Policy of New Rural Cooperative Medical System in Xinjiang

Measures for compensation of new cooperative medical system in agricultural and pastoral areas of Xinjiang Uygur Autonomous Region

I. Basic principles

Adhere to the fixed expenditure by income, balance income and expenditure, and ensure moderation; Scientifically allocate the proportion of funds, taking into account the benefits of hospitalization and outpatient service; Classified implementation, try our best to ensure and standardize operation; Correctly guide the flow of patients, make full use of primary health resources, and embody the basic principle of mutual aid for serious illness as a whole.

Second, the definition of the scope of participants.

Taking the family as a unit, any person with Xinjiang household registration or other rural household registration in Xinjiang, who has lived in rural areas in Xinjiang for more than 5 years, engaged in agricultural, forestry, animal husbandry and fishery production activities or made a living from agricultural, forestry, animal husbandry and fishery production, and their children can participate in the new rural cooperative medical system.

Encourage migrant workers to participate in the basic medical insurance for urban workers. If it is really difficult, you can voluntarily choose to participate in the basic medical insurance for urban residents or the new rural cooperative medical system where the household registration is located.

Three. Operating year and financing time

The annual operation time of the new rural cooperative medical system is from 65438+ 10 to 1 to 65438+2 to 3 1.

In principle, the fund-raising time of the new rural cooperative medical system is to start collecting individual participation fees for the next year in July each year, end on February 20, 65438, and before February 25, 65438, individual participation fees for farmers and herdsmen, civil affairs and social organizations, etc. All of them will be included in the financial accounts of the new rural cooperative medical fund in all co-ordination areas. Under special circumstances, the individual insurance payment of farmers and herdsmen can be extended to the end of February next year at the latest. The financial department, the health department and the new rural cooperative medical system will complete the statistical summary of the participation of farmers and herdsmen no later than March 5 next year.

Around (state, city), county (city, district) in accordance with the provisions of the arrangement of the new rural cooperative medical subsidy funds should be before the end of March each year all included in the overall area of the new rural cooperative medical fund financial accounts.

The central financial subsidy funds shall be pre-allocated before the end of May every year in the way of "pre-allocation at the beginning of the year and settlement at the end of the year", and the settlement of the subsidy funds for the new rural cooperative medical system shall be completed before the end of 10 every year. According to the number of participants reported by all localities at the end of February of that year, the financial subsidy funds of the autonomous region will be allocated in place before the end of March each year.

The final settlement time of the new rural cooperative medical fund is 65438+February 3 1 every year.

Four. Funding standard

Gradually improve the local financial subsidy standards at all levels and the individual financing level of farmers and herdsmen, actively explore the establishment of a stable, reliable and reasonable growth financing mechanism, and enhance the anti-risk ability of the new rural cooperative medical fund. From 20 10, the annual fund-raising standard for each person of the new rural cooperative medical system shall not be lower than 150 yuan. In the future, with the continuous improvement of the financing standard of the new rural cooperative medical system, the specific fund allocation ratio will be adjusted accordingly.

Verb (abbreviation of verb) the use of funds

The new rural cooperative medical fund can only be used for the compensation of medical expenses of farmers and herdsmen and the compensation scope stipulated by the deepening reform of medical and health system in the autonomous region, and shall not be used for the compensation of basic public health services (such as planned immunization, preventive health care and health education). ) The government should provide special funds, working funds for agencies, Catalogue of Essential Medicines for New Cooperative Medical Care in Agricultural and Pastoral Areas of Autonomous Region (version 20 10) and Catalogue of Service Facilities and Diagnosis and Treatment Projects for New Cooperative Medical Care in Agricultural and Pastoral Areas of Autonomous Region (version 2065438).

Sixth, the compensation mode.

From 20 10, the compensation mode of the new rural cooperative medical system in the autonomous region has been determined as "overall hospitalization and overall outpatient care", and all counties (cities, districts) that implement the compensation mode of "overall hospitalization and overall family account" must complete the adjustment of the compensation mode before 20 1 1. By 20 1 1, the compensation model of "in-patient overall planning+out-patient overall planning" has been fully promoted in the whole region.

Seven. Fund classification

Funds are divided into three categories: inpatient pooling funds, outpatient pooling funds and risk funds.

