Article 1 In order to further improve the medical security system for urban and rural residents in our province and improve the level of serious diseases, these measures are formulated according to the Opinions of the General Office of the State Council on the Full Implementation of Serious Diseases Insurance for Urban and Rural Residents (Guo Ban Fa [2015] No.57) and the relevant provisions of our province.
Article 2 The term "serious illness insurance for urban and rural residents" as mentioned in these Measures refers to the institutional arrangement to further protect the high medical expenses incurred by seriously ill patients on the basis of the basic medical insurance for urban and rural residents, which is the expansion and extension of the basic medical security system.
Article 3 The coverage of serious illness insurance covers urban and rural residents who enjoy basic medical insurance in our province.
Article 4 Basic principles for implementing serious illness insurance:
(a) people-oriented, to ensure serious illness;
(2) Overall coordination and policy convergence;
(3) government-led, market operation;
(4) Balance of payments and continuous implementation.
Fifth serious illness insurance shall be coordinated at the provincial level and be responsible at different levels. The province's unified collection, management and use of serious illness insurance funds. The selected commercial insurance institutions shall undertake specific business according to the overall planning area.
Sixth provincial human resources and social security departments are responsible for serious illness insurance; The provincial finance department is responsible for the budget management and accounting system management of the serious illness insurance fund; The provincial audit department is responsible for auditing and supervising the use of the serious illness insurance fund; The provincial insurance supervision department is responsible for the business supervision of commercial insurance institutions. Provincial human resources and social security departments shall, jointly with relevant departments, formulate assessment methods for major illness insurance of commercial insurance institutions, and cities under provincial jurisdiction and counties (cities) directly under provincial jurisdiction shall be responsible for specific implementation.
Basic medical insurance agencies at all levels (hereinafter referred to as medical insurance agencies) and commercial insurance institutions * * * do a good job in the management and service of serious illness insurance.
Chapter II Raising of Expenses
Seventh serious illness insurance fund from the provincial cities and counties (cities) to raise basic medical insurance funds for urban and rural residents, do not charge extra fees for urban and rural residents.
The funds for serious illness insurance in cities and counties (cities, districts) under the jurisdiction of each province were directly withheld by the provincial finance when the subsidies for basic medical insurance for urban and rural residents were issued in that year, and were transferred to the financial accounts of serious illness insurance in the province according to the financing standards of serious illness insurance in that year and the number of insured people in various places, and collected and paid by the financial departments at the city and county levels, and the provincial treasury was liquidated at the end of the year.
Eighth serious illness insurance financing standards according to the province's basic medical insurance for urban and rural residents in the year to determine the total financing of about 6%.
Article 9 Implement differentiated financing policies. According to the per capita disposable income level of residents in cities and counties (cities) under the jurisdiction of each province, the benefit of serious illness insurance and the population composition of urban and rural residents, the Provincial Department of Human Resources and Social Security shall, jointly with the Provincial Department of Finance, determine the funding standards for serious illness insurance in cities and counties (cities) under the jurisdiction of each province this year.
Article 10 The year of critical illness insurance is a natural year, that is, 10/day to February 1 day.
Chapter III Scope of Protection
Article 11 Hospitalization medical expenses incurred by insured residents within an insurance year (including outpatient medical expenses for chronic diseases and serious diseases [amount], the same below) shall be paid by the basic medical insurance fund for urban and rural residents in accordance with regulations, and the part of eligible medical expenses that individuals have accumulated over the deductible line of serious illness insurance shall be paid by the serious illness insurance fund in accordance with regulations. The self-payment scope of compliance medical expenses for serious illness insurance is determined by the Provincial Department of Human Resources and Social Security in accordance with relevant regulations.
Chapter IV Guarantee Level
Article 12 the deductible line. The deductible line of serious illness insurance is determined with reference to the per capita disposable income level of residents in our province. Insured residents who are hospitalized within an insurance year (including multiple hospitalizations) only pay the deductible of critical illness insurance once.
The critical illness insurance deductible is 6,543,800 yuan+0.5 million yuan.
Article 13 Proportion of installment payment. The proportion of segmented reimbursement of serious illness insurance is determined by considering the income and expenditure of serious illness insurance fund and the medical expenses of urban and rural residents. The medical expenses incurred by insured residents in hospitalization within an insurance year that exceed the deductible shall be paid by the serious illness insurance fund in proportion.
The proportion of reimbursement by installments is: 50% of 6,543.8+0.5 million yuan-50,000 yuan (including 50,000 yuan), 60% of 50,000 yuan-6,543.8+10,000 yuan (including 6,543.8+10,000 yuan), and 70% of 6,543.8+10,000 yuan.
Article 14 Maximum payment limit. The annual maximum payment limit of serious illness insurance is determined with reference to the economic development level of our province and the affordability of serious illness insurance fund.
The maximum compensation limit for serious illness insurance is 400,000 yuan.
Fifteenth major illness insurance deductible, the proportion of segmented reimbursement and the maximum payment limit shall be adjusted by the provincial human resources and social security department in conjunction with the provincial finance department.
Chapter V Medical Treatment and Settlement
Sixteenth serious illness insurance medical services to implement fixed-point management, basic medical insurance designated medical institutions are designated medical institutions for serious illness insurance.
Seventeenth serious illness insurance management according to the relevant provisions of the basic medical insurance.
