Pingxiang medical insurance regulations, Pingxiang medical insurance reimbursement scope

Implementation Plan of Pingxiang Urban Residents' Serious Illness Insurance (Trial)

According to the opinions of Jiangxi Provincial Development and Reform Commission and other six departments on establishing and improving the serious illness insurance system for urban and rural residents (No.537 [2013]) and the Notice of Jiangxi Provincial People's Government on printing and distributing the implementation plan for deepening the reform plan of medical and health system in Jiangxi Province during the Twelfth Five-Year Plan period (No.30 [2012]).

I. Guiding ideology and basic principles

Guided by Deng Xiaoping Theory, Theory of Three Represents and Scientific Outlook on Development, we will further improve the serious illness insurance system for urban residents, adhere to the principles of "people-oriented, overall arrangement, government-led, professional operation, sustainable development, local conditions and mechanism innovation", support commercial insurance institutions to give full play to their professional advantages, undertake serious illness insurance, improve the serious illness insurance system covering the whole city, and build a multi-level medical security system and a long-term mechanism for stable operation.

Second, the overall goal

Further improve the work of serious illness insurance for urban residents within the city, covering urban residents' medical insurance participants. By then, the multi-level medical security system in cities and towns will be further improved, and the problems of poverty caused by illness and returning to poverty due to illness will be effectively alleviated.

Three. Financing mechanism

(1) funding criteria. Raise serious illness insurance funds according to the proportion of 5% of the current financing standard of medical insurance for urban residents in this city. With the development of economy and society, the financing ratio of serious illness insurance for urban residents will be adjusted according to the financing ability of medical insurance, the high medical expenses caused by serious illness and the changes in the level of serious illness insurance.

(2) Sources of funds. According to the determined annual financing standard, it will be allocated from the urban residents' medical insurance fund to commercial insurance institutions as a serious illness insurance fund. When there is a balance in the medical insurance fund for urban residents, use the balance fund to raise funds for serious illness insurance; If the balance is insufficient or there is no balance, the annual financing standard for urban residents' medical insurance will be appropriately raised, and the sources of funds will be solved as a whole, and a multi-channel financing mechanism will be gradually formed.

(3) Overall planning level. Serious illness insurance for urban residents follows the principles of municipal overall planning, unified financing standards, unified reimbursement ratio and unified implementation plan, so that urban residents can enjoy the same treatment and services of serious illness medical insurance.

Fourth, the content of protection.

(1). The object of serious illness insurance is the insured of medical insurance for urban residents.

(2) scope of protection. Individuals who meet the deductible standard and above within the annual cumulative policy scope of insured residents bear part of the medical expenses and the medical expenses within the policy scope above the set limit, and the serious illness insurance fund shall be guaranteed according to the regulations. The medical expenses within the policy scope refer to the medical expenses that meet the basic medical insurance drug list, diagnosis and treatment project list, medical service facilities scope and payment standard.

(3) Protection level.

(1) The medical expenses incurred by the insured residents within the policy range of more than 60,000 yuan paid by the urban residents' medical insurance pooling fund during the year are included in the scope of major illness insurance subsidies, and are compensated according to the following standards: the first-class designated medical institutions compensate 90%; Secondary designated medical institutions compensate 85%; Three designated medical institutions compensation 80%; 70% compensation for external diagnosis. During the year, the maximum payment limit for this period was 6,543,800 yuan+0.4 million yuan.

(2) If the insured residents' annual accumulated hospitalization expenses in the policy and the expenses of special chronic diseases in the hospital outpatient reach the deductible standard, they will be included in the compensation scope of serious illness insurance and compensated according to the proportion of 50%. There is no annual maximum payment limit in this paragraph. The deductible standard of personal medical expenses is the per capita disposable income of urban residents in the previous year (the deductible standard of personal medical expenses is 2 1 1,000 yuan, that is, the per capita disposable income of urban residents in 20 12 years). For groups with special difficulties (urban minimum living allowances, severely disabled students and children in cities and towns, severely disabled people in cities and towns who have lost their ability to work, elderly people and minors over 60 years old from low-income families in cities and towns, and unemployed retired soldiers who are not included in the basic medical insurance for urban workers), the deductible standard for insured persons is reduced to 80% (the deductible standard for groups with special difficulties is 16800 yuan).

With the continuous improvement of fund-raising, management and security, the proportion of compensation for serious illness, the standard of deductible and the maximum payment limit will be gradually adjusted to minimize the burden of medical expenses of insured persons.

Verb (abbreviation of verb) payment method and medical fixed point

(1) Payment of funds. Medical insurance agencies in counties and districts will transfer the serious illness insurance fund to the account of commercial insurance institutions in time every year.