Individual contributions of participating farmers and herdsmen, central and local financial subsidies and other social donations are all included in the overall fund.

(1) hospitalization pooling fund. It is mainly used for the compensation that the hospitalization reportable expenses of participating farmers and herdsmen reach the deductible standard, the compensation for serious outpatient diseases (major chronic diseases) and the compensation for hospitalization delivery quota. In principle, the hospitalization pooling fund accounts for about 70% of the pooling fund after the risk fund is extracted, and it is managed by all pooling areas.

(two) outpatient co-ordination fund. Mainly used to compensate farmers and herdsmen for general outpatient and general chronic disease reportable medical expenses. In principle, the outpatient co-ordination fund accounts for about 30% of the co-ordination fund after the extraction of risk funds, and is managed by all co-ordination areas.

(3) Risk fund. Mainly used to make up for the temporary capital turnover difficulties caused by abnormal capital overruns. In principle, the risk fund shall be maintained at 10% of the total fund in that year, and shall be managed by the financial departments and health departments at the prefecture (city) level in each overall planning area.

Eight. Salary setting

Routine hospitalization compensation

1. Payline

Township-level designated medical institutions are not higher than 80 yuan, county-level designated medical institutions are not higher than 200 yuan, county-level non-designated medical institutions 500 yuan, prefecture-level designated medical institutions 350 yuan, autonomous region-level designated medical institutions 500 yuan, prefecture-level and autonomous region-level non-designated medical institutions 800 yuan. The deductible line of designated medical institutions determined by the local health administrative department outside the district is consistent with the deductible line of designated medical institutions at the same level in the district, and non-designated medical institutions outside the district will not be reimbursed. Don't cancel the deductible line at will.

Below the deductible line is the individual pays part. Participating farmers and herdsmen in the same year at all levels of designated or non-designated medical institutions hospitalized for many times, deductible shall not be double counting (except for patients participating in radiotherapy and chemotherapy for malignant tumors); Because of the same disease, the deductible is not deducted repeatedly, but the difference deductible amount of medical institutions at all levels should be deducted.

Five-guarantee households, low-income households, and key entitled groups shall not be deductible for hospitalization in designated medical institutions at or below the county level with valid certificates from local civil affairs departments.

Designated medical institutions outside the district shall be subject to the list approved and published by the local health administrative department.

2. Compensation ratio

Designated medical institutions at the township level are not less than 75%, designated medical institutions at the county level are not less than 60%, designated medical institutions at the prefecture (city) level are 50%, and designated medical institutions at the autonomous region level are 40%. On this basis, the compensation ratio of non-designated medical institutions at the same level in all co-ordination areas can be reduced by 15 percentage points. Designated medical institutions at the same level outside the region shall refer to the compensation provisions of designated medical institutions at all levels in the autonomous region. The proportion of compensation for farmers and herdsmen who did not go through the referral procedures according to the prescribed procedures was correspondingly reduced by 20 percentage points.

Step 3 headline

From 20 10, the annual compensation capping line should be no less than 6 times of the per capita net income of farmers and herdsmen in the whole region in the previous year, including routine hospitalization compensation, childbirth compensation, chronic disease compensation, newborn compensation and secondary compensation. And calculate the actual compensation amount obtained by each participating farmer and herdsmen within one year.

4. Others

(1) guaranteed bottom compensation. Medical expenses incurred by participating farmers and herdsmen after hospitalization in township-level designated medical institutions, if the compensation is insufficient in 50 yuan according to the specified requirements and compensation ratio, the minimum 50 yuan guarantee compensation shall be implemented.

(2) Traditional Chinese medicine ethnic medicine compensation. The expenses for participating farmers and herdsmen to see a doctor in designated medical institutions at all levels and to use traditional Chinese medicine and appropriate technical services of traditional Chinese medicine in the catalogue of the new rural cooperative medical system can be increased by 10 percentage point on the basis of the same compensation to enter the compensation scope accounting.

(3) Compensation for essential drugs. The expenses of participating farmers and herdsmen for hospitalization in designated medical institutions at township and county levels and the use of national essential drugs (basic parts) in the catalogue of the new rural cooperative medical system can be increased by 5 percentage points on the basis of equal compensation to enter the compensation scope accounting; The expenses for the use of national essential drugs (basic parts) in the catalogue of the new rural cooperative medical system by designated medical institutions at prefecture (city) level and autonomous region level can be increased by 10 percentage point on the basis of the same compensation to enter the accounting of compensation scope.

