Solving opinions!There will be major changes in Wuhan employee medical insurance | Quickly read Wuhan

General outpatient expenses of insured personnel are included in medical insurance reimbursement reimbursement

Personal accounts can be used to pay insured employees

I and their spouse, parents, children

When you seek medical treatment at the designated medical institution

Medical expenses that occur

... ...

July 15th

Wuhan Medical Insurance Bureau website issuance notice

For the establishment and improvement of basic medical insurance for employees in Wuhan

Outpatient aid guarantee mechanism

Implementation rules (draft for comments) ""

(The following referred to as "Implementation Rules")

Public comments

The "Implementation Rules" have 5 chapters and 37 articles, including general rules, personal account management, outpatient protection benefits, medical service management and supervision, and attachments. The publicity time is July 15 to July 24, 2022.

Relevant units and individuals are welcome to make amendments. For letters, please send to: [email protected]. Please indicate "Feedback of the Implementation Rules of the Implementation of the Outpatient Affairs Protection Mechanism".

Wuhan Medical Insurance Bureau explained the main content of the "Implementation Rules"

● About personal account adjustment.

The first is to establish a problem of insufficient security capabilities of personal account clinics, incorporate the general outpatient expenses of insured personnel into medical insurance reimbursement, and realize the dual guarantee of basic medical insurance reimbursement and personal account payment. The second is to adjust the measurement method of personal accounts. The personal account of the employee is included in a certain percentage of the original unit's payment and all the personal payment. The personal accounts of retirees are adjusted to the amount of pension at about 2%of the average level of pensions in the year of the regional reform of the regional reform. After the proportion of reforming personal accounts, all the increased funds entered the general outpatient clinic of employee medical insurance. In principle, all of them were used for employee outpatient guarantee, and employers and insured persons no longer paid separately.

● Regarding the scope of personal account payment.

Except for personal hygiene expenses, sports fitness or health care consumption, which are not used in public health expenses, and health care consumption, in the case of information system support, they can be used to pay the insured employees, their spouses, parents, children, children, children The medical expenses incurred during medical treatment in a designated medical institution, and the cost of purchasing drugs, medical devices, and medical consumables at designated retail pharmacies. At the same time, explore personal accounts for personal accounts and spouses, parents, and children to participate in the basic medical insurance and long -term care insurance for urban and rural residents. For those who go abroad and settle in, the balance of personal accounts can be paid to me by applying for them; those who have died of insured employees, their personal account balance can be paid to their legal heirs or designated beneficiaries at one time.

● Regarding the general outpatient medical treatment of employees' medical insurance.

During an insurance year, the insured ordinary outpatient medical treatment occurred in line with the medical insurance of "Hubei Province Basic Medical Insurance, Work Injury Insurance, Maternity Insurance Drug Catalog", "Hubei Province Basic Medical Insurance Diagnosis and Treatment Project Management, Medical Service Facilities Scope and Payment Standard Catalog" The cost is included in the scope of payment of the general outpatient overall fund. The general outpatient clinic coordination fund payment sets the starting payment standard and the annual payment limit. During an insurance year, the working personnel were paid by 700 yuan and the retirees were 500 yuan; the annual payment limit of the in -service personnel was 3500 yuan, and the annual payment limit for retirees was 4,000 yuan. The outpatient annual payment limit is effective within a insurance year, without rolling or accumulation.

During a insurance year, the cost of the general outpatient overall fund starting standard and the lesson below the annual payment limit shall be borne by the general outpatient clinic and individuals according to the following regulations: at the third -level designated medical institution, the payment ratio of the funds will be 50%. Personal payment ratio is 50%; in the secondary designated medical institution, the payment ratio of the fund is 60%, and the personal payment ratio is 40%. The payment ratio is 20%. The personal payment ratio of retirees is 80%of the personal payment percentage of in -service personnel.

Increased the payment ratio of grass -roots medical institutions, the purpose is to encourage the insurers to first consult at the grassroots level to alleviate medical difficulties. Considering that the prevalence of common diseases, multiple onset, and chronic diseases is higher than young people, and medical needs are greater. This reform also pays attention to the protection of retirees, and the reimbursement policy is further tilted to retirees.

● Regarding the scope of the medical insurance fund not to pay.

The following medical expenses are not included in the scope of payment scope of the general outpatient overall funding fund: medical expenses outside the payment scope of the medical insurance fund; the use of drug and diagnosis and treatment service items within the scope of the medical insurance fund payment shall be affordable The outpatient medical expenses occurred during the hospitalization; the medical expenses incurred during the insured unit or individual owed the basic medical insurance premiums (including the replenishment fee); The medical expenses incurred outside the fixed -point retail pharmacy; the medical expenses that the insured treats the outpatient diagnosis (chronic) disease; it does not meet other expenses stipulated in the basic medical insurance.

● Regarding the problem of medical insurance settlement methods.

Participants have a medical treatment at the general outpatient clinic of designated medical institutions and settle personal burdens for personal medical insurance electronic vouchers or social security cards. The payment part of the general outpatient funding fund is settled by the medical insurance agency and designated medical institutions. For ordinary outpatient medical expenses occurred in the place where the placement of the place where the place where the place where the place where the place where the resettlement is resettled, if it fails to achieve a direct settlement, it shall copy the ID card, outpatient medical records, cost receipts, and expense details in the first quarter of the following year. The medical insurance agency reviews and settlement. ● Regarding the problem of supporting fixed pharmacies and online pharmaceutical services settlement.

Our city has gradually incorporated the use of drug guarantee services provided by qualified fixed -point retail pharmacies into the scope of outpatient guarantee, and supports the exterior prescriptions prescribed by the fixed -point medical institutions provided by the insured by the fixed -point retail pharmacies issued by the fixed -point medical institutions. Settlement. The payment ratio of the insured persons with the purchase of medicines is implemented according to the designated medical institution level issued by it. The exploration will include the qualified "Internet+" medical services in the outpatient guarantee scope, and implement the equivalent payment policy of online and offline medical insurance.

● Regarding the supervision and management of medical insurance funds.

By strengthening the management and daily supervision of the agreement, according to the various laws, policies and regulations of basic medical insurance and medical care, the diagnosis and treatment behavior within the scope of fixed -point medical institutions and insured persons.

● Regarding policy adjustment issues.

The adjustment of the general outpatient planning fund starting standard, fund payment ratio, and annual payment limit shall be submitted to the municipal people's government to implement the plan according to the financial department of the municipal financial department to implement it. Gradually adjust and improve the scope of disease -like diseases (chronic) diseases and diseases, and explore the transition from disease protection to cost guarantee. Adjust the standards for hospitalization in a timely manner, and do a good job of policy connection between ordinary outpatient clinics and hospitalization coordination. In accordance with the improvement of fundraising standards, the maximum payment limit of urban and rural residents' medical insurance clinics will be adjusted in a timely manner, and the level of guarantee is gradually improved.

Click "Reading the original text" at the end of the article to obtain the implementation rules for the implementation of fixed management of medical insurance for medical institutions (drafts for comments) and the implementation rules for the implementation of fixed -point management of retail pharmacy in Wuhan.

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