Linyi: General outpatient medical expenses can be reimbursed for medical insurance!

Author:On Linyi Client Time:2022.09.08

"Implementation Rules for the Implementation of the Establishment of the Establishment of the Basic Medical Insurance Outpatient Clinic for the Establishment of Employees in Linyi City"

Ordinary outpatient medical expenses can be reimbursed for medical insurance!

In order to further improve the basic medical insurance system of employees with mutual assistance and responsibility, optimize the structure of medical insurance funds, improve the efficiency of medical insurance funds, better solve the problem of outpatient guarantee for employees participating employees, and effectively reduce the burden of medical expenses for daily outpatient medical expenses participating employees. Recently, the "Implementation Rules for the Establishment of the Establishment of Employees' Basic Medical Insurance Clinic for the Establishment of Employees" was issued and issued.

1. Unified employee medical insurance general outpatient clinics coordinate treatment guarantee standards

Establish and improve the guarantee mechanism of overall overall preparations for employees. The general outpatient medical expenses that comply with medical insurance policies that are in accordance with the regulations of medical insurance policies are included in the scope of payment of the overall fund, and the guarantee guarantee for ordinary outpatient clinics shall be enjoyed in accordance with regulations. Continuously refine and improve policies, standardize outpatient guarantee management measures, and facilitate the protection of the basic outpatient medical needs of the people. Implement the province's unified medical security treatment list system, and ensure that the content and treatment payment of ordinary outpatient clinics in the city are unified.

Scientifically set the city's unified employee clinic overall funds for annual starting standards, payment ratios, and maximum payment limit, and set different levels of designated medical institutions at different levels to set a differentiated payment standard and payment ratio, appropriately tilted to grass -roots medical institutions to promote hierarchical diagnosis and treatment.

The cumulative annual starting standards of first -level, secondary, and third -level medical institutions are 200 yuan, 400 yuan, and 800 yuan, respectively. Insured personnel are calculated accumulating the general outpatient payment standards at different levels of designated medical institutions at different levels. In the policy scope of the first, secondary, and third -level medical institutions on -level employees, the proportion of the policy scope occurred by 70%, 60%, and 50%, respectively, and the retirees were 5 percentage points higher than the employee, which were 75%and 65%, respectively. , 55%. During a natural year, the highest annual payment limit for the cost of general outpatient medical expenses was 1,500 yuan. The maximum payment limit in 2022 was 750 yuan (calculated from the implementation of the overall overall system of employees).

According to the implementation of the overall system of the employee clinic, the reform of personal accounts, and funding capabilities, the maximum payment limit is raised in a timely manner, and the level of guarantee is further improved. Insurance employees have a general outpatient clinic for medical expenses at the designated pharmaceutical institutions, and implement the scope of the national medical insurance drugs, diagnosis and treatment projects and medical service facilities and medical insurance payment standards.

Take the employee Xiao Wang as an example. Before that, Xiao Wang went to the hospital to buy medicine to buy medicines for medical insurance cards (medical insurance electronic vouchers) or cash settlement costs. Now, the first time I go to the first -level designated hospital for medical treatment is 1,000 yuan, the cost of the policy scope is 900 yuan, the deduction of 200 yuan is deducted, the remaining reimbursement ratio is 70%, and the medical insurance reimbursement is 490 yuan. Pay medical card payment or cash payment.

Because the insured persons have accumulated the accumulated calculation of the general outpatient payment standards at the same level medical institution at the same level, the second time the little king will go to the first -level designated hospital outpatient medical treatment for 500 yuan, and the cost of the policy scope is 450 yuan. The reimbursement ratio is 70%, the medical insurance reimbursement is 260 yuan (the maximum payment limit has reached 750 yuan in 2022), and the personal burden of 240 yuan can be paid or cash payment.

In addition, insured personnel have accumulated cumulative calculations on general outpatients at different levels of medical institutions at different levels. Assuming that Xiao Wang went to the third -level designated medical institution, he needed to deduct a total of 800 yuan for the annual starting standard.