Traditional Chinese medicine belongs to the national basic medicine (grass-roots part) and is implemented according to the compensation provisions of traditional Chinese medicine.

(4) compensation for the elderly and family planning. In agricultural and pastoral areas, the elderly aged 65 years and above and couples who receive the "two certificates" of family planning, the hospitalization expenses incurred after their insurance can be increased by 5 percentage points on the basis of the same compensation ratio of designated medical institutions at the same level. This preferential policy of increasing the compensation ratio cannot be enjoyed at the same time.

Five-guarantee households, low-guarantee households in agricultural and pastoral areas, elderly people aged 65 and above and couples who receive the "two certificates" of family planning can also enjoy preferential policies to increase the zero deductible and compensation ratio by 5 percentage points in designated medical institutions below the county (city, district).

(5) others. The out-of-hospital examination and treatment expenses incurred by participating farmers and herdsmen during hospitalization shall be compensated according to the level of the medical institution where they live. Cross-year hospitalization compensation standard is based on the date of discharge.

(VI) Medical expenses incurred by farmers and herdsmen who go out to work, visit relatives and go to school due to illness shall be compensated according to the compensation ratio of medical institutions at the same level under the condition of providing accurate proof of working, visiting relatives and going to school.

(2) Compensation for delivery in hospital

The compensation for hospital delivery should be fixed.

1. Normal delivery. In case of normal delivery (natural delivery, normal cesarean section and vaginal midwifery) of pregnant women who meet the family planning requirements, the subsidy policy for hospitalization delivery of rural pregnant women shall be implemented first, and then the new rural cooperative medical fund shall be implemented to compensate 300 yuan for the delivery quota. The sum of the fixed subsidy for normal delivery projects and the fixed compensation funds for the new rural cooperative medical system shall not exceed the total medical expenses for normal delivery in principle.

2. Pathological delivery. In line with the provisions of family planning, the hospitalization expenses incurred due to pathological delivery of pregnant women (such as prenatal, intrapartum and postpartum complications) shall be subsidized according to the rural maternity hospitalization subsidy policy, and the remaining expenses shall be reported according to the hospitalization compensation standard of designated medical institutions at the same level. If the compensation standard for hospitalization expenses is lower than that of 300 yuan, the compensation shall be guaranteed in 300 yuan.

3. others. Participating pregnant women can go out to work or visit relatives and friends, and give birth in the designated medical institutions of the new rural cooperative medical system confirmed locally. During the year, it is necessary to hold a copy of the new rural cooperative medical certificate, a copy of the household registration book (or ID card), a copy of the birth certificate (birth certificate), a copy of the birth certificate or the infant death certificate, a unified invoice for hospitalization, and a declaration form until the insured area applies for the new rural cooperative medical system, and implement the relevant policies for hospitalization compensation.

(3) Non-hospitalization compensation

1. outpatient fee compensation

Participating farmers and herdsmen must hold the "new rural cooperative medical certificate" in the township designated medical institutions for outpatient treatment. Patients with chronic diseases are treated in the designated medical institutions of the new rural cooperative medical system designated by the agency in the overall planning area with valid documents such as the new rural cooperative medical system card and chronic disease outpatient card (uniformly formulated and issued by the overall planning area).

(1) Compensation for general outpatient medical expenses

① Compensation scope: routine treatment expenses such as intramuscular injection, intravenous injection, enema, dressing change, minor debridement and suture, acupuncture and cupping; Expenses for routine examinations such as B-ultrasound, electrocardiogram, radiation and laboratory tests; Drug expenses (village level, township level) in the catalogue of basic drugs for new cooperative medical care in autonomous region (version 20 10).

(2) Compensation ratio: the compensation ratio for single outpatient expenses of township-level designated medical institutions is 30%, and that of village-level designated medical institutions is 40%; The maximum compensation for a single outpatient service of township-level designated medical institutions is 1 1 yuan; the designated medical institutions at the village level are 6 yuan, and the single prescription is limited (that is, there is no limit on the number of outpatient services for farmers and herdsmen throughout the year); the designated medical institutions at the village level are 300 yuan and the designated medical institutions at the township level are 500 yuan.

