I entered the rural cooperative medical system. I'm from Guocheng Town, Laizhou, and I'm going to see a doctor in Yidao Town Hospital. Can outpatient expenses and hospitalization expenses be reimburse

I entered the rural cooperative medical system. I'm from Guocheng Town, Laizhou, and I'm going to see a doctor in Yidao Town Hospital. Can outpatient expenses and hospitalization expenses be reimbursed? Township People's governments, sub-district offices, new district administrative committees, rural economic development zones, Dazong Lake tourist resort administrative committees, and relevant departments and units directly under the district:

In order to conscientiously implement the spirit of national and provincial opinions on deepening the reform of the medical and health system during the Twelfth Five-Year Plan period, further improve the financing standard of the new rural cooperative medical system, expand the scope of compensation for major diseases, improve the benefit of the participating people, and effectively reduce the burden of medical expenses for participating patients, the financing standard and compensation scheme of the new rural cooperative medical system in our district are now adjusted as follows:

I. Funding criteria

The district government decided to raise the financing standard of the new rural cooperative medical system in our district from 350 yuan per capita to 380 yuan in 20 13 years, in which the financial subsidies of provinces, municipalities and districts were raised from 285 yuan to 305 yuan, and the individual participation funds were raised from 65 yuan to 75 yuan. The participation funds of low-income households, five-guarantee households and key entitled groups are arranged by the district finance in the medical assistance funds.

Second, the participants

Residents within the jurisdiction, urban residents living in towns and villages and primary and secondary school students in agricultural registered permanent residence participate in the new rural cooperative medical system as a whole, and individuals can also participate in the new rural cooperative medical system by paying commercial insurance; Infants and retired soldiers born from the last payment period to the next payment period of the new rural cooperative medical system can participate in the new rural cooperative medical system in that year; Those who have participated in medical insurance for urban workers, urban residents and primary and secondary school students shall not participate and enjoy it repeatedly.

Third, the scope of compensation

(a) unified drug list. Designated village clinics (community health service stations) all use the drugs in the National Essential Drugs Catalogue (basic part); All designated medical institutions at the town level use the drugs in the National Essential Drugs Catalogue (Basic Part) and the Supplementary Drugs Catalogue of Basic Medical and Health Institutions in Jiangsu Province (Basic Part); District-level designated medical institutions use the provincial unified basic drug list and the provincial supplementary drug list, and the drug use in the inpatient list reaches 90%. If it fails to meet this standard, it will be settled with the patient according to this ratio, and the handling institution will settle with the medical institution according to the facts.

(two) unified diagnosis and treatment project directory (see table: new rural cooperative medical treatment project directory).

(three) the unified implementation of outpatient special disease compensation. Outpatient drug and treatment fees for insulin-dependent diabetes, tertiary hypertension, systemic lupus erythematosus, aplastic anemia, apoplexy sequelae, Parkinson's disease, hemophilia, severe psychosis, etc. Will be included in the outpatient special disease compensation.

Fourth, the compensation standard

Outpatient compensation

1. There is no deductible for general outpatient medical expenses compensation. The compensation rates at the town and village levels are 45% and 50% respectively, and the annual maximum payment limit is 700 yuan. Referral to district-level designated medical institutions for outpatient treatment, and medical expenses within the scope of compensation are compensated by 20%; The general outpatient medical expenses of municipal and above medical institutions are not covered by compensation.

2. The daily outpatient prescription limits of designated medical institutions at the town and village levels are 50 yuan and 30 yuan respectively.

3. Outpatient treatment of special diseases is mainly undertaken by designated medical institutions in districts and towns, and the annual compensation capping line is 1000 yuan.

4, the general medical expenses charged by the town and village medical institutions shall be included in the scope of payment of the new rural cooperative medical system, and 80% compensation shall be given.

(2) Hospitalization compensation

1, deductible. Inpatient medical expenses compensation set deductible, town, district, city and provincial designated medical institutions deductible each time were 200, 400, 500 and 600 yuan. For the anti-rejection outpatient treatment of radiotherapy and chemotherapy for malignant tumor and organ transplantation, the accumulated medical expenses within the scope of the settlement policy shall be deducted from the deductible line 10%, and then reported according to the hospitalization compensation standard of medical institutions at the same level, and the annual accumulated compensation shall not exceed 1 10,000 yuan.

2. Policy payment ratio.

Town level

District level

Municipal level

Provincial level

Eighty-five

70

60% within 30,000 yuan

Over 30,000, 65%

50% within 30,000 yuan

More than 30,000, 60%

3. Top line. The top line of individual annual medical expenses compensation is 654.38+10,000 yuan, and the annual cumulative calculation includes outpatient service, hospitalization and other compensation.

(3) Compensation for major diseases

1, the diseases included in the pilot project to improve the level of medical security for major diseases of rural residents will be compensated by 70% according to the standard of limited medical expenses in our district after being referred to the designated hospitals that have signed major disease service agreements. If the participating patients choose their own drugs, diagnosis and treatment items or go to medical institutions outside the district for diagnosis and treatment, the medical expenses shall be implemented in accordance with relevant regulations.

