I. Basic Principles and Work Objectives
(1) Basic principles: individual contributions, social assistance and government support shall be adopted for fund-raising; Urban areas (including suyu district, Sucheng District, Suqian Economic and Technological Development Zone, Hubin New District and Yanghe New District) and counties implement fund management; The use of the fund is based on income and expenditure, with a balance of payments and a slight balance; The operation process is open, fair and just.
(II) Work objectives: The population coverage rate of the new rural cooperative medical system will remain above 98%, among which the coverage rate of the target population will reach1.000%; The outpatient co-ordination fund accounts for 20% of the total fund-raising in that year, and the inpatient co-ordination fund accounts for 70% of the total fund-raising in that year; The annual balance rate of the Fund is controlled within 10%, and the cumulative balance rate is controlled within 20%. The proportion of compensation for hospitalization expenses within the scope of county and township policies has reached more than 75%.
Second, the participants
(a) within the jurisdiction of the rural residents (including rural primary and secondary school students) to participate in the domicile of the new rural cooperative medical system.
(two) urban residents and other people living in cities and towns for a long time can participate in the local new rural cooperative medical system; Those who have participated in the basic medical insurance for urban workers and urban residents shall not participate in the new rural cooperative medical system.
(three) babies and retired soldiers born between the last payment period and the next payment period of the new rural cooperative medical system can participate in the new rural cooperative medical system in that year; Within fifteen working days from the date of birth, if parents apply to participate in the new rural cooperative medical system, the medical expenses incurred since the date of birth shall be included in the compensation scope of the new rural cooperative medical system fund; Those who did not participate in the new rural cooperative medical system within 0/5 working days after birth/kloc-will be included in the compensation scope of the new rural cooperative medical system fund from the date of replacement.
(IV) The rural minimum living security object, the five-guarantee object, orphans, key entitled groups and other medical assistance objects shall all be included in the new rural cooperative medical system by the people's government in the overall planning area.
Three. Funding standard
The fund-raising standard of the new rural cooperative medical system in the city is 480 yuan per capita, of which the individual payment is 100 yuan, and the financial subsidy standard at all levels is 380 yuan. Rural residents, five objects, orphans, key entitled groups and other civil assistance objects should pay the expenses, and the county (district) financial department will fully subsidize them from the medical assistance fund.
Fourth, designated institutions.
In accordance with the provisions of the new rural cooperative medical system management, approved by the administrative department of health and signed a service agreement with the new rural cooperative medical system management office, the village clinics (community health service stations) that implement the integrated management of rural health institutions are included in the designated medical institutions of the new rural cooperative medical system. The designated medical institutions of the new rural cooperative medical system must apply to the new rural cooperative medical system management office for renewal of the service agreement within one month before the expiration of the agreement, otherwise the agreement relationship will be automatically terminated.
Verb (abbreviation for verb) medical treatment and referral
(a) the implementation of free referral system in the overall planning area, to encourage the first diagnosis at the grassroots level.
(two) to co-ordinate the referral outside the region and implement the referral filing system. If the participating patients admitted to the designated medical institutions at the county level need to be referred to the higher-level hospital for hospitalization, the municipal designated medical institutions shall be given priority. If it is really necessary to be referred to other hospitals outside the city for hospitalization, the transfer hospital (at or above the county level) shall issue a referral certificate and go through the filing formalities at the new rural cooperative medical management office in the overall planning area. The filing period is 15 days. Those who have not gone through the referral procedures are regarded as abnormal referrals. Referral to the First People's Hospital of the city or the Infectious Disease Hospital of the city does not require approval.
(three) urban insured persons can choose their own doctors in all designated medical institutions in urban areas. If it is necessary to transfer to outside the city for treatment, it must be proved in writing by the First People's Hospital of the city, Suqian People's Hospital of Nanjing Gulou Hospital Group, Suqian Branch of Shanghai Oriental Hospital (especially for cardiovascular and orthopedic diseases), Children's Hospital of the city (especially for children with congenital heart disease), Infectious Disease Hospital of the city, and Third Hospital of Suqian City (especially for mental patients), and it can only be pressed after being examined and approved by the New Rural Cooperative Medical Management Office of the city.