The expenses for participating farmers and herdsmen to use the national essential drugs (grass-roots part) in the catalogue of the new rural cooperative medical system in the outpatient service of designated medical institutions at the township level can be increased by 5 percentage points on the basis of the same compensation, and entered the accounting of compensation scope.

③ Compensation method: The outpatient co-ordination expenses are paid to the rural designated medical institutions in the form of "total budget, fixed lump sum, installment payment, over-expenditure without compensation and performance appraisal". The total budget of outpatient co-ordination expenses is fixed in townships and villages for one year. After the quota is determined, it will be paid in installments. Before payment, check and evaluate the drug use and charges, service standards and medical quality of rural designated medical institutions.

④ The compensation mode in family account is implemented according to the current policy.

(2) Compensation for outpatient medical expenses of chronic diseases

① Compensatory diseases: diabetes (type II), hypertension (above stage II), cerebral hemorrhage and cerebral infarction recovery period, cor pulmonale, rheumatic heart disease, coronary heart disease, malignant tumor, renal failure, psychosis, cretinism, tuberculosis, echinococcosis and brucellosis.

(2) Compensation scope: it is applicable to the medical expenses needed for treating chronic diseases and the medical expenses within the scope of the Catalogue of Basic Medicines for New Cooperative Medical Care in Agricultural and Pastoral Areas of Autonomous Region (20 10 Edition) (township and county level).

③ Diagnostic procedure: The patient applies to the agency in the overall planning area, and provides the effective disease diagnosis certificate and relevant inspection report issued by the local, state and municipal second-class and above medical institutions. The chronic disease treatment certificate will be issued after being examined and registered by the overall regional agency and reported to the health department at the same level for approval.

④ Proportion of compensation for general chronic diseases: No deductible line is set, and the designated medical institutions for chronic diseases will settle the report immediately, and make compensation according to 40% of the reported medical expenses. The annual cumulative ceiling line is 2000 yuan, which is calculated separately from the general outpatient expenses, and the funds are paid from the outpatient co-ordination fund. General chronic disease compensation content shall not be repeated and accumulated with general outpatient compensation content.

⑤ Proportion of compensation for major chronic diseases: The total medical expenses of outpatient radiotherapy and chemotherapy for malignant tumor patients, outpatient dialysis for uremia patients and dietotherapy for phenylketonuria patients shall be implemented according to the hospitalization compensation regulations of designated medical institutions at the same level, and shall be declared once every six months, and the funds shall be paid from the hospitalization pooling fund.

⑥ For cretinism and tuberculosis, the project subsidy funds shall be paid first, and the rest shall be paid according to the regulations.

All landowners chronic disease patients outpatient and inpatient annual cumulative compensation shall not exceed the local hospitalization capping line.

2. Physical examination

(1) health examination object

The health examination object (subject) of the new rural cooperative medical system refers to the participating farmers who have not received any hospitalization and outpatient compensation in the last year of the new rural cooperative medical system. It is recommended that every household take part in the health check-up, and specific groups can also be identified among the farmers and herdsmen participating in the check-up according to local conditions.

(2) Time and method of physical examination

Physical examination shall be conducted in the following year in principle. You can take a combination of perennial health examination and centralized health examination. Perennial physical examination refers to the time when the examinee chooses to go to the designated medical institution for physical examination within the physical examination year; Centralized physical examination means that the subjects are concentrated in the designated medical institutions for physical examination within the specified time, and the designated medical institutions can also provide on-site physical examination services.

(3) the use of health examination funds

In principle, the funds for health examination will be used in family account or outpatient clinics to plan the surplus funds of the year, and the government can also actively strive for special funds for health examination. Medical institutions undertaking health check-up tasks should give certain fee reductions and concessions to patients.

(4) Physical examination items

Reasonable determination of health examination items, on the basis of general physical examination and three routine examinations, the examinee can also choose at least four items from blood sugar, liver function, chest X-ray or chest X-ray, electrocardiogram, B-ultrasound (hepatobiliary spleen or kidney, bladder, prostate or uterine appendix), routine gynecological examination, blood biochemical examination, and infectious disease detection (hepatitis B, hepatitis C, AIDS, syphilis). In principle, health examination items should be selected independently.

