Detailed rules for the implementation of outpatient mutual assistance guarantee of basic medical insurance for employees in Yuxi City

Article 1 In order to further improve the outpatient security system of workers' basic medical insurance (hereinafter referred to as "workers' medical insurance") and effectively reduce the burden of workers' outpatient medical expenses, according to the Guiding Opinions of the General Office of the State Council on Establishing and Improving the Outpatient Mutual Assistance Security Mechanism of Workers' Basic Medical Insurance (Guo Ban Fa [202 1] 14) and the Implementation Measures of the General Office of Yunnan Provincial People's Government on Printing and Distributing the Outpatient Mutual Assistance Security of Workers' Basic Medical Insurance in Yunnan Province.

Article 2 These Detailed Rules shall apply to the medical insurance participants of Yuxi employees (including flexible employees, hereinafter referred to as the participants).

Article 3 The outpatient mutual assistance guarantee of medical insurance for employees shall adhere to the basic guarantee, implement overall planning and mutual assistance, and earnestly safeguard the rights and interests of the insured; Adhere to a smooth transition, maintain policy continuity, and ensure a smooth convergence of treatment before and after the reform; Adhere to synergy, improve the outpatient service guarantee mechanism and improve the personal account system.

Article 4 The term "employee medical insurance outpatient mutual assistance" as mentioned in these Detailed Rules includes employee general outpatient medical insurance, outpatient chronic diseases, outpatient special diseases, outpatient emergency rescue, national negotiated drug outpatient medical insurance and daytime surgery.

Fifth county (city, district) people's government should strengthen organizational leadership, establish a coordination mechanism, and implement the reform of the outpatient mutual assistance guarantee mechanism for employee medical insurance.

City, county (city, district) medical insurance department is responsible for organizing the implementation of the medical insurance outpatient mutual security work within their respective administrative areas.

Relevant departments of cities and counties (cities, districts) jointly carry out fund management, medical and health administration, market supervision and regulation, and combat fraud and insurance fraud in combination with their own work responsibilities.

Chapter II Fund Management

Sixth basic medical insurance premiums paid by the insured units (including the fees paid by flexible employees) are all included in the overall fund. The basic medical insurance premiums paid by employees are included in personal accounts. After adjusting the overall fund and personal account structure, the increased overall fund is mainly used for outpatient mutual aid security and improving the outpatient treatment of insured persons.

Seventh Municipal Medical Insurance Bureau in conjunction with the Municipal Finance Bureau to further standardize and improve the medical insurance fund management system. Medical insurance agencies should strengthen the budget management of medical insurance funds, improve the workflow, and do a good job in revenue and expenditure information statistics.

Chapter III Outpatient Support

Article 8 The medical expenses incurred by the insured in the general outpatient service of the designated medical institution within the policy scope stipulated by the medical insurance (hereinafter referred to as "the expenses within the policy scope") shall be included in the general outpatient service guarantee.

In a natural year (the same below), the minimum payment standard of the overall fund within the policy scope for each general outpatient service of the insured is: designated medical institutions (including village clinics, community health service stations, etc.) at or below the first level. , the same below) 30 yuan, 60 yuan, a secondary designated medical institution, and 90 yuan, a tertiary designated medical institution.

Within the scope of general outpatient service policy, the proportion of expenses paid by the overall fund is: 60% for the first-class and below designated medical institutions, 55% for the second-class designated medical institutions and 50% for the third-class designated medical institutions. The contribution rate of retirees is 5 percentage points higher than that of on-the-job employees.

Medical expenses incurred by the insured in non-designated medical institutions shall not be paid by the medical insurance fund.

Article 9 The annual maximum payment limit of the cost pooling fund within the scope of general outpatient service policy is 6,000 yuan, which is calculated separately from the annual maximum payment limit of hospitalization. The expenses of more than 6,000 yuan within the scope of the general outpatient service policy shall be reimbursed according to the proportion of the medical insurance hospitalization pooling fund for employees of medical institutions, and combined with the annual hospitalization maximum payment limit.

