Implementation!Personal account can pay family medical expenses

A few days ago

Dalian Municipal Government website released

Dalian establishes and improves basic medical insurance for employees

Implementation plan for outpatient protection mechanism

The following is referred to as "Plan"

Dalian employee medical insurance personal account reform

And outpatient protection system

Simultaneously launched in the second half of 2022

It mainly involves the following aspects

Establish and improve the common outpatient coordination mechanism

The medical insurance clinic stipulated in the medical insurance clinic of Dalian City is changed to the treatment of slow special diseases for outpatient clinics, retaining some outpatient treatment with some long -term treatment cycles and heavy cost burdens, and gradually regulating in accordance with the province's unified deployment.

Hypertension, diabetes and other outpatient costs that occur and common diseases are merged into the scope of the general outpatient clinic.

Ordinary outpatient clinics cover all the insured personnel participating in the employee's medical insurance, gradually improve the level of general outpatient clinics, and realize that the medical expenses of the outpatient clinic are transitioned from the type of disease to the cost guarantee.

Do a good job in the merger and connection of ordinary outpatient coordinated treatment and other outpatient protection benefits and hospitalization protection treatment.

Scientific setting general outpatient treatment standards

The proportion of payment within the scope of the general outpatient policy of employees' medical insurance is not less than 50%, and the treatment payment can be appropriately tilted to retirees.

Set differentiated payment ratios for different levels and types of designated medical institutions, and appropriately tilt to specialized medical institutions such as grass -roots medical institutions and specialized medical institutions such as infectious diseases and mental illness.

In accordance with the principles of strengthening and reasonable sharing, scientifically set up payment standards and maximum payment limit. The starting payment standard and the maximum payment limit are set up in a timely manner based on the annual settings and the fund situation.

In principle, the starting payment standard is not less than 300 yuan, and the maximum payment limit is not less than 8,000 yuan in principle.

Steady transition to the original outpatient clinic stipulated disease treatment

After the implementation of the general outpatient clinic system formulated by the "Plan", the original outpatient specifications of the employee medical insurance (except the retained outpatient clinics, except for the slow disease species of the clinic, the same below). Within the highest payment limit of the medical insurance fund, it can continue to enjoy the treatment in accordance with the designated scope and reimbursement ratio of the original policy until the end of 2022.

During this period, the original outpatient treatment of patients with the identified patients and the annual starting standards of the general outpatient clinics were calculated separately, and the maximum payment limit of the annual medical insurance fund of the general outpatient medical insurance fund was deducted from the payment amount of the medical insurance fund specified in the original clinic.

On January 1, 2023, the original clinic stipulated that the disease policy was terminated.

Standardize outpatient coordination guarantee services

The designated medical insurance institutions in the administrative area of ​​our city may voluntarily apply for a general outpatient medical institution.

In accordance with the unified deployment of medical insurance payment in the province's "Internet+" medical services, medical institutions and retail pharmacies that gradually carry out "Internet+" medical services have been gradually included in general outpatient clinics.

Strengthen the management of the agreement of general outpatient clinics, clarify the access and exit conditions, and implement dynamic adjustment. The prices of drugs, medical consumables and diagnosis and treatment services provided by the general outpatient medical institutions to the insured to implement a unified maximum price limit and other medical insurance related policies.

Explore the price monitoring management and information disclosure of drugs paid by the medical insurance fund, and guide the market price order positively.

Improvement of personal accounts

Improve the clinic guarantee mechanism and improve the personal account system simultaneously.

The basic medical insurance premium paid by the employer is included in the overall fund. The personal account of the employee of the employer is 2%in accordance with the insurance payment base of his own insurance; the flexible employment personnel do not establish a personal account during the payment period, and all the medical insurance premiums paid will be included in the overall fund.

In accordance with the requirements of the State Council and the Provincial Government, those who enjoy the treatment of retired medical insurance, the personal account is included in about 2%of the average level of the basic pension of the city in 2022, which is fixed to 80 yuan per month.

After adjusting the structure of the overall fund and personal account, the increased coordinated funds are mainly used for outpatient protection of outpatients and improved the medical protection treatment of outpatient clinics of insureds.

Standardize the scope of personal accounts

Personal account funds can be used to pay the insured person and their spouses, parents, and children in the designated medical institution for medical expenses, and purchase drugs, medical devices, medical devices, medical devices, medical devices, medical devices, and medical insurance in designated retail pharmacies The cost of personal burden on consumables.

Personal accounts can be used for personal payment such as spouses, parents, and children to participate in the basic medical insurance, long -term care insurance, and commercial supplementary medical insurance.

Personal accounts shall not be used for public health expenses (except for national policy permits), sports fitness or health care consumption, which are not expenditures that do not belong to the scope of basic medical insurance protection.

Serious investigation and punishment of over -diagnosis and treatment and other violations of laws and regulations

According to the "Plan", establish and improve the supervision and management system that is compatible with the guarantee of the outpatient protection, and guide the rational use of medical resources. Strictly implement the budget management system of the medical insurance fund, and strengthen the fund audit system and internal control construction.

Establish and improve the safety prevention and control mechanism of the medical insurance fund, strengthen the medical insurance big data intelligent monitoring and audit inspection of medical insurance big data for outpatient medical expenses, and seriously investigate and deal with illegal issues such as over -diagnosis and treatment, unreasonable medication, and personal account cash.

Establish a dynamic management mechanism for the entire process of payment of outpatient clinics, and strengthen the review of the use and settlement of outpatient coordination treatment, settlement and other links.

Improve the management of outpatient medical services, and guide designated pharmaceutical institutions and medical insurance doctors to provide diagnosis and treatment security services through performance assessment and credit evaluation mechanism.

In accordance with the national unified deployment, accelerate the construction of medical security information platforms, and steadily promote the direct settlement of outpatient expenses.

By coordinating the construction of the grass -roots medical service system, improving family doctors' contract services, standardizing long -prescription management, and improving the policy of slow -clinics, the insured persons are guided to the first consultation at the grassroots level, and standardized the diagnosis and treatment of grass -roots medical institutions.

Improve the paid mechanism that is adapted to the guarantee of the outpatient clinic

For ordinary outpatient services, on the basis of project payments, explore the implementation of outpatient case paid, paying method, and outpatient coordinator payment.

For grass -roots medical services, explore the implementation of a family doctor's contract service payment mechanism to strengthen the management of chronic diseases;

In accordance with relevant national regulations, implement the province's unified medical insurance payment standards, and guide medical institutions and patients to actively use drugs with accurate effects and reasonable prices.

Relying on the medical security information platform, we will strengthen the collection and analysis application of outpatient expenses, and lay the foundation for improving the outpatient payment mechanism.

Source: Dalian Evening News

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