Hubei employee medical insurance welcoming major changes: ordinary outpatient medical expenses will be included in medical insurance reimbursement

Ji Mu Journalist Zheng Jingjing

(Picture source: website screenshot)

On June 27, the website of the Hubei Provincial People's Government issued the "Implementation Opinions of the General Office of the Provincial People's Government on Establishing and Implementation of the Emphasis on the Inspect Walking for the Outpatient Medical Insurance Clinic" (hereinafter referred to as the "Opinions"). The "Opinions" shows that the establishment of general outpatient medical insurance clinics by the end of 2022.

General outpatient medical expenses will be included in medical insurance reimbursement

The "Opinions" pointed out that in order to thoroughly implement the "Guidance Opinions of the General Office of the State Council on the establishment and improve the guarantee mechanism of the basic medical insurance clinic for employees" (Guoqi Fa [2021] No. 14) Basic medical insurance (hereinafter referred to as employee medical insurance) system for employees, better solve the problem of outpatient guarantee for employee medical insurance insured person, effectively reduce the burden of medical expenses, and establish a sound guarantee mechanism for the medical insurance clinic for employees in Hubei Province with the consent of the Provincial People's Government. Makes the following opinions.

The "Opinions" shows that the establishment of a general outpatient clinic for employees. The funds required for the overall planning of employee medical insurance clinics will be expended from the basic medical insurance fund of the employee's basic medical insurance. Establish a general outpatient clinic for employee medical insurance by the end of 2022. The employee medical insurance insured personnel occurred at the designated outpatient medical institution belonging to the medical insurance drug, diagnosis and treatment items, medical service facilities, and the medical expenses (including emergency) within the scope of the payment standard directory. A part of a natural annual year exceeds the general outpatient clinic coordinating payment standards and the highest payment limit below, and the medical insurance fund will be paid in proportion to the medical insurance fund.

In terms of starting payment standards, in principle, the employee is not higher than the average salary of the average salary of the employment personnel of the full -caliber urban unit in the previous year (or the previous year) of the overall region. The average salary of employment personnel is 0.8%, and the specific standards are determined by each city (state). If the average salary of employment personnel employees in the full -caliber urban unit of the year, the average salary of employment personnel of the full -caliber urban unit in the past year was determined as the base.

In terms of payment ratios, the general outpatient medical expenses that exceed the policy scope of the starting payment standard and within the highest payment limit of the year, the proportion of the employee's payment is not less than 50%, and the retirees are not less than 60%. All localities should improve the medical insurance differentiation payment policy of different levels of medical institutions, and open the gap between the payment ratio of various medical institutions. In principle, it is not less than 10%. Properly increase the proportion Essence The specific payment ratio is determined by each city (state) according to the actual situation. The proportion of payment for the general outpatient medical treatment expenses of the general outpatient clinic for general outpatient clinics is determined by each city (state).

In terms of the maximum payment limit, the highest payment limit of the employee of the year is not lower than the average salary of the average salary of the employment personnel of the full -caliber urban unit in the previous year (or the previous year) in the preparation area. The average salary of employment personnel in the caliber of urban units is about 3.5%, and the specific standards shall be determined by each city (state). The maximum payment limit of the general outpatient clinic is in charge of hospitalization, outpatient chronic diseases, special diseases (hereinafter referred to as outpatient clinics), and the maximum payment limit for national medical insurance negotiation drugs, respectively, and the maximum payment limit of the employee medical insurance overall fund. The maximum payment limit for outpatient clinics is limited to the use of the year, and it must not be accumulated to the following year.

The "Opinions" stated that each city (state) should be based on the characteristics of outpatient medical services, and determine the starting standard, payment ratio, and maximum payment limit on the basis of scientific calculations, and reasonably set the level of general outpatient treatment of insured personnel to ensure the safety of medical insurance funds run. The starting payment standard, payment ratio, and maximum payment limit can be adjusted in a timely manner according to the operation of the local fund. When the adjustment of the city (state) medical security department, the municipal (state) medical security department needs to formulate a adjustment plan with the financial department to implement it after the approval of the people's governments at the level. All localities should do a good job of connection with the policy of payment of the hospital, and guide the insured personnel to reasonably choose to seek medical treatment in the outpatient or hospitalization. Simultaneously improve the overall planning of the basic medical insurance clinics of urban and rural residents, and adjust the maximum payment limit of urban and rural residents' medical insurance clinics in a timely manner in accordance with the funding standards, and gradually improve the level of guarantee.