(2) reimbursement methods. Medical expenses and personal out-of-pocket expenses (including hospitalization expenses and special chronic diseases in hospital outpatient service) exceed the deductible standard within the scope of the annual policy, and commercial insurance institutions shall promptly compensate the medical insurance expenses for serious illness.

(3) Designated medical institutions. Designated medical institutions for urban residents' medical insurance are designated medical institutions for urban residents' serious illness insurance, and no new designated medical institutions for serious illness insurance will be added.

(4) seek medical treatment in different places. Insured patients need medical treatment in different places outside the province (city), which shall be handled in accordance with the basic medical insurance referral regulations.

Sixth, the way of undertaking.

(1) competent department. The municipal human resources and social security department, as the competent department and the tenderer of the serious illness insurance for urban residents, determined a commercial insurance institution to undertake the serious illness insurance business for urban residents in the city through public bidding in accordance with the basic policy requirements such as the determined financing standard, deductible line, reimbursement scope, compensation ratio and medical treatment settlement management.

(2) Bidding and contract management. Commercial insurance institutions that meet the basic access conditions voluntarily participate in bidding according to law. The bidder shall sign an insurance contract with the successful commercial insurance institution, specifying the responsibilities, rights and obligations of both parties, and the contract term shall not be less than 3 years in principle. Bidding documents and contract templates shall be operated in accordance with the unified format of the whole province. The competent department of serious illness insurance for urban residents shall follow the principle of balance of payments and guaranteed profit, and reasonably control the profit level of commercial insurance institutions. Establish an assessment system centered on the level of protection and the satisfaction of the insured, and effectively protect the actual benefit level of the insured.

(3) Reasonably control the profitability of commercial insurance institutions in accordance with the principles of balance of payments and guaranteed profit. 20% of the actual balance of the serious illness insurance fund of commercial insurance institutions in that year was used to improve the handling capacity and network construction of medical insurance at all levels in the city and promote the steady development of basic medical insurance in the city; 30% of the actual balance of the serious illness insurance fund in that year was used for medical compensation for the personal medical burden of the insured.

(4) Improve the service level and provide "one-stop" service. Commercial insurance institutions should establish a serious illness insurance settlement information system, real-time interconnection with the information systems of urban residents' medical insurance agencies and designated medical institutions, set up a special service window in the medical insurance agency hall, and implement real-time settlement of serious illness reimbursement. To meet the requirements of Qifubiaozhun single hospitalization, should provide instant settlement service; If the accumulated expenses for multiple hospitalizations reach the Qifubiaozhun, all compensation will be in place within 10 working days; For patients who seek medical treatment in different places outside the province (city), the settlement service shall be completed within 15 working days from the date of application.

Seven. Supervision and management

(a) to strengthen the supervision of commercial insurance institutions to undertake serious illness insurance. The premiums obtained by commercial insurance institutions undertaking serious illness insurance shall be accounted for separately to ensure the safety and solvency of funds. The human resources and social security department shall urge commercial insurance institutions to effectively perform their duties in accordance with the contract requirements and improve the service quality and level through daily spot checks, information supervision and the establishment of complaint acceptance channels. The financial department shall strengthen the management of the financial expenses and accounting related to the purchase of serious illness insurance services from commercial insurance institutions by using the basic medical insurance fund. The audit department shall, in accordance with the provisions, audit the premium operation of commercial insurance institutions. Due to breach of contract or other acts that seriously damage the rights and interests of the insured, the tenderer may terminate or terminate the cooperation in advance, and shall be investigated for responsibility according to law.

(two) to strengthen the control of medical institutions and medical expenses. Commercial insurance institutions should give full play to the role of medical insurance mechanism, cooperate with medical insurance agencies and health departments to promote the reform of payment methods, and medical institutions should standardize medical behavior in accordance with the norms of diagnosis and treatment and clinical pathways, control the proportion of patients at their own expense, and effectively reduce medical expenses.

(three) the establishment of information disclosure, social participation supervision system. Commercial insurance institutions shall submit a report on undertaking serious illness insurance to the administrative department of human resources and social security and the medical insurance agency at the end of each year. Ministry of Human Resources and Social Security will disclose to the public the signing of agreements with commercial insurance institutions, as well as the financing standards, treatment levels, payment procedures, settlement efficiency and annual revenue and expenditure of serious illness insurance, and accept social supervision.

Eight. Implementation time

The implementation plan of Pingxiang's serious illness insurance for urban residents (for trial implementation) was implemented from June 5438+1 October1. Other related issues not covered in this implementation plan shall be implemented according to the Interim Measures for Supplementary Medical Insurance for Serious Illness of Urban Residents in Jiangxi Province (No.232 [2009] of Jiangxi People's Society).

Pingxiang Human Resources and Social Security Bureau is responsible for the interpretation of this implementation plan.