The scope and standard of compensation for intransitive verbs
(1) scope of drug use
The scope of drug use in medical institutions above the first level shall be subject to the Catalogue of Essential Drugs for New Rural Cooperative Medical System in Jiangsu Province (revised edition in 2009). Village clinics (community health service stations) use drugs according to the national essential drugs list and the provincial supplementary essential drugs list; The scope of drug use in hospitals implementing the basic drug system is based on the Catalogue of Essential Drugs for New Rural Cooperative Medical System in Jiangsu Province (revised in 2009), the Catalogue of National Essential Drugs and the Supplementary Catalogue of Essential Drugs in Jiangsu Province.
(B) outpatient compensation standards
1. general outpatient compensation
The outpatient expenses of designated medical institutions at township and village levels can be compensated according to the proportion of 45% and 50% respectively. Prescription fee per person per day in township designated medical institutions 100 yuan, and 30 yuan per person per day in village clinics. The general medical expenses of village clinics (community health service stations) and hospitals that implement the basic drug system are 6 yuan, of which patients pay 1 yuan, and the rest of 5 yuan is paid from the New Rural Cooperative Fund. There is no deductible line for outpatient service of designated medical institutions in towns and villages, and the highest compensation for participants is 200 yuan (including general medical expenses) every year.
The outpatient medical expenses of other medical institutions inside and outside the city will not be compensated.
2. outpatient special disease compensation
(1) Outpatient expenses for myelodysplastic syndrome, malignant tumor, end-stage renal disease, organ transplant anti-rejection therapy, aplastic anemia, hemophilia, etc. According to the proportion of 80% compensation, the maximum compensation per person per year is 60,000 yuan; Chronic hepatitis B complicated with cirrhosis, nephrotic syndrome, systemic lupus erythematosus, Parkinson's disease and other outpatient expenses can be compensated by 80%, with a maximum compensation of 40,000 yuan per person per year.
(2) Outpatients with diabetes, tertiary hypertension, apoplexy sequelae and severe mental illness can compensate for the expenses. Compensation should be given according to the proportion of 80%, with a maximum compensation of 4,000 yuan per person per year. Only when patients with severe mental illness are hospitalized in designated hospitals can outpatient expenses be compensated.
In the outpatient treatment of the above-mentioned special outpatient diseases in medical institutions outside the city, compensation shall be given in accordance with the proportion of 60% of the above compensation standards.
The outpatients with the above-mentioned special diseases shall go through the examination and approval procedures for outpatient special diseases at the new rural cooperative medical management office in the overall planning area with the inpatient medical records, inspection reports and diagnosis certificates issued by secondary and above medical institutions (mental patients are psychiatric hospitals), and can enjoy the compensation for outpatient special diseases only after examination and approval.
(3) hospitalization compensation standard
1. Payline
The hospitalization deductible lines of first-class hospitals, second-class hospitals, third-class hospitals and hospitals outside the city are 200 yuan, 600 yuan, 1.000 yuan and 1.500 yuan respectively.
2. Compensation standard
(1) First-class designated medical institutions, after the deductible is reduced, the rest will be compensated by 85%. In hospitals that implement the basic drug system, the compensation standard of the new rural cooperative medical system will be adjusted according to the implementation of the basic drug system.
(2) Secondary designated medical institutions, after the hospitalization deductible is reduced, the rest will be compensated according to the proportion of 80%.
(3) Three-level designated medical institutions, after deducting the deductible, the rest will be compensated in two stages. The compensation ratio of 100 1 20,000 yuan (including 20,000 yuan) is 60%, and the compensation ratio of more than 20,000 yuan is 70%.
(4) In hospitals outside the city, after the deductible is reduced, the rest will be compensated in two stages. The compensation ratio of 150 1 20,000 yuan (including 20,000 yuan) is 50%, and the compensation ratio of more than 20,000 yuan is 60%.
(5) The first onset of cerebral infarction is managed at a price limit of 5,500 yuan. Hospitalization due to cerebral infarction is implemented according to the general patient compensation policy, and other diseases included in major rural diseases in medical insurance coverage are implemented according to relevant provincial and municipal documents.
(six) pregnant women in medical institutions in hospital delivery costs to implement single disease price management, beyond the price part shall be borne by the designated medical institutions. Namely: normal delivery and vaginal surgery 1.500 yuan, secondary hospital 1.600 yuan, tertiary hospital 1.700 yuan; The first-level hospital for cesarean section 1800 yuan, the second-level hospital is 2,200 yuan, and the third-level hospital is 2,600 yuan.
