In order to implement the spirit of the Notice of the General Office of the People's Government of Zhejiang Province on Accelerating the Establishment and Improvement of the Serious Illness Insurance System (Zhejiang Zhengban [20]14]122), further improve the medical security system in our city and establish a multi-level medical security system, on the basis of the serious illness insurance system for urban and rural residents, with the consent of the Municipal People's Government, we hereby
I. Work objectives
In accordance with the requirements of the construction of serious illness insurance system in the province, with the goal of everyone enjoying basic medical security, overall planning and step-by-step implementation. On the basis of the current basic medical security system, we will further improve the medical insurance system for serious illness in our city, gradually implement municipal overall planning, improve the overall level of medical insurance for serious illness in our city and the level of medical security, and effectively reduce the burden of medical expenses for serious illness of insured persons.
The serious illness insurance mentioned in this implementation opinion includes serious illness insurance for employees and urban and rural residents. The city's serious illness insurance system is temporarily set up for a two-year transition period (-), that is, on the basis of the current implementation of serious illness insurance for urban and rural residents, the employee's serious illness insurance is established. During the transition period, the employee and urban and rural residents' serious illness insurance funds are unified and unified, and the payment and treatment are differentiated. In accordance with the requirements of building a medical security system with basic medical insurance as the main body, serious illness insurance as the extension, medical assistance as the foundation, and social charity and commercial insurance as the supplement, we will strengthen system integration. When conditions are ripe, we will unify the policy system, financing standards and treatment levels with the city as the unit, and the fund will implement unified revenue and expenditure.
Second, the policy measures
(a) the scope of insurance
Participate in the basic medical insurance for employees (including flexible employment insured) and the basic medical insurance for urban and rural residents are unified into the scope of serious illness medical insurance system.
(2) Financing mechanism
In accordance with the principle of fairness and sustainability, establish a multi-channel financing mechanism that is reasonably shared by the government, units and individuals. The required funds will be temporarily borne by 70% of the government or units and 30% of individuals. The specific financing standards for serious illness insurance will be determined by the people's governments of counties (cities). The serious illness insurance premium of employees' medical insurance insured shall be allocated from the basic medical insurance fund for employees and the basic medical insurance fund for urban and rural residents in a lump sum every year. Among them, the individual contributions of employees shall be transferred from personal accounts, and those without personal accounts shall be paid by the insured individuals, and the local tax department shall be responsible for the collection of serious illness insurance premiums for employees; The financing standard for urban and rural residents is determined by unified calculation based on the original basis and the special drug expenses included in the payment scope of serious illness insurance. According to the operation of the serious illness insurance fund, timely adjust the financing standards.
In principle, the total fund-raising standard for employees' serious illness insurance units and individuals in Wenzhou City is 40 yuan per capita. For employees who have not established personal accounts for medical insurance, the personal contribution of their serious illness insurance premiums shall be paid by the insured individuals (the serious illness insurance premiums for on-the-job employees shall be collected annually by the local tax authorities, and the serious illness insurance premiums for retirees shall be paid by the wages <: Pension > Withheld by the issuing unit, paid once a year). The principle of raising funds for serious illness insurance for urban and rural residents in Wenzhou City is 30 yuan per year.
The serious illness insurance fund shall be managed by two lines of revenue and expenditure and special financial accounts, with separate accounts, accounting separately and earmarking.
