 50%, and the outpatient expenses of township hospitals are compensated by 90% of the policy compensation ratio. The specific measures shall be issued separately by the Provincial Health Department.
Adjust the compensation ratio of 9 diseases, such as radiotherapy and chemotherapy of malignant tumor, anti-rejection of organ transplantation, hemophilia, aplastic anemia, systemic lupus erythematosus, liver cirrhosis (decompensated period), chronic cardiac insufficiency, stroke and sequelae, and myasthenia gravis. , so as to achieve the same proportion of hospitalization compensation as the same level hospitals, no longer set the capping line by itself, but use the capping line for hospitalization medical expenses compensation.
Improve the dialysis support level of severe uremia, adopt a fixed compensation method, and compensate 70% of the dialysis cost according to no more than three dialysis times per week, with an annual limit of 40,000 yuan, which obviously reduces the medical expenses burden of patients with severe uremia. (four) to carry out the overall work of general outpatient service.
Further improve the general outpatient compensation scheme, and effectively link the general outpatient compensation of township hospitals (community health service centers) with the hospitalization compensation of low-cost sections in towns and villages. There is no deductible line for each outpatient service, and compensation is made according to 60%. Improve the capping line of general outpatient service, with the annual capping line around 400 yuan per person. The specific standards are determined by the overall planning area according to the operation of the fund. All localities should actively create conditions to bring village health centers that implement rural integrated management and basic drug system and can be networked with the information system of the new rural cooperative medical system into the designated scope of the general outpatient service of the new rural cooperative medical system, so as to facilitate rural residents to seek medical treatment for common diseases, but only one health center can be set up in each administrative village. According to the proportion of 40 ~ 50% compensation, of which the village health clinic general outpatient compensation capping line is about 50 yuan per person per year.
Incorporate general medical expenses into the reimbursement scope of the new rural cooperative medical system. It is necessary to further increase the publicity of general outpatient clinics, expand publicity channels, improve the awareness rate, and guide participating farmers to actively use the general outpatient clinics of the new rural cooperative medical system. It is necessary to strengthen the training of medical staff in designated medical institutions, improve the level of outpatient service and improve the compensation efficiency of the new rural cooperative medical system. All localities should simplify the reimbursement procedures and service processes of general outpatient clinics, further accelerate the popularization and application of social security cards, and make full use of information technology to facilitate farmers' reimbursement and compensation.
(5) Improve the protection of major diseases in rural areas.
Further consolidate and improve the level of protection for children with leukemia and congenital heart disease in rural areas, expand the scope of designated medical institutions, refine screening procedures, and improve referral treatment and settlement. Gradually increase the number of diseases, and include major diseases such as breast cancer, cervical cancer and multidrug-resistant tuberculosis in the scope of protection.
Four, strengthen the new rural cooperative medical fund management and supervision of designated medical institutions.
(A) to strengthen the management of funds
Counties (cities, districts) with high fund balance rate should adjust the compensation scheme in a targeted manner, reasonably increase the compensation ratio, implement secondary compensation, and improve the fund utilization rate. In areas where there is a risk of fund cost overruns, it is necessary to strengthen the control of hospitalization rate and the supervision of medical expenses, appropriately adjust the overall compensation plan, and keep the fund running smoothly.
(2) Actively promote the reform of payment methods.
Counties (cities, districts) should carry out general outpatient co-ordination while implementing the total prepayment system for outpatient co-ordination. Continue to carry out the reform of hospitalization payment according to disease type (group), total amount and bed day in 1 1 county, and gradually push it forward after gaining experience. Actively pilot the reform of payment methods such as paying by bed day for hospitalization and paying by head for outpatient service. Through the reform of payment methods, we will control the unreasonable rise of medical expenses, ensure the safety of the fund, and strive to achieve remarkable results during the year.
(C) to strengthen the supervision of the new rural cooperative medical system
It is necessary to further strengthen the refined management of the new rural cooperative medical system, improve the means of supervision and improve the level of supervision. Strict implementation of the provincial health department to determine the medical expenses increase limit, the proportion of drugs outside the directory, for the per capita hospitalization expenses increase and the proportion of medical expenses outside the directory exceeds the prescribed designated medical institutions, should be dealt with severely in accordance with the provisions. Strengthen the daily supervision of designated medical institutions. Rational drug use, rational inspection, rational use of antibiotics, payment reform, fee control and drug control outside the catalogue are important contents of the assessment of designated medical institutions and are important conditions for the qualification of designated medical institutions. Health administrative departments at all levels should incorporate the implementation of the new rural cooperative medical system in designated medical institutions into the scope of hospital evaluation, strengthen supervision and inspection guidance on the operation of the new rural cooperative medical system, and standardize the service behavior of designated medical institutions.
(4) Strengthen the management of referral.
In line with the principle of facilitating the people and seeking medical treatment nearby, we respect farmers' right to choose independently. Neighboring areas can explore the establishment of a mutual recognition system for designated medical institutions of the new rural cooperative medical system, which is convenient for participating farmers to seek medical treatment nearby. County-level new rural cooperative medical management institutions strengthen referral management and guide farmers to be hospitalized nearby. It is necessary to formulate a referral examination and approval system in light of the actual situation, reasonably control the proportion of patients who turn to counties for medical treatment, and control the rate of turning to counties for medical treatment at around 25%. When the participating patients are transferred to medical institutions outside the province, they should have referral opinions from provincial designated hospitals and be approved by the county-level new rural cooperative medical management department. The proportion of compensation can be appropriately reduced for patients who have gone through the referral procedures but have not visited medical institutions outside the county, and the specific proportion is determined by the counties themselves. Medical expenses incurred by medical institutions going abroad shall not be compensated.
(5) Strengthen the management of medical cards (social security cards)
Make full use of social security cards to improve the management, payment and settlement of the new rural cooperative medical system, and all overall planning areas should strengthen the management of card use, speed up the issuance of social security cards for rural residents, and improve the card use environment of designated medical institutions. Intensify publicity, guide the participating farmers to use the cooperative medical certificate (card) correctly, especially in outpatient service, so as to facilitate the settlement of the certificate (card).
Counties (cities, districts) should, in accordance with the guidance and combined with the actual situation, introduce a 20 12 local compensation adjustment plan as soon as possible. The health and financial departments of all districts and cities shall, in accordance with the requirements of this opinion, strengthen the guidance on the adjustment of the compensation scheme of the new rural cooperative medical system in counties (cities, districts) under their jurisdiction, be responsible for the audit of the compensation adjustment scheme of counties (cities, districts), and report it to the provincial leading group for the record. Compensation policy to break through this opinion, should put forward specific basis, the provincial new rural cooperative medical system leading group office for approval before implementation. Each county (city, district) 20 12 new rural cooperative medical compensation adjustment scheme and each district and city 20 12 large-scale hospitalization medical expenses supplementary compensation adjustment scheme should be implemented before the end of February.
Other compensation policies not covered by this opinion shall continue to be implemented according to the compensation scheme issued by the Provincial Health Department and the Department of Finance.
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