2, referral to designated hospitals for major diseases hospitalization medical expenses compensation is not limited by the individual annual compensation cap line.

Verb (abbreviation of verb) other clauses

1. If the family is not fully involved, the medical expenses that meet the compensation policy will be compensated according to the proportion of the family participating population.

2, cross-year inpatients, must continue to participate in order to enjoy continuous compensation. The medical expenses incurred after April 1 can only be compensated for the newly insured persons (except married, newly born and retired soldiers) in this area.

3. Strengthen the management of going abroad for medical treatment, strive to control the referral rate outside the region within 10%, and strive to control the referral rate outside the city within 5%, and conscientiously implement the step-by-step referral system; For the participants who go through the referral procedures in time and are referred to the designated medical institutions at the district, city or provincial level for hospitalization, the medical expenses incurred shall be guaranteed and compensated, and the actual compensation ratio is 35%; The medical expenses incurred in the hospitalization of designated medical institutions at the district level and outside the district, without referral, shall be compensated according to 60% of the prescribed standards (except for emergency and migrant workers).

4, normal delivery, vaginal surgery, midwifery and cesarean section medical expenses in addition to government subsidies 500 yuan, the rest according to the standard of single disease compensation.

5, the full implementation of the district, town, village designated medical institutions outpatient total prepaid, total control, according to the disease settlement and pay by bed day and other payment reform.

6. For the medical assistance objects approved by the departments of civil affairs, Federation of Trade Unions, labor and social security, the medical expenses incurred in medical treatment, except the new rural cooperative medical system, shall be compensated according to the compensation standard of medical assistance in Yandu District.

7. According to the spirit of the document "Opinions on Further Strengthening the Life Assistance for Orphans and the Medical Work for Patients with Mental Illness" (No.2012) issued by the district government office, the principle of "designated hospitals and free treatment" is implemented for patients with mental illness. The designated hospital in our district is the District Mental Disease Prevention and Treatment Hospital, and the district joint management office is based on the funds reported by the New Rural Cooperative Medical System in the District Fine Prevention Hospital last year.

Six, standardize the management of designated medical service institutions

1, cancel the referral system between towns and villages, implement information interconnection of participants, and report medical expenses in time; Patients in town health centers (first-class hospitals) who can't be diagnosed and treated due to limited conditions should be referred to central health centers (second-class hospitals) with service capacity for treatment. First-and second-level hospitals should implement graded diagnosis and treatment, and realize the orderly development of first-and second-level hospitals by regularly adjusting the balance of payments.

2, strict implementation of the district, town and village grading publicity system, designated medical service institutions should publicize the service charges, drug prices, cooperative medical fund income and expenditure, supervision and reporting telephone and other content. ; Before every month 15, publicize the salary of the insured within the jurisdiction of last month. The publicity position should be eye-catching and the content should be clear to ensure the participants' right to know and supervise.

3, the designated medical institutions to implement performance appraisal management, to do not perform the duties of cooperative medical care, do not comply with the relevant provisions of cooperative medical care, unreasonable inspection, medication, treatment, outpatient patients into inpatients, "hanging bed" in hospital or decomposition of inpatient units, according to the actual cost of 2-3 times to be punished; The relevant personnel who engage in malpractices for selfish ends and resort to deceit to defraud settlement funds shall be fined 2-5 times of the amount defrauded, and informed criticism, the responsible unit, shall be rectified within a time limit. Overdue rectification, suspend or cancel the qualification of designated medical service institutions, and investigate the responsibility of relevant personnel.

4. Implement the management of doctor service agreement in designated medical institutions of the new rural cooperative medical system, strengthen the monitoring role of medical insurance on medical services, establish an effective restraint mechanism that pays equal attention to incentives and punishments, improve the service quality of medical practitioners in designated medical institutions of the new rural cooperative medical system, promote rational examination, rational drug use and rational treatment, and achieve the goal of providing quality services at low cost.

5, participants in the designated medical institutions for medical treatment, according to the compensation scheme directly for medical expenses compensation, expenses paid by the designated medical institutions, monthly statistics reported to the district management office, after verification, according to the total amount of the designated medical institutions approved throughout the year in chronological order. Designated medical institutions shall, in principle, implement measures such as quota management, total amount control and over-expenditure compensation, and strengthen self-discipline.

6, designated medical institutions according to 1% of the total medical expenses of the participating personnel settlement funds, at the end of each year unified remitted to the district management office, as a cooperative medical work assessment and reward fund.

7, improve the service attitude and conditions of designated medical service institutions, improve the service quality and efficiency, so that the comprehensive satisfaction of the participating people remains above 95%.

New Rural Construction in Yandu District of Yancheng City

Cooperative medical management Committee

20 13 65438+ 10/0/5

CC: Office of the District Party Committee, Office of the Standing Committee of the District People's Congress, Office of the District Government, Office of the District Political Consultative Conference, District Court, District Procuratorate and District People's Armed Forces Department.

The Office of the Management Committee of the New Rural Cooperative Medical System in Yandu District of Yancheng City was released on 20 13 10 15.