Medical institutions should establish health records for patients. The filing work is strictly in accordance with the Ministry of Health's Regulations on the Management of Urban and Rural Residents' Health Records (2009 Edition).

(5) Appropriation of health examination funds

According to the established charging standard of the new rural cooperative medical system health examination project and the preferential conditions provided by medical institutions, the payment standard of the new rural cooperative medical system fund is reasonably determined. In principle, the charging standard should be acceptable to the providers, demanders and payers of medical examination services.

After the completion of the medical examination, the agency of the new rural cooperative medical system will carefully check the medical institutions that carry out the health examination of the new rural cooperative medical system, and publicize the medical institutions, the list of patients, medical examination items, medical examination fees, etc. If there is no objection or report during the publicity period, the medical examination funds can be allocated to medical institutions. It is forbidden to directly allocate medical examination funds from the New Rural Cooperative Fund to medical examination institutions in the form of budget arrangement or pre-allocation.

(6) Others

The implementation of health examination depends on the balance of outpatient co-ordination funds in all co-ordination areas, but it should be connected with the residents' health records and health examination proposed in the equalization of basic public health services.

(4) Other compensation

1. Hospitalization compensation for special major diseases

During the operation year of the new rural cooperative medical system, participating farmers and herdsmen suffering from major diseases can enjoy serious illness compensation from the overall fund of the new rural cooperative medical system in addition to routine hospitalization compensation.

(1) compensation range. In the annual operation of the new rural cooperative medical system, the hospitalization of participating farmers and herdsmen conforms to the hospitalization diseases of the new rural cooperative medical system, and the medical expenses incurred in a single hospitalization exceed 40 thousand yuan (including 40 thousand yuan), which belongs to the scope of serious illness compensation.

(2) Compensation standard. According to the overall situation of raising and using the local new rural cooperative medical fund, all localities can take one-time compensation for the hospitalization medical expenses that are not compensated in the hospitalization medical expenses, and each person can only enjoy it once a year. The maximum compensation does not exceed the local hospitalization compensation cap line, and does not cover the due part of routine hospitalization compensation.

(3) compensation method. After the hospitalization of farmers and herdsmen, they shall go through the application procedures for serious illness compensation with the new rural cooperative medical certificate, household registration book (or ID card), hospitalization diagnosis certificate, unified invoice for hospitalization, and list of hospitalization medical expenses to the new rural cooperative medical institutions in their respective co-ordination areas. Anyone who meets the requirements should be compensated immediately. The specific implementation measures shall be formulated by the overall planning area.

2. Neonatal compensation

The medical expenses incurred by the unborn newborn due to illness 10 days after delivery (including 10 days) in the annual fund-raising process of the new rural cooperative medical system should be included in the scope of compensation. The hospitalization expenses incurred due to illness after 10 days after the birth of the newborn will not be compensated in the new rural cooperative medical system operation year, and pregnant women are encouraged to pay the participation fund in advance for their soon-to-be-born children.

3. Secondary compensation

In the annual operation of the new rural cooperative medical system, it is estimated that the balance rate of the overall fund of the new rural cooperative medical system (excluding risk funds) is above 20%, and the participating farmers and herdsmen who have already incurred hospitalization compensation in the annual operation of the new rural cooperative medical system can get two compensations.

(1) compensation range. Where in the new rural cooperative medical system operation year, the participating farmers and herdsmen who have hospitalization compensation but the accumulated hospitalization compensation expenses have not reached the prescribed ceiling line (except for major chronic diseases and hospitalization normal delivery compensation) belong to the scope of secondary compensation.

(2) Compensation standard. The hospitalization compensation expenses of farmers and herdsmen will be compensated by 2 times in proportion. Specifically, the amount of compensation for the second compensation of participating farmers and herdsmen = the cost of compensation for the first hospitalization of participating farmers and herdsmen × the expected summary of the new rural cooperative medical fund this year, and the expected total compensation of the new rural cooperative medical fund this year.

