Heavy!General outpatient treatment costs are included in medical insurance reimbursement reimbursement

Wuhan Evening News June 27 (Reporter Hu Qiongzhi) The curtain of medical insurance reforms in the city's 6.2 million employees will start. On June 27, the General Office of the Hubei Provincial People's Government issued the "Implementation Opinions on Establishing and Implementation of the Establishment and improvement of the basic medical insurance clinic for basic medical insurance clinics" (hereinafter referred to as the "Implementation Opinions").

According to the "Implementation Opinions", this year, the city will comprehensively establish a general outpatient clinic of employee medical insurance. General outpatient medical expenses will be included in the scope of payment of the employee medical insurance overall fund payment. The proportion of payment within the policy scope is not less than 50%. At the same time, improve the measurement of personal accounts of employee medical insurance, standardize the scope of personal accounts, and improve the level of guaranteeing the protection of employee medical insurance clinics. The reporter from the Yangtze River Daily learned that Wuhan is in combination with the operation of the medical insurance fund and related data of the employee's medical insurance fund in recent years, to conduct detailed calculation analysis, refer to other prefectures and city treatment standards, draft the implementation rules, and is steadily advancing according to steps.

According to reports, the introduction of the "Implementation Opinions" is the relevant requirements for implementing the reform of the national medical insurance system. At noon on the 27th, a reporter from the Yangtze River Daily interviewed Gu Xuefei, the director of the Medical Security Research Office of the National Health and Health Commission Health and Health Commission's Health and Health Commission's Health and Health Commission.

Why reform?

The medical insurance for employees in our city has been established in 2001, and it is a guarantee model that combines social overall planning and personal accounts. Medical Insurance Coordinating Fund to ensure the inpatients and outpatient diseases, and personal accounts to ensure the cost of minor illnesses and drug expenses. According to reports, this reform is also the first major reform of personal accounts in our city's medical insurance system for 21 years.

With the development of socioeconomic and economy, the limitations of personal accounts are gradually prominent. It is mainly manifested in insufficient outpatient guarantee. It is usually not used, and it is not enough. Personal accounts between families cannot be used for each other and poor ability tolerance; if there is not enough sickness, it cannot be used by those who are not sick; they will occur when using chaos in violation of regulations, and even fraud.

"The core of the employee medical insurance clinic reform reform is the transformation from the original personal accumulation guarantee model on outpatient medical expenses to the fund's airspace guarantee model." Gu Xuefei introduced that from the key protection of major diseases, the inpad by the hospital, the small disease, and the outpatient clinic clinic Extension, balanced outpatient clinic and inpatient guarantee. Establishing a sound outpatient guarantee will reduce the funds that are planted in personal accounts for outpatient protection, and at the same time. Continuously expand the scope of slow diseases of employees' medical insurance clinics, and gradually incorporate outpatient diseases with heavy costs into the scope of medical insurance payment to reduce the burden on the people.

Employee medical insurance clinic reimbursement starts from 50%

"With the gradual improvement of the guarantee mechanism of the outpatient help mechanism, it has explored the transition from the type of disease protection to the cost guarantee." Essence "Outpatient clinics are usually common diseases and more onset. In the past, they thought that these diseases were small and personal affordable, but the reality was not the case. The cost of outpatient diseases was not necessarily low, such as tumor chemotherapy, organ transplantation outpatient anti -excretion, leukemia treatment, treatment of leukemia Wait, the cost is often higher than the hospital, and the burden is very heavy. "

Gu Xuefei said that in the past, many people would think that personal accounts were their own "money", and they were willing to use more medical insurance parts, which also led to some unreasonable medical behaviors. For example, it could have been resolved in the outpatient clinic. Therefore, the corresponding improvement of outpatient guarantee is a big direction for medical insurance reform.

Outpatient coordination is a form of medical insurance benefits. Simply put, the basic medical insurance incorporates the outpatient expenses of insured personnel into the scope of reimbursement of the overall fund reimbursement. In the current medical insurance system, the expenses of the outpatient clinic are mainly paid by personal account funds.

The "Implementation Opinions" proposes that the chronic diseases of outpatient clinics such as hypertension and diabetes have been put into operation, and ordinary outpatient medical expenses with multiple diseases and common diseases are gradually incorporated into the scope of the payment fund payment. The general outpatient clinic covers all employees' medical insurance insured persons, and the payment ratio starts from 50%. At the same time, according to the affordability of the medical insurance fund, combined with the actual situation, gradually explore the transition from the protection of diseases to the cost guarantee. The treatment cycle of malignant tumor outpatient treatment has a long treatment cycle, large health damage, heavy cost burden, and its effective treatment.

Adjust the proportion of personal accounts in medical insurance

One of the main changes in this reform is to activate part of the funds on personal accounts. After adjusting the structure of the overall fund and personal account, the increased coordinated funds are mainly used for outpatient protection guarantees and improved the treatment of insured personnel.

"The precipitation of a large number of personal account funds is a matter worthy of attention." Gu Xuefei introduced that the medical insurance statistics show that the cumulative deposit of the basic medical insurance account of employees in 2021 has reached 1.18 trillion yuan. In recent years, due to the rise in medical expenses, aging aging, and improvement of medical insurance reimbursement treatment, the overall funding fund of medical insurance in many places in the country is facing the risk of "wearing the bottom". This situation not only caused a serious restriction of medical insurance for the help of medical insurance, but also increased the management cost of the system.

The "Implementation Opinions" proposes to improve personal accounts. The individual account of employees in the employee of the employer is determined by 2%of the payment base for their participation. All the basic medical insurance premiums paid by the unit are included in the overall fund. In principle, the personal account of retirees is set into a fixed fund in principle, and the standard is determined by the standard at 2.5%of the average level of basic pensions in the previous year.

After this reform, the reimbursement level of the clinic will be increased, on the one hand, it will reduce the burden on the people to see the clinic, and on the other hand, reduce the balance of personal accounts. "The part that has been settled will not move, and the new outpatient clinics are derived from the part of the unit's payment to allocate personal accounts." Expand the scope of use of personal accounts of medical insurance

The employee's medical insurance clinic reform is incremental reform on personal accounts. The existing accumulated funds (stock funds) of personal accounts are clearly owned by individuals. In a certain period of time, personal accounts of employees still exist. Gu Xuefei said that on this basis, the scope of personal account use is to activate the stock and improve the efficiency of the use of personal account funds.

The "Implementation Opinions" proposes to standardize the scope of personal accounts.

Personal accounts are mainly used to pay for employees within the policy scope of fixed medical institutions or fixed -point retail pharmacies.

Under the premise of achieving information system support, realizing personal accounts can be used to pay the insured person and their spouse, parents, and children in the designated medical institution for medical expenses, and purchase drugs and medical treatment at designated retail pharmacies and medical stores. The cost of personal burden of device and medical consumables is incurred.

At the same time, the "Implementation Opinions" proposes to explore personal accounts for personal accounts to participate in large -scale medical expenses, long -term nursing insurance and other personal payment, as well as spouses, parents, and children participating in the basic medical insurance for urban and rural residents, large medical expenses subsidies for employees, long -term care Insurance and other personal payment.

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[Edit: Yu Lina]

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