In line with the family planning policy, rural pregnant women who participate in hospital delivery shall be compensated according to the above-mentioned hospitalization compensation standards, and the total compensation expenses of the new rural cooperative medical system and the financial subsidy expenses for hospital delivery shall not exceed the actual expenses. Do not meet the family planning policy, no compensation.
(7) Adjust the daily payment standard for mental patients. First-level medical institutions: 1-2 days 180 yuan, 3- 12 days 130 yuan, 3-20 days10 yuan, more than 20 days 100 yuan; Secondary medical institution: 1-2 days in 230 yuan, 3- 12 days 150 yuan, 03-20 days 120 yuan, more than 20 days 100 yuan. The treatment of electroconvulsive therapy for severe mental patients is settled separately, and the compensation is 80%, which is not limited by daily payment limit.
(8) Adjust the proportion of critically ill patients and the number of days before elective surgery. 120 the proportion of critically ill patients in township medical institutions increased from 5% to 7%. The preoperative days of patients undergoing elective surgery increased from 1 day to 2 days.
3. Some diseases in tertiary medical institutions are subject to price limit management according to diseases.
4. If the actual amount of hospitalization compensation is lower than the proportion of guarantee compensation compared with the total hospitalization expenses, the guarantee compensation shall be implemented. The proportion of payment for malignant tumor patients is 50%, and that for other diseases is 40%.
5. Referral between urban areas as a whole, the participants who have gone through the examination and approval procedures for referral shall be executed according to the normal compensation standard, and the participants who have not gone through the examination and approval procedures for referral shall be executed according to 70% of the normal compensation standard. Referral to a hospital outside the city, the participants who go through the examination and approval procedures for referral shall be 70% of the normal compensation standard. The participants who have not gone through the referral examination and approval procedures shall be subject to 40% of the normal compensation standard, and no guaranteed compensation shall be implemented.
(4) Compensation standard for infectious diseases. Centralized treatment of infectious diseases, encouraging hospitalization. Patients with infectious diseases in urban areas are treated centrally by the Municipal Infectious Disease Prevention and Control Center, and patients with infectious diseases in Shuyang, Siyang and Sihong counties are treated centrally by 1-2 medical institutions designated by the county health administrative department. The outpatient expenses can be compensated by 50%, with a maximum compensation of 3,000 yuan per person per year; Reimbursable hospitalization expenses are compensated at 80%. The outpatient and hospitalization expenses of infectious diseases in other medical institutions shall not be compensated.
(five) to encourage the use of traditional Chinese medicine treatment. The use of traditional Chinese medicine treatment, outpatient and hospitalization expenses according to the "measures" compensation standards, patients use Chinese herbal medicine cost compensation of 30%, the total cost of compensation shall not exceed the actual cost. Traction, acupuncture and other treatment items are compensated.
(6) rehabilitation. The Municipal Human Resources and Social Security Bureau, the Municipal Health Bureau, the Municipal Finance Bureau, the Civil Affairs Bureau, and the Municipal Disabled Persons' Federation "Notice of Suqian Municipality on Printing and Distributing the Trial Measures for Including Some Rehabilitation Projects in the Scope of Basic Medical Security" (Su Ren She Fa [2065 438+02] 187No.) provide therapeutic rehabilitation. Comprehensive limb training for paraplegia, rescue rehabilitation for disabled children aged 0-6, adaptation of assistive devices for children aged 0-6 with physical vision disabilities and children with hearing disabilities, etc. 18 rehabilitation projects are included in the scope of hospitalization compensation.
(7) trauma. Traumatic patients are compensated according to 80% of the compensation standard.
(eight) according to the project payment and settlement of designated medical institutions, the cost standard in accordance with the original price department approved the implementation of the standard. Designated medical institutions to adjust the service price settlement in written form to the new rural cooperative medical management office to apply, after the new rural cooperative medical management office to study and approved in writing before implementation.
(9) critical illness insurance. In accordance with the relevant provisions of the Interim Measures for Serious Illness Insurance in Suqian City (No.[2065 438+03]2 12).
(10) compensation capping line. The accumulative compensation limit for the expenses of the new rural cooperative medical system is 6.5438+0.7 million yuan per person per year, including hospitalization expenses of 6.5438+0.65438+0.00 million yuan and outpatient expenses of 60,000 yuan.