The medical expenses of maternity clinics are still implemented in accordance with the current regional policies.

Explore the incidental "Internet+" medical services in the outpatient guarantee scope of qualified "Internet+" medical services

The "Opinions" also pointed out that the outpatient slow disease system was improved. According to the affordability of the medical insurance fund and the local reality, the outpatient slow special disease management services paid by the overall fund payment are gradually regulated. Gradually explore the transition from disease protection to expense protection. Treatment of malignant tumor outpatient treatment, uremia dialysis, organ transplantation (including tissue and cell transplantation) postoperative anti -reject therapy, severe psychiatric patient drug maintenance treatment, diabetic insulin therapy, tuberculosis and other treatment cycles, large health damage, expenses, expenses, expenses The burden and effective treatment can be included in the outpatient disease. Special treatments that are suitable for being carried out in outpatient and more economical than inpatients, and can be managed with reference to hospitalization. The specific management measures for outpatient diseases will be formulated separately, and the cost of slow special diseases in the first outpatient clinic in the new management measures is still implemented in accordance with the current regional policies.

Enhance the guarantee capabilities of fixed -point retail pharmacies. All localities should strengthen the management of fixed -point pharmacies, incorporate the use of drug guarantee services provided by qualified fixed -point retail pharmacies into the scope of outpatient guarantee, support external prescriptions to provide drugs and settlement in fixed -point retail pharmacies, and give full play to the role of fixed -point retail pharmacies. Select fixed -point retail pharmacies with qualified compliance, management specifications, good reputation, and meeting the conditions such as electronically traceability and other conditions for the drugs sold, and carry out the management of "dual channels" (two channels of designated medical institutions and fixed retail pharmacies) in negotiated drugs. When the insured persons need to be met at the need for outpatient medical institutions, designated medical institutions shall support the preparation of the insured personnel to perform the prescription at the eligible fixed -point retail pharmacies. 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. Start personal account reform by the end of 2022

The "Opinions" emphasized that the improvement of personal accounts. The personal account reform was launched by the end of 2022. The individual account of employees in employees in employees in the employee is determined by 2%of the basis of their participation in the insurance payment base. The standard is determined by the standard at 2.5%of the average level of basic pensions in 2021 in each city (state). If the city (state) that has been coordinated by the general outpatient clinic of employees, if the personal account entry method does not match the above standards, it is necessary to formulate a transition method to ensure that it is adjusted to the prescribed standard by the end of 2023. Synchronized adjustment of the payment rate of the single -building coordination is to pay the fee rate of the unit, and the personnel who participate in the employee's medical insurance in a single building are not included in the personal account after retirement. Due to the changes in employment and employment status, personnel who participate in employee medical insurance in different time periods and unified bouncing methods in different time periods can be included in personal accounts in accordance with the standards lower than the standards of insured personnel in the form of binding. The counting method is formulated by each city (state). After adjusting the structure of the overall fund and personal account, the increased coordinated funds are mainly used for outpatient guarantee guarantees and improved the treatment of insured personnel.

Standardize the scope of personal accounts. Personal accounts are mainly used to pay for insured personnel within the scope of policy scope of fixed -point 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. Exploring personal accounts for personal payment for personal participation in large employees, long -term care insurance, etc., as well as individual contributions such as spouses, parents, and children participating in the basic medical insurance for urban and rural residents, large medical expenses subsidies for employees, and long -term care insurance. Personal accounts shall not be used for public health costs, sports fitness or health care consumption, which are not expenditures that do not belong to the scope of basic medical insurance protection. For employees who go abroad and settle in the country, the balance of personal accounts can be paid to me after applying for them; those who participate in the insurance employee can be paid to their legal heirs or designated beneficiaries at one time. All cities (states) should improve the management methods of personal accounts, master the specific situation of the use of personal accounts and outpatient medical expenses, do a good job of revenue and expenditure information, and analyze and summarize the effectiveness of reform.

In addition, the "Opinions" also made requirements on the policy connection, strengthening supervision and management, and improving paid mechanisms that are adapted to the protection of outpatients.

- END -