(3) Compensation clause. Where in the new rural cooperative medical system operation year, the sum of the second compensation fee and the original compensation fee shall not exceed the prescribed cap line; The participating farmers and herdsmen who have received multiple hospitalization compensation are only calculated according to the first hospitalization reimbursable expenses; Enjoy the security compensation, the secondary compensation has exceeded the original minimum compensation standard, and the secondary compensation amount shall be deducted from the paid minimum compensation amount. The proportion of secondary compensation depends on the fund balance.

(4) The second compensation is not a routine compensation item, and whether it is carried out depends on the operation of the new rural cooperative medical fund in each overall planning area.

Nine. service specifications

(a) the overall planning area should be based on the principle of facilitating the masses and seeking medical treatment nearby, and respect the farmers and herdsmen's independent choice of medical treatment. Participate in the new rural cooperative medical institutions of farmers and herdsmen in the autonomous region, and realize "free choice, independent choice of doctors, instant registration and instant report". Participating farmers and herdsmen in other neighboring county-level and township-level designated medical institutions for medical treatment can be reimbursed according to the same treatment as the designated medical institutions of the new rural cooperative medical system in the overall planning area, and the designated medical institutions of the adjacent county-level and township-level new rural cooperative medical system should accept the supervision and inspection of the new rural cooperative medical system in the overall planning area where participating farmers and herdsmen are located. Participating farmers and herdsmen patients transferred to designated medical institutions at or above the county level for medical treatment should be strictly in accordance with the relevant policies and regulations of the Autonomous Region New Cooperative Medical System Referral and Referral Management Measures (Trial).

(two) all localities should strictly implement the catalogue of the new rural cooperative medical system, and include the drugs, diagnosis and treatment items and service facilities in the catalogue of the new rural cooperative medical system into the scope of compensation, and shall not separately formulate the catalogue of compensation for the new rural cooperative medical system.

Designated medical institutions at all levels should strictly control the use of self-funded drugs, self-funded inspection items and the proportion of self-funded medical expenses to the total medical expenses. Designated medical institutions below the county (city) and county (city), the proportion of drugs and medical expenses outside the catalogue of the new rural cooperative medical system in the total medical expenses shall not exceed 10%, and the designated medical institutions above the county (city) shall not exceed15%; County (city) and designated medical institutions below the county (city), the amount of drugs outside the catalogue of the new rural cooperative medical system should be controlled within 10% of the total drug cost; Designated medical institutions above the county (city) should be controlled within 25%. Unreasonable expenses incurred by designated medical institutions beyond the scope and beyond the standard clinics shall be borne by designated medical institutions once verified. Designated medical institutions at all levels should formulate and implement various preferential policies and measures for participating farmers and herdsmen in light of their own reality.

(three) actively carry out the reform and innovation of payment methods such as fixed payment or limited payment for single diseases. The health administrative department of the overall planning area, the new rural cooperative medical institution and the relevant departments can choose common diseases to carry out pilot projects and gradually expand the diseases. According to the medical cost, determine the price of disease charges, and reasonably determine the proportion of patients' self-payment and fund payment. It is necessary to strengthen the audit management of disease identification and admission standards. It is forbidden for medical institutions at all levels to take measures such as "diagnosis upgrade" or "minor illness treatment" to raise the cost of single diseases. From 20 10, the instant reimbursement service for compensation expenses of designated medical institutions of the new rural cooperative medical system at or above the prefecture (city) level will be gradually promoted in the whole region, and it will take two years to realize the goal of instant reimbursement for medical expenses of participating farmers and herdsmen when they leave the designated medical institutions of the new rural cooperative medical system at the autonomous region level and prefecture (city) level in the whole region.

X. Relevant explanation

(a) the compensation measures shall be implemented as of the date of issuance. All localities should actively adjust the compensation provisions in the local implementation plan in combination with this compensation method in order to meet the established requirements stipulated in this compensation method.

(II) When adjusting the compensation provisions in the local implementation plan, all localities should follow the principle of absolute and relative unity, that is, the key compensation indicators of designated medical institutions at or above the county level should strictly implement the provisions of this compensation method, and the key compensation indicators of designated medical institutions below the county (city) level are allowed to float positively on the basis of the unified standards stipulated in this compensation method.

(three) when the standards of finance at all levels and the financing of farmers and herdsmen are improved, the corresponding compensation clauses in this compensation method will be updated and adjusted in time.

(four) the compensation measures shall be interpreted by the new cooperative medical management office of the autonomous region.