(1 1) compensation time. In principle, the compensation for the new rural cooperative medical system is completed within a natural year, and the inter-annual compensation for special circumstances does not exceed 6 months.
Seven. There is no scope of compensation
(a) the expenses incurred by the participants in using drugs outside the catalogue shall not be compensated, and those paid according to the bed date and disease type shall be implemented according to the relevant documents. Designated medical institutions should control the proportion of drug expenses outside the catalogue used by participants. Village clinics must all use drugs in the list of essential drugs, and the expenses for the use of drugs out of the list by first-class medical institutions shall not exceed 5%, the expenses for the use of drugs out of the list by secondary medical institutions shall not exceed 10%, and the expenses for the use of drugs out of the list by tertiary medical institutions shall not exceed 15%. When designated medical institutions use drugs outside the catalogue, they must inform them in advance and obtain the signature and consent of the participating personnel or immediate family members.
(two) according to the provisions should be paid by the industrial injury or maternity insurance fund; Fees payable for medical insurance for urban workers and residents; Expenses borne by a third party; Expenses borne by the public health department; Overseas medical expenses.
(3) Non-basic medical expenses (mainly referring to senior wards, special wards, special care, family beds, etc.) are in medical institutions at all levels.
(four) without the approval of the price and health departments of medical institutions, medical services, inspection and treatment projects, without authorization to raise the fees.
(five) fighting, alcoholism, drug abuse, sexually transmitted diseases, traffic accidents, intentional self-injury, unproductive pesticide poisoning, medical accidents (disputes), family planning expenses.
(6) Registration fee, medical record fee, visiting fee, registration fee, Chinese medicine decoction fee, medical travel fee, ambulance fee, escort bed fee, bed-wrapping fee, consultation fee, food (nutrition) fee, daily necessities fee, certificate fee, health care file bag fee, stretcher fee, air conditioning (including heating) fee, TV fee, telephone fee and personal cooking fee.
(seven) all kinds of weight loss, bodybuilding and treatment of freckles, pigmentation, gray hair and medical beauty expenses; Expenses for rhinoplasty, breast augmentation, double eyelid surgery, nevus removal, ear piercing, verruca plana, tooth implantation, tooth cleaning, dentition correction, treatment of colored teeth, glasses, myopia treatment, artificial eyes, wigs and artificial limbs; Expenses for using traction equipment, crutches, leather steel carapace, waistline, deformed insole, medicated pad, medicated pillow and cold and hot compress bag; Expenses for massage, magnetic therapy and hyperthermia (except for tumor patients).
(eight) all kinds of medical consultation, medical appraisal and health prediction fees, commercial medical insurance fees, physical therapy fees, male and female infertility, sexual dysfunction examination and treatment fees.
(nine) the nominal hospitalization or hospitalization expenses that obviously do not meet the hospitalization conditions; I live in a super-standard ward, which exceeds the cost of ordinary beds.
(ten) the cost of transplanting various organs or tissues, installing artificial organs and placing materials in the body during the treatment.
(eleven) other circumstances in which no compensation is provided by the state or province.
Eight. indemnifying measure
(a) participants in the city designated medical institutions outpatient treatment need to provide the new rural cooperative medical certificate (card), hospitalization need to provide the new rural cooperative medical certificate (card), the original and photocopy of the ID card, outpatient medicine fees, hospitalization fees reported on the spot.
(II) The hospitalization expenses incurred by the participants outside the city, and the materials of the participants in Shuyang County, Siyang County and Sihong County shall be reviewed by the county new rural cooperative medical management office and go through the compensation procedures; The materials of urban participants shall be reviewed by the Municipal New Rural Cooperative Management Office and the compensation procedures shall be handled.
1. Participants should provide the following information when applying for compensation: new rural cooperative medical certificate (card); Original and photocopy of ID card; City and county new rural cooperative medical management office agreed to the referral approval form; Valid bills issued by the hospital (original), computer-printed hospitalization expense settlement list, discharge summary, etc.
2. Participants who go out to work or live outside the city for a long time should provide the following information when applying for compensation for going abroad for medical treatment: the new rural cooperative medical certificate (card); Original and photocopy of ID card; Long-term residence certificate of the village (neighborhood) committee or work unit; Valid bills issued by the hospital (original), computer-printed hospitalization expense settlement list, discharge summary, etc.
