New policy of retirement medical insurance in Dalian in 2023

Issued by Dalian Medical Security Bureau

Two important announcements!

Medical insurance for employees and medical insurance for urban and rural residents

Problems related to outpatient co-ordination treatment

These Provisions shall be implemented as of June 65438+ 10/day, 2023.

Details are as follows:

Dalian employee medical insurance insured

General outpatient co-ordination

The medical expenses for general outpatient (emergency) consultation (hereinafter referred to as general outpatient medical expenses) incurred by the insured in the general outpatient co-ordination designated medical institutions shall be paid by the employee medical insurance co-ordination fund according to the following standards:

Note: The proportion of employees' medical insurance fund paid to those who enjoy retirement benefits increased by 5 percentage points. If the insured person signs a contract with the family doctor of the primary medical institution to upgrade the service package and go to the primary medical institution for treatment, the payment ratio of the employee medical insurance pooling fund will increase by 10 percentage point.

Chronic special diseases in outpatient department

Treatment policy

1. The medical expenses incurred by the insured in the outpatient treatment of chronic special diseases in designated medical institutions shall be included in the coverage of outpatient chronic special diseases. The catalogue of chronic diseases and special diseases in our city, the duration of treatment and the level of treatment shall be implemented according to the regulations (table below).

2, the province's unified standards for the cost of some chronic diseases and special diseases in accordance with the provisions of Liaoning Province. High-value drugs settled separately by medical insurance are not included in the scope of chronic diseases and special diseases in outpatient clinics.

3. Insured patients can enjoy outpatient treatment of various chronic diseases and special diseases at the same time, but they cannot have their cake and eat it at the same time. The outpatient co-ordination treatment of chronic diseases and special diseases and the general outpatient co-ordination treatment can have both. An outpatient medical fee can only be paid for one treatment. The insured person enjoys the treatment of chronic diseases and special diseases in outpatient department, and the maximum payment limit in that year is calculated on a monthly basis. The annual maximum payment limit for outpatient chronic diseases and special diseases is the total payment of basic medical insurance and supplementary medical insurance. Dialysis-related expenses incurred during hospitalization are included in hospitalization expenses and reimbursed according to hospitalization standards.

(2) Time limit for enjoying treatment

Outpatient chronic special disease treatment period expires, stop enjoying the treatment qualification, still need to continue treatment, should re-apply for identification. Patients with chronic and special diseases have a long-term or five-year treatment period, and if there is no compliance medical expenses for 24 consecutive months after identification, their treatment qualification will be stopped.

(3) Handling service

The insured can enjoy the treatment of chronic diseases and special diseases in outpatient service only after being confirmed by clinical examination.

(4) Dialysis settlement method

Outpatient dialysis expenses are settled by the monthly one-time payment standard of the medical insurance pooling fund and the designated medical institutions in the overall planning area. The balance is half a year, and the overrun is not made up, and the balance is reasonably retained. The employee medical insurance co-ordination fund has a monthly lump sum of 7,300 yuan per person, and if the actual payment amount of the insured person in the designated medical institution is less than 90% of the total lump sum, it shall be settled according to the actual amount; More than 90%, according to the general contracting quota settlement.

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Any other business

(1) Combination of treatment

Not included in the scope of outpatient chronic diseases and special diseases, the original outpatient diseases, outpatient fixed-point drug supply, outpatient surgery, prenatal examination, outpatient family planning surgery, emergency rescue and discharge treatment will be included in the general outpatient co-ordination treatment, and unified cost guarantee will be implemented. Family planning operation in the hospital is guaranteed by medical insurance hospitalization. The prenatal examination fee shall be subject to a transitional policy. Those who give birth on or before September 30, 2023 can enjoy both the original prenatal examination fee and the fixed subsidy treatment; Those who gave birth on or after June 65438+ 10/day in 2023 will no longer enjoy the fixed subsidy for prenatal examination fees.

(2) seeking medical treatment in different places

Employees who meet the requirements of long-term residence in different places will enjoy the treatment of general outpatient co-ordination and outpatient chronic diseases and special diseases in accordance with the treatment standards of this Municipality after filing in their long-term residence. Workers' medical insurance insured persons temporarily seek medical treatment in different places, and do not enjoy the overall treatment of general outpatient medical insurance for employees who seek medical treatment. Outpatient chronic diseases and special diseases enjoy treatment according to the treatment standard of this Municipality. The insured dialysis treatment in different places, according to the monthly limit of 7300 yuan reimbursement.

(3) Other circumstances.

When the insured person fills the prescription in the Internet medical prescription circulation pharmacy, the payment standard of the employee medical insurance pooling fund is determined according to the level of the designated medical institution that issues the prescription. The outpatient medical expenses incurred by the insured in the designated Internet medical institutions are combined with the offline outpatient medical expenses, and the payment standard of the employee medical insurance pooling fund is determined according to the level of the entity designated medical institutions supported by the designated Internet medical institutions. If the insured person enjoys the overall treatment of general outpatient service midway, the Qifubiaozhun and payment limit shall be implemented according to the annual standard.

