Recently, the Municipal Government Office issued the Implementing Measures for Yibin City Employees' Basic Medical Insurance Outpatient *** Relief Guarantee Mechanism (hereinafter referred to as the Measures). The relevant contents are explained below.

I. Background and basis for the introduction of the Measures

Since the establishment of the employee health insurance in 1998, the implementation of a combination of social coordination and individual account protection mode, the coordinated fund to protect the cost of hospitalization and outpatient slow special disease expenses, individual account to protect the cost of outpatient common diseases and drug costs, individual accounts in the promotion of public labor insurance medical system to the social health insurance system, the transfer of the system to the social health insurance system. Individual accounts have played a positive role in promoting the transition from a publicly-funded labor insurance medical system to a social medical insurance system. With the development of society and economy, the enhancement of people's health consciousness and the change of medical behavior, the change of disease spectrum and the advent of aging society, the individual account can no longer adapt to the needs of social development under the new economic norm, and its limitations have gradually come to the fore. The main problem is that the protection function is insufficient, **** financial insufficiency, the effect of reducing the burden is not obvious.

The national and provincial levels have issued the "General Office of the State Council on the establishment of a sound employees' basic medical insurance outpatient *** relief protection mechanism of the guiding opinions" (State Office of the State Council [2021] No. 14), "Sichuan Province to establish and improve the employees' basic medical insurance outpatient *** relief protection mechanism of the implementation of the measures" (Sichuan Office of the State Council [2022] No. 85), a clear and perfect personal accounts, strengthen the outpatient *** relief protection, management and supervision of five aspects of the content, and requires local refinement of the policy measures to ensure a smooth transition of the treatment of insured persons.

Second, the "approach" introduced the significance of

The establishment of a sound employee health insurance outpatient *** relief protection mechanism, is the country, the province to deepen the reform of the medical security system clearly put forward the task of deployment. This reform is conducive to enhancing the risk protection function of the health insurance fund, return to the origin of social insurance mutual ****, promote the family and social security, is conducive to better play the role of the health insurance fund of the strategic purchasing, optimize the allocation of primary health care resources, enhance the capacity of primary health care services, guide the masses of grass-roots medical care, promote the linkage of the three doctors. In accordance with the relevant requirements of the state and province, the introduction of the Measures is of great significance to promote the fairness and sustainability of the system, and to give full play to the medical insurance ****building*** enjoyment, mutual **** relief, and other important significance.

Three, the meaning of the employee health insurance outpatient ****ji protection mechanism

"****ji" is also known as the "law of large numbers", which means that everyone's money together to the occurrence of risky events (disease), the number of people who have to pay for their health insurance. Now, on top of the individual account, you can also be reimbursed through the "****** protection", that is, through the integrated fund. Employee outpatient ****ji protection mainly includes employee health insurance general outpatient co-ordination (hereinafter referred to as employee health insurance outpatient co-ordination) protection, employee "two diseases" outpatient medication protection, outpatient special disease protection and so on.

Four, the significance of the reform of the individual account of the employee health insurance

First, the previous insured employees in the outpatient medical expenses can only be paid by the individual account or cash, can not be reimbursed, medical protection is not sufficient; Second, the accumulated balance of the individual account is large.

Therefore, in accordance with national guidance, the provincial government explicitly requested the reform of individual account crediting methods, reduce the amount of crediting, the individual account to reduce the funds into the management of the integrated fund, to protect the operation of the outpatient integrated system.

Fifth, after the reform of the workers' health insurance personal account changes

First, the personal account of the crediting method has changed. Active employees (including flexible employment) personal account in accordance with their own contributions to the base 2%, the unit to pay the basic medical insurance premiums are all included in the integrated fund; retiree personal account from the integrated fund by a fixed amount into the amount of the city's average basic pension level of 2.8% in 2022, a single co-ordinator does not establish a personal account. After adjusting the structure of the integrated fund and personal account, the amount of personal account is reduced, the increase in the integrated fund is mainly used for outpatient **** financial security, improve the outpatient reimbursement treatment of insured persons.

For example: if an active employee contribution base for 80,000 yuan / year, the implementation of the new policy, the amount of personal account for 80,000 × 2% = 1600 yuan / year (133.3 yuan / month). If the city's average pension in 2022 for 46,500 yuan / year, then the implementation of the new policy, the retiree personal account transfer amount of 46,500 × 2.8% = 1302 yuan / year (108.5 yuan / month).

Second, the scope of use of personal accounts changed. After the reform, further broadened the scope of use of personal accounts, the realization of the personal account in the family members of the **** relief. The Measures put forward the scope of use of the individual account is: "mainly used to pay the insured person in the designated medical institutions within the scope of the policy out-of-pocket expenses incurred. It can be used to pay for the medical expenses incurred by the insured person, his/her spouse, parents and children at designated medical institutions, the expenses incurred by the insured person at designated retail pharmacies for the purchase of medicines, medical equipments and medical consumables, and the individual contributions to the basic medical insurance for urban and rural residents, supplemental medical insurance, insurance for serious and serious illnesses, and long-term nursing care insurance, etc., which are all carried out by the government and related to medical protection. . Individual accounts shall not be used for public **** health expenses, sports and fitness, health care consumption, health checkups and other expenditures that do not fall within the scope of basic medical insurance coverage."

Sixth, the conditions of enjoying the outpatient insurance benefits of the workers' health insurance

Participating in the workers' health insurance and in the period of enjoyment of the benefits of the people, are entitled to enjoy the outpatient insurance benefits of the workers' health insurance in accordance with the provisions of the co-ordination of the benefits.