(3) Designated medical institutions publicize the compensation for medical expenses in their own units every month, and the township new rural cooperative medical management office publicize the compensation for medical expenses in township hospitals and village clinics every month.
Nine. Fund raising, management and supervision
(a) the township (town) people's government is responsible for raising the fees paid by individual farmers, and the county (district) financial department is responsible for the implementation of financial subsidies. The county finance department is responsible for transferring the new rural cooperative medical fund to the county new rural cooperative medical account, and the finance departments of suyu district, Sucheng District, Suqian Economic and Technological Development Zone, Hubin New District and Yanghe New District are responsible for transferring the new rural cooperative medical fund to the city new rural cooperative medical account.
(II) Shuyang County, Siyang County, Sihong County urban new rural cooperative fund into the financial new rural cooperative fund account management, earmarking, balance into the next year to continue to use. The audit department is responsible for regular special audits on the management and use of the new rural cooperative medical fund.
(3) In the process of fund-raising, it is strictly forbidden to collect fees for hitchhiking, change the fund-raising standard without authorization, advance funds for those who have not participated, and avoid discrepancies between accounts and facts. It is strictly forbidden to intercept, occupy or misappropriate funds.
(4) Designated medical institutions and their staff shall provide medical services in accordance with the requirements of the agreement, abide by laws and regulations, abide by professional ethics, implement clinical technical operation norms, carry out business training, improve service quality and efficiency, and ensure reasonable examination and treatment, rational drug use and control of medical expenses.
(five) before the designated medical institutions implement the independent pricing of medical service charges, they still implement the charging standards approved by the original price department; Such as the implementation of independent pricing, must be reported to the municipal health authorities for the record, after on-the-spot investigation, and depending on the safety of the fund, give a written reply before implementation.
(six) the average annual hospitalization expenses of designated medical institutions shall be controlled within 5% of the average hospitalization expenses in the previous three years, and the average hospitalization days shall be zero. If it exceeds the prescribed standards, 2 points and 1 point will be deducted from the total annual assessment score of the new rural cooperative medical system in designated medical institutions, respectively, and the hospitalization compensation in the relevant month will be deducted according to the excess ratio.
(VII) The report of the designated medical institutions of the new rural cooperative medical system is linked to the basic public health services and other key tasks, and if the tasks cannot be completed on schedule, the settlement ratio of the designated medical institutions shall be reduced (but the designated medical institutions and participating personnel shall report according to the prescribed proportion) until the designated qualification of the new rural cooperative medical system is suspended or cancelled.
(8) Designated medical institutions defraud the fund fees of the new rural cooperative medical system by forging certification materials and other means, and the health administrative department shall order them to return the defrauded fund fees, and impose a fine of more than 2 times and less than 5 times the amount defrauded, and the agency shall terminate the designated service agreement of the new rural cooperative medical system; If the directly responsible person in charge and other directly responsible personnel have obtained the qualification for practice, the administrative department of health shall revoke their practice certificates according to law.
If the insured cooperates with designated medical institutions to defraud the new rural cooperative medical fund by means of false hospitalization, the agency will include it in the blacklist of integrity and punish it according to the seriousness of the circumstances in the future.
(9) If anyone cheats the expenses of the new rural cooperative medical care fund by forging proof materials and using other people's new rural cooperative medical care certificates, the administrative department of health shall order him to refund the compensation expenses defrauded, and impose a fine of not less than two times but not more than five times the amount defrauded. If the case constitutes a crime, it shall be handed over to judicial organs for handling.
(ten) health administrative departments at all levels, the new rural cooperative medical institutions and township health centers should strengthen the supervision and management of designated medical institutions within their respective jurisdictions, and implement a step-by-step signature review system for the new rural cooperative medical institutions. Township (street) hospitals (community health service centers) should check the identity and hospitalization of participating patients admitted to designated medical institutions and village clinics (community health service stations) within their jurisdiction; City, county, district new rural cooperative medical institutions to review the compensation materials submitted by township (street) hospitals (community health service centers), and random checks, found that there are violations of the new rural cooperative medical funds to be severely punished.
X. supplementary provisions
(1) These Measures shall be implemented as of April 1 year. "Notice of the office of the municipal government on printing and distributing the measures for the administration of new rural cooperative medical care in Suqian" (14) shall be abolished at the same time.
(two) these Measures shall be interpreted by the Municipal Health Bureau.