Article 18 If the medical expenses incurred by insured residents in hospitalization in designated medical institutions exceed the deductible line of serious illness insurance, they shall be settled immediately in designated medical institutions. According to the regulations, the medical expenses that should be borne by individuals shall be settled by themselves and designated medical institutions; Medical expenses that should be paid by the serious illness insurance fund shall be settled by commercial insurance institutions and designated medical institutions according to regulations.
Article 19 If the medical expenses paid by the insured exceed the deductible for hospitalization in a medical institution that does not have the immediate settlement conditions according to the regulations, the insured residents can go through the reimbursement procedures for serious illness insurance at the service outlets designated by the commercial insurance institutions in the insured area.
Chapter VI Business Management
Twentieth provincial human resources and social security departments selected commercial insurance institutions to undertake serious illness insurance in this province through government bidding.
Article 21 The Provincial Department of Human Resources and Social Security shall, in accordance with the relevant provisions, clarify the necessary conditions for commercial insurance institutions to undertake serious illness insurance, adhere to the principles of openness, fairness, impartiality and good faith, establish and improve the bidding mechanism, standardize the bidding procedures, and select commercial insurance institutions to undertake serious illness insurance. It is necessary to introduce a competitive mechanism and choose more than two commercial insurance institutions to undertake serious illness insurance business, and the cooperation period should be no less than 3 years. Start the next round of bidding 6 months before the expiration of the cooperation period.
The annual profit rate of commercial insurance institutions (including operating costs) should be controlled within 3% of the total amount of serious illness insurance funds raised in that year.
Twenty-second provincial human resources and social security departments sign insurance contracts with selected commercial insurance institutions to clarify the responsibilities, rights and obligations of both parties, and the insurance contracts are signed once a year.
Twenty-third selected commercial insurance institutions shall undertake serious illness insurance business in provinces and counties (cities). Provincial human resources and social security departments should formulate rules for the division of service areas and reasonably determine the service areas according to the principle of voluntary consultation.
Twenty-fourth commercial insurance institutions should set up service windows or service outlets in medical insurance agencies at all levels to provide "one-stop" services for the insured, and at the same time do a good job in cost audit, case investigation and intelligent monitoring.
Article 25 Establish and improve the management information system of payment and settlement of serious illness insurance, realize effective docking with the management information system of basic medical insurance, and ensure that the medical expenses of serious illness insurance and basic medical insurance are settled synchronously and immediately in designated medical institutions. Commercial insurance institutions shall reasonably share the operation and maintenance service fees of the medical insurance management information system.
Twenty-sixth provincial human resources and social security departments should establish an evaluation index system with the security level and the satisfaction of the insured as the core, strengthen supervision and inspection, and urge commercial insurance institutions to improve the service quality and level according to the contract requirements.
Article 27 A commercial insurance institution shall disclose to the public the contract signing, financing standard, treatment level, payment process, settlement efficiency and annual income and expenditure of serious illness insurance. Due to breach of contract or other acts that seriously damage the rights and interests of the insured, the contract may be dissolved or terminated in advance as agreed, and the responsibility shall be investigated according to law.
Chapter VII Fund Management
Twenty-eighth serious illness insurance fund to implement special account accounting, earmarking.
Twenty-ninth provincial finance department to set up financial accounts. Commercial insurance institutions set up serious illness insurance fund accounts.
Article 30 The provincial medical insurance agency shall report the use plan of the serious illness insurance fund to the provincial financial department every quarter, and the financial department will directly transfer the serious illness insurance fund from the financial special account to the serious illness insurance fund account of the commercial insurance institution after the audit.
Article 31 Establish a risk adjustment fund system. The provincial finance department draws a certain amount from the serious illness insurance fund as a risk adjustment fund to adjust the policy loss. The scale of the risk adjustment fund is maintained at 5% of the total amount raised by the serious illness insurance fund in that year.
Article 32 When the provincial medical insurance agency liquidates the serious illness insurance fund, if the commercial insurance institution makes a profit in the current year, the balance will be transferred to the provincial financial special account after deducting the prescribed profit rate. If the adjustment of the basic medical insurance policy for urban and rural residents leads to the loss of the serious illness insurance fund in the current year, the commercial insurance institution shall bear the loss within the profit margin, and the rest shall be solved by risk adjustment and raising the financing level for the next year. Non-policy losses shall be borne by commercial insurance institutions.
Thirty-third provincial medical insurance agencies regularly carry out annual liquidation of serious illness insurance of commercial insurance institutions, and settle serious illness insurance expenses with commercial insurance institutions according to regulations.
Thirty-fourth strengthen the management of funds, strengthen supervision and inspection. Provincial human resources and social security departments should establish a serious illness insurance fund operation information disclosure system. Provincial financial departments should strengthen the supervision and inspection of the income and expenditure and management of the serious illness insurance fund. Provincial audit departments should strictly audit the serious illness insurance fund in accordance with their duties.
Chapter VIII Supplementary Provisions
Thirty-fifth the establishment of human resources and social security departments and multi-sectoral cooperation linkage mechanism. Strengthen the convergence of policy formulation, treatment payment and management services. Strengthen the complementary linkage between basic medical insurance, serious illness insurance, supplementary medical insurance for people with serious and serious diseases, medical assistance, emergency medical assistance, commercial health insurance and charitable assistance.
Thirty-sixth approach by the Provincial Department of human resources and social security is responsible for the interpretation of.
Article 37 These Measures shall come into force as of 20071October 2065438+ 1 day. The original serious illness insurance for urban residents and the relevant policies of the new rural cooperative medical system were abolished at the same time.
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