VII. Scope and standard of reimbursement of outpatient medical insurance

General outpatient expenses incurred by insured employees at designated medical institutions, all outpatient medication, examination and treatment costs in accordance with the basic medical insurance catalog are included in the scope of reimbursement of the Employees' Medical Insurance Outpatient Coordination Fund.

Eight, the meaning and amount of the starting line of the outpatient co-ordination of employees' health insurance

The starting line refers to the medical expenses actually incurred by the insured person in the designated medical institutions which are within the scope of the policy, and the medical insurance fund pays for them in accordance with the prescribed ratio only after the insured person has borne a part of the medical expenses, and the amount of medical expenses borne by the individual is the amount of the payment made by the medical insurance fund to the insured person. The amount of medical expenses paid by the individual first is the starting line for the medical insurance fund to pay for the medical expenses of the insured person, and the medical expenses below the starting line are paid by the individual. The Measures stipulate that the starting line for outpatient medical expenses under the employee health insurance is 200 yuan for active employees and 150 yuan for retirees; if the total out-of-pocket expenses within the scope of the policy exceed 200 yuan for active employees and 150 yuan for retirees within a natural year, the excess will be reimbursed according to the proportion. The starting line is paid only once in a natural year and is not recalculated every time you visit a doctor.

Nine, after the implementation of the policy of outpatient co-ordination of employee health insurance, the insured workers in the designated medical institutions outpatient medical treatment and in the eligible designated retail pharmacy drug reimbursement ratio

(a) the standard of outpatient co-ordination of employee health insurance treatment: the annual starting standard of 200 yuan for active employees, retirees 150 yuan; the payment ratio of the three-tier The payment ratio is 50% for fixed-point medical institutions and fixed-point retail pharmacies, 60% for fixed-point medical institutions of the second level and below, and an increase of 10 percentage points for retirees on the basis of the corresponding payment ratio mentioned above. The policy is formulated to give some policy favoritism to the retirees.

For example: retired workers in the second level of designated medical institutions outpatient medical, incurred a total cost of 600 yuan, of which, the policy scope of medical expenses for 500 yuan, non-policy scope of the cost of 100 yuan (the fund will not be reimbursed), the policy scope of the 500 yuan of the cost of deducting the starting line of 150 yuan, the remaining 350 yuan reimbursement at a rate of 70% of the outpatient co-ordination fund reimbursement for employees The amount is (500-150) × 70% = 245 yuan.

(2) the insured workers in other areas outside the city designated medical institutions for medical treatment or purchase of medicines, employee health insurance outpatient coordinated starting line, reimbursement rate, the fund payment limit and so on, and the place of participation (Yibin City) consistent.

Tenth, the annual payment limit of employee health insurance outpatient coordination

The annual payment limit for employees and retirees is 1200 yuan and 1600 yuan respectively.

The annual payment limit of the employee outpatient coordination refers to the maximum amount of reimbursement that can be made by the Employee Health Insurance Fund to the insured person in a natural year, and after exceeding the annual payment limit, the medical expenses will be fully borne by the insured person.

Eleven, employee health insurance for hypertension, diabetes outpatient coverage

Participating in the employee health insurance and take medication for hypertension, diabetes (hereinafter referred to as "the two diseases") patients included in the scope of outpatient **** financial protection, "the two diseases", "the two diseases", "the two diseases", "the two diseases", "the two diseases", "the two diseases", "the two diseases", "the two diseases", "the two diseases" and "the two diseases". The "two diseases" patients meet the criteria for outpatient special diseases, outpatient special disease management into the scope of the implementation of outpatient special disease policy; does not meet the criteria for outpatient special diseases, the insured person by the designated medical institutions in accordance with the diagnostic and treatment specifications for the diagnosis of the "two diseases" and the patient. For the record, they can enjoy the outpatient medication protection of "two diseases" under the employee medical insurance, and its recognition standard, scope of medication, protection treatment, management services, etc. are consistent with the outpatient medication protection of urban and rural residents (the "two diseases" patients under the employee medical insurance will be treated at the designated medical institutions). The outpatient medication expenses within the policy scope for lowering blood pressure and lowering blood sugar incurred by patients with "two diseases" in designated medical institutions are reimbursed without a starting line, and the proportion of payment from the integrated fund is 70%. The annual payment limit for hypertension is 200 yuan per person. The annual payment limit for diabetes mellitus is 300 yuan per person per year. The annual payment limit for diabetes is 300 yuan/person/year. If you suffer from hypertension and diabetes at the same time, the maximum payment limit will be calculated together, and the maximum reimbursement will be 200 RMB for hypertension and 300 RMB for diabetes), which will be implemented from January 1, 2023 onwards. Outpatient special disease policy and "two diseases" outpatient drug coverage policy shall not be duplicated.

XII, voluntarily apply for the provision of employee health insurance outpatient coordinated medication protection services pharmacy conditions

qualification compliance, standardized management, good reputation, reasonable layout, sales and inventory management system and health insurance system docking, and to meet the sale of medicines to achieve electronic traceability, the price of medicines is not higher than the centralized procurement of drugs and equipment in Sichuan Province, and pharmaceutical price regulatory platform for the same products listed prices, and also to support the dispensing of prescription The designated retail pharmacies can voluntarily apply for the provision of employee health insurance outpatient coordinated medication protection services.

If a designated retail pharmacy has applied to become a health insurance retail pharmacy but has not applied for outpatient co-ordinated medication protection services for employees' health insurance, it does not affect its ability to provide services using the employees' individual accounts.

Thirteen, the difference between the old and new policies

Fourteenth, the implementation time

from January 1, 2023, effective for five years.