There will be major changes in Wuhan Medical Insurance!Reimburse in outpatient clinics starts 50%starting up

Wuhan employee medical insurance will change greatly!

The scope of the clinic reimbursement expands

Employee medical insurance clinic reimbursement starts from 50%

Spouse, parents, children

Can buy medicines with personal accounts of insured

Native

June 27th

The General Office of the People's Government of Hubei Provincial People's Government

"Regarding the establishment and improvement of basic medical insurance for employees

Implementation Opinions of the Outpatient Affairs Protection Mechanism ""

(The following referred to as "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, and conducts detailed calculation and analysis, and steadily advanced according to steps.

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 Health Development Research Center.

Expand outpatient disease

Incident in the scope of employee medical insurance payment scope

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. This reform is also the first major reform of personal accounts since the establishment of the medical insurance system of our city in 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 each other; Those who are not sick are enough, and those who are not sick cannot be used; they occur when they use chaos in violation of regulations, and they even have fraud.

"The core of the employee medical insurance outpatient reform reform is the transformation from the original personal accumulation guarantee model on outpatient medical expenses to the fund baire protection model." , 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.

Employee medical insurance clinic reimbursement starts from 50%

According to reports, the reimbursement of medical expenses within the scope of the hospital's medical insurance in our city has reached more than 80%. "Outpatient clinics are usually common diseases and more onset. In the past, they thought that these diseases were small, but reality was not the case. For example, tumor chemotherapy, etc., the cost is often higher than hospitalization."

Gu Xuefei said that in the past, many people would think that personal accounts were their own "money", and they were more willing to use medical insurance coordinated parts. For example, those who could have been resolved in outpatient clinics became hospitalized. Therefore, the corresponding improvement of outpatient guarantee is a big direction for medical insurance reform.

To put it simply, the basic medical insurance incorporates the outpatient costs of the insured persons 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 that after adjusting the structure of the overall fund and personal account, the increased overall funds are mainly used for outpatient protection guarantees and improved the treatment of insured personnel.

Gu Xuefei introduced that the medical insurance statistical bulletin showed that the cumulative deposit of the basic medical insurance account of employees in 2021 has reached 1.18 trillion yuan. A large amount of funds have precipitated in personal accounts or were abused, which seriously restricted the help of medical insurance, and 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.

Expand the scope of use of personal accounts of medical insurance

"The part that has been settled will not move. The new outpatient clinic coordinated funds are derived from the part of the unit's payment allocation." The accumulation of funds (existing funds) is clearly owned by individuals. 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 careInsurance and other personal payment.Source: Reporter Hu Qiongzhi Editor: Cheng Jiayi School Division: Tong Yongzhong

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