After the implementation of the New Deal, what changes have been made in the overall protection treatment of the general outpatient service of medical insurance for employees in our city?

First, the level of outpatient medical insurance for employees is higher. The general outpatient medical expenses incurred in the designated medical institutions for outpatient co-ordination at all levels can be paid by the medical insurance co-ordination fund in proportion, and the upper limit of payment in a natural year is 6.5438+0.2 million yuan.

Second, the employee medical insurance clinic is more fair and inclusive. Patients with chronic diseases can enjoy outpatient medical expenses without passing the examination. The outpatient medical expenses incurred by the insured in the designated medical institutions due to illness in accordance with the medical insurance catalogue are all included in the scope of protection according to the policy.

Third, it is more scientific to determine the treatment standards at different levels. According to the requirements of graded diagnosis and treatment, determine the standard of outpatient co-ordination treatment. The lower the level of medical institutions, the lower the threshold and the higher the payment level. Insured persons and retirees who have signed contracts with family doctors are given preferential policies. The reimbursement rate of employees in contracted primary medical institutions reached 80%, and the reimbursement rate of retirees in contracted primary medical institutions reached 85%.

Fourth, there are many designated institutions for general outpatient co-ordination. Insured persons can enjoy the overall treatment of general outpatient service in hospitals at all levels, community health service centers, township hospitals, outpatient departments, Internet hospitals with designated medical institutions and pharmacies that undertake prescription circulation in our city.

Dalian urban and rural residents basic medical insurance insured

General outpatient co-ordination

The general outpatient (emergency) medical expenses (hereinafter referred to as general outpatient medical expenses) incurred by the insured in the general outpatient department in accordance with the medical insurance policy of designated medical institutions shall be paid by the residents' medical insurance pooling fund according to the following standards:

Note: If the insured signed a contract with the family doctor of the primary medical institution to upgrade the service package and went to the primary medical institution for treatment, the proportion of payment from the residents' medical insurance pooling fund will increase by 5 percentage points.

Chronic special diseases in outpatient department

Treatment policy

The medical expenses incurred by the insured in the outpatient treatment of chronic diseases and special diseases in designated medical institutions within the scope of medical insurance policy shall be included in the coverage of outpatient chronic diseases and special diseases. The catalogue of chronic diseases and special diseases in our city, the duration of treatment and the level of treatment shall be implemented according to the regulations (table below).

(2) Time limit for enjoying treatment

Outpatient chronic special disease treatment period expires, stop enjoying the treatment qualification, still need to continue treatment, should re-apply for identification. Patients with chronic and special diseases have a long-term or five-year treatment period, and if there is no compliance medical expenses for 24 consecutive months after identification, their treatment qualification will be stopped.

(3) Handling service

The insured can enjoy the treatment of chronic diseases and special diseases in outpatient service only after being confirmed by clinical examination.

(4) Dialysis settlement method

The settlement method with the resident medical insurance outpatient dialysis designated medical institutions shall be implemented with reference to the relevant regulations on the management of employee medical insurance, and the monthly lump sum amount of the resident medical insurance co-ordination fund shall be 6000 yuan per person.

Any other business

(1) Combination of treatment

Residents' medical insurance for outpatients with hypertension and diabetes will be retained and continued to be implemented. Not included in the scope of outpatient chronic diseases and special diseases, the original outpatient prescribed diseases, outpatient fixed-point drug supply, emergency rescue and discharge treatment will be merged into general outpatient co-ordination treatment, and unified cost guarantee will be implemented. Among them, the insured persons who have been recognized as enjoying the treatment of the first kind of diseases (except schizophrenia) and chronic heart failure diseases stipulated by the original outpatient service enjoy the transitional treatment of diseases: the annual payment limit of ordinary outpatient service is raised to 2000 yuan.

(2) seeking medical treatment in different places

In accordance with the provisions of long-term residence in different places, residents' medical insurance insured persons enjoy the treatment of chronic diseases and special diseases in general outpatient clinics according to the treatment standards of this Municipality. Residents' medical insurance insured persons temporarily seek medical treatment in different places, and they do not enjoy the overall treatment of residents' medical insurance general outpatient service at the place where they seek medical treatment. Outpatient chronic diseases and special diseases enjoy treatment according to the treatment standard of this Municipality. The insured in different places dialysis treatment, according to the monthly reimbursement limit of 6000 yuan.

(3) Other circumstances.

When the insured distributes drugs in the Internet medical prescription circulation pharmacy, the payment standard of the residents' medical insurance pooling fund is determined according to the level of the designated medical institution that issues prescriptions. The outpatient medical expenses incurred by the insured in the designated Internet medical institutions are combined with the offline outpatient medical expenses, and the payment standard of the residents' medical insurance pooling fund is determined according to the level of the designated medical institutions supported by the designated Internet medical institutions. If the insured person enjoys the overall treatment of general outpatient service midway, the Qifubiaozhun and payment limit shall be implemented according to the annual standard.

Xiao Min reminds: Pay attention to Dalian local treasure WeChat official account, and reply to medical insurance in the chat dialog box to view Dalian medical insurance policies and guidelines.