(3) the level of protection
1. Treatment content. In a medical insurance year, after the medical expenses incurred by the medical insurance participants for hospitalization and outpatient service for special diseases are reimbursed according to the local basic medical insurance, the compliance medical expenses accumulated by the insured individuals, the special drugs that are included in the payment scope of serious illness insurance in Zhejiang Province at designated medical institutions or with prescriptions, and the expenses of such drugs that meet the reimbursement requirements in different places, which exceed the local qifubiaozhun for serious illness insurance, are included in the payment of serious illness insurance. For the special drugs included in the payment scope of serious illness insurance in Zhejiang Province, according to the spirit of the Notice of Zhejiang Provincial Department of Human Resources and Social Security on Including Gleevec 15 Drugs in the Payment Scope of Serious Illness Insurance (Zhejiang People's Social Development [20 1 5] 1No.), from1. The expenses incurred by the insured in the designated medical institutions and related pharmacies that meet the scope of payment of serious illness insurance shall be settled directly by the insured and the designated medical institutions and related pharmacies; Medical expenses that should be paid by individuals shall be charged directly to the insured by designated medical institutions and related pharmacies. Special drugs for serious illness insurance in Zhejiang Province are as follows:
serial number
Drug name
form of a drug
manufacturer
common name
trade name
1
Imatinib mesylate
imatinib mesylate capsules
tablet
NovartisPharmaSchweizAG
2
Pemetrexed disodium
Libitai
injection
EliLilly& Company
three
Gefitinib
iressa
tablet
AstraZenecaUKLimited
four
Doxorubicin hydrochloride liposome
Ribaoduo
injection
Shanghai Fudan Zhangjiang biomedicine co., ltd
five
Cetuximab
Aibituo
injection
MerckKGaA (Germany)
six
decitabine
Qingweike
injection
Zhengda Tianqing Pharmaceutical Group Co., Ltd.
seven
Anti-human T cell rabbit immunoglobulin
ATG-FreseniusS
injection
FreseniusBiotechGmbH
eight
Trastuzumab
Herceptin
injection
GenentechInc.
nine
Recombinant human coagulation factor VIIa
Noqi
injection
Novo Nordisk Denmark
10
Rituximab
Rituximab
injection
RocheDiagnosticsGmbH
1 1
Ying fu Li Xi Dan kang
Leike
injection
CilagAG
12
Lanthanum carbonate
Foslino
chewable tablet
ShirePharmaceuticalContractsLimited
13
nimotuzumab
Taixinsheng
injection
Baitai pharmacy biology co., ltd
14
Lanruipeptide acetate
Somadulin
injection
IPSENPHARMABIOTECH
15
Teripartite
Futaiao
injection
LillyFrance
In the future, the special drugs included in the payment of serious illness insurance in our city will be adjusted accordingly according to the adjustment of the catalogue of special drugs for serious illness insurance in Zhejiang Province. Insured persons who use or buy special drugs for serious illness insurance outside Zhejiang Province shall be included in the medical insurance expenses according to the negotiated price of access in Zhejiang Province. The applicable population, indications, usage and dosage, and payment standards of special drugs for serious illness insurance shall be implemented in accordance with regulations and strictly controlled.
2. Standard of treatment. Wenzhou serious illness insurance is settled according to the medical insurance year. In a medical insurance year, Wenzhou City has a Qifubiaozhun for serious illness insurance. In principle, the Qifubiaozhun is determined with reference to the per capita income level of urban and rural residents in the previous year, and the maximum compensation limit for serious illness insurance is temporarily set at 10 times (inclusive) of the Qifubiaozhun. Among them, the Qifubiaozhun of Wenzhou urban serious illness insurance subsidy is determined to be 32,600 yuan, and the maximum amount of urban serious illness insurance is uniformly adjusted to 10 times (inclusive) of the Qifubiaozhun. The compliant medical expenses incurred by the insured in a medical insurance year after being reimbursed by the basic medical insurance exceed the Qifubiaozhun are included in the scope of payment of serious illness insurance, and the reimbursement ratio is implemented according to the following standards:
(1) The compliance expenses above the threshold of employee's critical illness insurance shall be shared by the critical illness insurance fund and individuals. The employee's serious illness insurance fund shall be reimbursed by stages: the reimbursement ratio is 60% for the part that is higher than Qifubiaozhun and 5 times lower than Qifubiaozhun (inclusive); The reimbursement rate is 70% for the part that is 5 times higher than the minimum threshold and lower than the minimum threshold 10 times (inclusive).
(2) The reimbursement rate for compliance expenses above the threshold of critical illness insurance for urban and rural residents to 10 times (inclusive) is 50%.