Tenth workers medical insurance outpatient chronic disease policy within the scope of the overall fund Qifubiaozhun for 300 yuan, and hospitalization Qifubiaozhun calculated separately; The overall fund payment ratio is 80%; The payment limit of the single disease pooling fund is 3,000 yuan, and each additional disease increases by 1 1,000 yuan. The maximum annual payment limit of the overall fund is 5000 yuan, which is calculated separately from the maximum annual payment limit of hospitalization.

Eleventh staff medical insurance outpatient special disease policy within the scope of the cost, the overall fund annual Qifubiaozhun for 800 yuan, and hospitalization Qifubiaozhun were calculated; In secondary and above designated medical institutions, expenses exceeding the policy scope of Qifubiaozhun shall be implemented according to the proportion of hospitalization reimbursement of medical institutions (among them, there is no Qifubiaozhun for chronic renal failure and special diseases in severe psychiatric outpatient service, and the proportion of reimbursement within the policy scope is 90%), and the annual maximum payment limit of the overall fund and the annual maximum payment limit of hospitalization shall be calculated together.

Article 12 When an emergency rescue (including pre-hospital first aid) that meets the requirements of the health department occurs in an outpatient clinic, the Qifubiaozhun and payment ratio of the overall fund within the policy scope shall be implemented according to the level of the medical institution (the first level and below shall be implemented according to the first level), and the annual maximum payment limit of the overall fund and the annual maximum payment limit of hospitalization shall be calculated together.

Article 13 During the agreement period, if the insured uses qualified drugs negotiated by the national medical insurance, he shall pay for them first and then deduct the expenses within the scope of the policy. The overall fund Qifubiaozhun is implemented in 800 yuan, and each negotiated drug only pays once a year, which is calculated separately from the hospitalization Qifubiaozhun; The proportion of overall fund payment is implemented according to the proportion of payment for medical treatment or prescription hospitalization in designated medical institutions; The annual maximum payment limit of the overall fund and the annual maximum payment limit of hospitalization are calculated together.

Article 14 The Qifubiaozhun of the daytime operation pooling fund shall be halved according to the hospitalization Qifubiaozhun of designated medical institutions, and calculated separately from the hospitalization Qifubiaozhun; The proportion of overall fund payment is implemented according to the proportion of hospitalization payment of designated medical institutions; The annual maximum payment limit of the overall fund and the annual maximum payment limit of hospitalization are calculated together.

Chapter IV Personal Account Management

Article 15 The basic medical insurance premiums paid by individual employees are all included in my personal account, and the inclusion standard is 2% of my insured payment base, and all the basic medical insurance premiums paid by the employer are included in the overall fund.

The individual accounts of retirees will continue to be allocated by the overall fund according to the quota, and the allocated amount will be gradually adjusted to 2% of the average basic pension level in the year when the reform was implemented in the overall planning area.

Sixteenth personal accounts are mainly used to pay out-of-pocket expenses incurred by the insured in designated medical institutions or designated retail pharmacies. Available for payment:

(1) Medical expenses incurred by the insured, their spouses, parents and children in designated medical institutions, and expenses incurred by individuals in purchasing medicines, medical devices and medical consumables with national medical insurance standard codes in designated retail pharmacies.

(two) the insured spouse, parents and children to participate in the basic medical insurance for urban and rural residents and other individual contributions.

(three) the insured and their spouses, parents and children to participate in large medical expenses subsidies, long-term care insurance and the purchase of commercial health insurance and other personal contributions.

(four) other expenses in accordance with the provisions of the state and province.

The scope of spouse, parents and children is governed by the Civil Code of People's Republic of China (PRC) and other laws. Spouses, parents and children are limited to the insured in Yunnan Province.

Seventeenth personal accounts shall not be used for public health expenditure, physical fitness, health care consumption and health examination and other expenses that do not fall within the scope of payment of basic medical insurance.

Eighteenth individual account balances can be carried forward and inherited. When the employee's medical insurance relationship is transferred, if the personal account balance cannot be transferred due to special reasons such as no personal account in the transfer place, you can apply for one-time cancellation.