2. Clarify the implementation criteria for the implementation of hospitalization, emergency treatment and treatment, etc.

Standardize and improve employee clinic slow disease diseases and medical insurance policies. By the end of 2022, the category of the basic disease of the basic disease of the unified outpatient clinic in the province was performed, the names and identification standards of the basic diseases were uniformly adjusted, and the scope of slow disease diseases were continuously expanded to expand the outpatient diseases paid by the coordinated fund. According to the fund withdrawal ability and the level of ordinary outpatient clinics, through the conversion of outpatient guarantee mechanisms, it is explored to the transition from the disease protection of some slow disease diseases to the transition from the disease protection. For the settlement of hospitalized medical insurance benefits for day surgery and day ward.

Expansion of outpatient drug guarantee channels. Support the fixed -point medical institutions for settlement and distribution at fixed retail pharmacies, incorporate the use of drug guarantee services provided by the eligible fixed -point retail pharmacy into the outpatient guarantee scope, implement the unified general outpatient payment policy with the uniform outpatient clinic with three -level designated medical institutions, and pay the year -on -year payment. Calculation of standards and maximum payment limit of the year.鼓励将符合条件的“互联网+”医疗服务纳入医疗保障支付范围，以医保电子凭证为介质打通慢性病复诊医保线上支付渠道，实现线上挂号、在线复诊、在线续方、处方流转、医保支付、 Drug delivery and other service functions.

Insurance employees who are transferred to hospital for emergency treatment are ceded in the scope of policies before hospitalization (calculated by the merger of observation medical expenses and hospitalization expenses in the scope of the hospital (according to the reimbursement of the hospital), the outpatient expenses that have not been transferred to the hospital are coordinated by the outpatient clinic. Fund payments, within the scope of the policy of rescue of outpatient rescue, medical expenses are reimbursed at a time in hospital. Ordinary outpatient clinics and outpatient clinics are treated in accordance with the scope of their respective treatment guarantee, and the maximum payment limit for payment standards and the overall funding fund is calculated. If the reimbursement fee of the general outpatient clinic has been paid by the employee's personal account, the coordinated fund will no longer be paid.

During the hospitalization of the insured employees and during the long -term care insurance medical specialty treatment, we no longer enjoy the general outpatient treatment treatment; enjoy the long -term nursing insurance institution care and home care benefits, you can enjoy the general outpatient coordinated treatment. Ordinary outpatient clinics of employees exceed the highest payment limit, and are not included in the scope of the guarantee of basic medical insurance, large medical subsidies, and major illness insurance. Improve the paid mechanism for outpatient protection. The designated medical institutions of ordinary outpatient clinics shall be determined and announced to the society in accordance with relevant regulations. Increase the outpatient medical services into the management content of the designated agency of the targeted institution of medical insurance, establish a statistical analysis system for outpatient expenses, improve the management measures of designated medical institutions, strengthen the supervision of medical behavior of insured personnel, and control unreasonable expenses. Promote the reform of the outpatient payment method, and implement the payment method such as the first -person payment for ordinary outpatient services; for the slow special disease of the outpatient clinic, the composite payment method such as the first payment of the person and the type of disease can be implemented; Pay according to the project. For national medical insurance negotiations that are paid separately, they will not be included in the scope of the total medical insurance costs of designated medical institutions. Do a good job in the connection between the signing service of family doctors and the management measures of general outpatient and outpatient and clinics, and guide the insured personnel to seek the first consultation at the grassroots level to promote the improvement and improvement of the grassroots medical and health service system. Adjust and improve the overall payment policy for medical treatment in the province and inter -provincial and different places, and reform and simplify the classification and filing of medical staff in different places. Accelerate the construction of the medical security information platform and realize the interconnection with the designated pharmaceutical institutions. All designated pharmaceutical institutions in the city realize the direct settlement and inter -provincial networking of the provinces of general outpatient and outpatient slow disease costs.