After the expiration of the transition period, the payment and treatment of employees' serious illness insurance and urban and rural residents' serious illness insurance will be determined separately.
(4) Handling and management
Before the municipal co-ordination, the specific financing standards, Qifubiaozhun, treatment payment standards, etc. shall be determined by all co-ordinates according to the standard requirements stipulated in the document Notice of the General Office of the People's Government of Zhejiang Province on Accelerating the Establishment and Perfection of the Serious Illness Insurance System (Zhejiang Zhengban Fa [2014]122) combined with local conditions. Serious illness insurance is organized and implemented by all co-ordinates; and the specific handling is managed by the co-ordinating agency. Encourage commercial insurance companies to undertake serious illness insurance, strengthen the bidding management of serious illness insurance, and standardize the bidding behavior of serious illness insurance in accordance with the requirements of the "Guidelines for the Bidding Management of Serious Illness Insurance in Zhejiang Province (Provisional)" (Zhejiang People's Social Letter [2015] No.30). The specific bidding management method shall be determined by the overall human resources and social security department in conjunction with the local financial department. Increase the daily supervision of commercial insurance companies that undertake serious illness insurance, and establish and improve the assessment system with performance and satisfaction of insured persons as the main content. We will further improve the system of immediate settlement of medical reports and realize "one-stop" settlement of basic medical insurance, medical assistance for serious illness and serious illness insurance as soon as possible.
The serious illness insurance for employees in Wenzhou city is entrusted to a commercial insurance company. Through public bidding, the profit rate of commercial insurance institutions is reasonably controlled, business risks are assumed, and a dynamic adjustment mechanism for excess balance and policy losses is established, following the principles of balance of payments and guaranteed profit.
After overall planning at the municipal level, the specific financing standards, Qifubiaozhun and treatment payment standards shall be formulated by the Municipal Human Resources and Social Security Bureau in conjunction with the Municipal Finance Bureau and reported to the Municipal People's Government for approval before being determined and announced separately.
Third, the job requirements
(a) seriously organize the implementation.
The work of serious illness insurance involves the connection of two levels, multiple departments and multiple systems in cities and counties (cities, districts). All co-ordinates should earnestly strengthen the organization and leadership of the work of serious illness insurance, scientifically calculate and determine the specific financing standards and treatment levels according to the principle of balance of payments. The human resources and social security department should earnestly perform the duties of the lead department, and conscientiously do a good job in policy formulation, organization and coordination, guidance and supervision in conjunction with relevant departments; The financial (local tax) department should do a good job in the allocation of funds in financial accounts, the collection of serious illness insurance premiums and the financial supervision of serious illness insurance; The health department should strengthen the supervision of medical institutions and medical services; Market supervision departments should strengthen the supervision of drug supply channels and improve risk prevention and control measures; The insurance supervision department should strengthen the supervision of the undertaking behavior and service quality of commercial insurance companies; Medical insurance agencies should do a good job in accounting, financial accounting and supervision of the implementation of the agreement. At the same time, strengthen communication and cooperation between departments, exchange information and form a joint force; Strengthen publicity, do a good job in policy guidance at different stages of serious illness insurance in a timely manner, and ensure that the municipal-level overall planning of serious illness insurance in our city is promoted in an orderly manner.
(2) Strengthen dynamic supervision.
Relevant departments should scientifically formulate implementation plans and do a good job in data calculation; The overall planning should do a good job in the data calculation and analysis of special drug expenses, especially in the policy convergence between serious illness insurance and basic medical insurance in the transitional period. It is necessary to do a good job in information maintenance of special drugs and systematic development of related businesses to ensure that business and technology are implemented in place. It is necessary to strengthen risk assessment, timely grasp the possible risks of municipal overall planning, and put forward countermeasures and solutions. It is necessary to strengthen the dynamic supervision of special drugs for serious illness insurance, do a good job in statistical analysis of data, prevent and control unreasonable medical behaviors and expenses, and ensure the quality of medical services.
Fourth, the implementation time
This opinion will be implemented from 1 month 1 day.
Wenzhou Municipal People's Government Office
August 2 1 day;