Chapter V Expense Settlement

Nineteenth insured people through the province's unified "smart health insurance" information system online handling platform, will meet the conditions of the spouse, parents, children to join the list of individual account payers. When a person who joins the list of personal account payers visits a doctor, he can deduct it from the personal account at the designated medical institution with the medical insurance certificate of the insured person (including social security card and medical insurance electronic certificate, the same below). If the personal account is not enough to pay, it will be paid by the medical purchaser.

Twentieth insured outpatient medical treatment or drug purchase within the scope of the policy, with my medical insurance certificate according to the following provisions:

(a) belongs to the overall fund payment, by the designated medical institutions to upload real-time cost information and immediate settlement.

(2) If it belongs to personal account payment, the designated medical institution will upload the fee information in real time and deduct it from the personal account; Personal account is not enough to pay, paid by the insured.

Twenty-first retired resettlement personnel, long-term outside personnel and insured persons who seek medical treatment in different places according to regulations may go to designated medical institutions in different places outside the overall planning area for medical treatment after filing, and the outpatient mutual assistance guarantee fee shall be settled online. If the online settlement is not realized for medical treatment, the insured person will settle the account with his medical insurance voucher, medical expense invoice, medical record and other materials to the medical insurance agency in the insured place.

Twenty-second outpatient medical expenses in accordance with the provisions of the "internet plus" shall be settled and reimbursed according to the Internet hospital relying on the entity designated medical institutions.

Twenty-third establish and improve the drug "dual channel" guarantee mechanism. Insured personnel with external prescriptions in the "dual-channel" designated retail pharmacies to prescribe, and the expenses incurred within the scope of the policy shall be settled and reimbursed according to the level of designated medical institutions that prescribe.

Twenty-fourth municipal medical insurance bureau should combine the actual income and expenditure of medical insurance fund, pay attention to the scientific connection between outpatient mutual aid policy and hospitalization treatment, and improve the settlement method of outpatient mutual aid on the basis of ensuring the normal enjoyment of relevant treatment.

Chapter VI Management Supervision

Twenty-fifth improve the management and service measures to guide the rational use of medical resources. By promoting the construction of primary medical service system, improving the contract service of family doctors and standardizing the management of long prescriptions, the insured will be guided to make the first visit at the primary level. Combined with the improvement of outpatient chronic diseases and special diseases management measures, standardize the diagnosis and treatment and referral behavior of designated medical institutions at the grass-roots level.

Twenty-sixth municipal medical insurance bureau should combine the implementation of outpatient mutual assistance, improve the safety prevention and control mechanism of medical insurance funds, and severely crack down on insurance fraud. Further strengthen the fund audit system and internal control system, strengthen the supervision of medical behavior and medical expenses, severely investigate and deal with all kinds of illegal acts involving medical insurance funds, further strengthen the supervision of outpatient expenditure in designated medical institutions, and ensure the safe, efficient and rational use of medical insurance funds.

Twenty-seventh in order to ensure the safety of medical insurance funds, give full play to the role of multi-sectoral linkage, and implement the joint meeting system of combating fraud and defrauding medical insurance funds in our city, the problems found by members of the joint meeting in supervision should be dealt with in a timely manner. Problems that do not belong to the scope of responsibilities of this unit shall be promptly handed over to the relevant units for handling according to law.

Twenty-eighth pay attention to publicity and guidance, innovate publicity methods, enrich publicity means, carry out extensive publicity and accurately interpret policies. Establish public opinion monitoring and disposal mechanism, actively respond to social concerns, and create a good public opinion atmosphere.

Chapter VII Supplementary Provisions

Twenty-ninth workers' medical insurance outpatient mutual assistance and medical assistance for workers, civil servants and other policies are linked to each other to maintain the overall stability of the level of treatment and protection.

Thirtieth employee medical insurance outpatient mutual assistance security mechanism remained stable for a certain period of time. In the future, the Municipal Medical Insurance Bureau and the Municipal Finance Bureau will study and adjust within the scope of provincial policies according to the actual social and economic development of our city.

Article 31 These Detailed Rules shall be implemented as of June 65438+1 October1day, 2023. If the original relevant provisions of our city are inconsistent with these rules, these rules shall prevail.

Yuxi Municipal People's Government Office issued in June 2022 at 65438+ 10/1.