Shanghai Medical Insurance Personal Account Classification Standard 2023

Shanghai Medical Insurance Personal Account Classification Standard 2023:

1. Improve personal account entry methods.

From July 1 day, 2023, all the basic medical insurance premiums paid by employees will be included in my personal medical account, and the inclusion standard is 2% of my insured payment base, and all the basic medical insurance premiums paid by the unit will be included in the overall fund;

2, strengthen the outpatient service * * * economic security function.

Improve the medical insurance outpatient expenses guarantee mechanism for employees, and adjust the treatment standards for outpatient and emergency departments from July 2023 1;

3. Standardize the scope of personal accounts.

Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies. From July 2022 1, the scope of personal accounts will be gradually expanded. Personal accounts can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies. Explore the personal accounts of spouses, parents and children participating in the basic medical insurance for urban and rural residents. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance;

4. Strengthen the supplementary guarantee function of local additional funds.

The local additional medical insurance premiums paid by the employer are all included in the local additional fund and accounted for separately. From June 65438+1 October1day in 2023, the outpatient and emergency medical expenses will be included in the payment scope of the overall fund, and will no longer be paid by local additional funds. Local supplementary funds continue to pay all the burden reduction expenses, including the comprehensive burden reduction of employees' medical insurance, and some medical expenses above the maximum payment limit of the overall fund. Explore the multi-channel financing and supplementary guarantee functions of local additional funds in coping with the aging population;

5. Strengthen supervision and management.

Improve the management service measures, innovate the system operation mechanism, guide the rational use of medical resources, ensure the stable operation of medical insurance funds, and give full play to the guarantee function. Strictly implement the budget management system of medical insurance fund, and strengthen the construction of fund audit system and internal control system. Further improve the dynamic management mechanism of the whole process of personal accounts and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of medical behavior and medical expenses, improve the supervision system of administrative law enforcement at the municipal and district levels, continue to carry out special actions to crack down on fraud and insurance fraud, strengthen joint supervision across departments, strengthen social supervision, and accelerate the construction of intelligent supervision system;

6, accelerate the construction of primary medical service system, improve the family doctor contract service, standardize the long-term prescription management, and guide the insured to the primary medical treatment. Improve the payment mechanism suitable for outpatient economic security.

Strengthen the linkage of "three doctors" and promote the deepening of the reform of the medical and health system. We will continue to deepen the reform of payment methods of medical insurance, promote the system of payment by disease (DIP) and the system of payment by disease diagnosis (DRG) under the general budget management, and provide better medical services for the masses and reduce their burden of medical treatment. Scientifically and reasonably determine the payment standard of medical insurance, and guide the active use of drugs with definite curative effect and reasonable price. In addition, eligible "internet plus" medical services will be included in the scope of payment.

The reimbursement methods of medical insurance are as follows:

1, local reimbursement

If the insured person is reimbursed for medical treatment in a local designated medical institution, the medical expenses incurred can be directly settled with the medical insurance card at the time of settlement, and the settlement center can directly calculate the reimbursable amount, so it is very convenient for the insured person to pay the medical expenses at his own expense;

2. Off-site reimbursement

At present, medical insurance is not fully connected to the whole country. Therefore, when seeing a doctor in a designated medical institution in a different place, it is usually necessary for the insured person to advance the expenses by himself, keep all the documents, and then go to the social security handling center where the insured person is located for manual reimbursement.

To sum up, starting from 2023, the medical insurance settlement system in different places will be officially implemented. For those who live in different places for a long time and temporarily go out for medical treatment across provinces, the medical insurance expenses incurred can be directly reimbursed without going back to the insured place for reimbursement.

Legal basis:

Article 26 of People's Republic of China (PRC) Social Insurance Law

The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.