In order to further improve the basic medical security level of rural residents, according to the Regulations on New Rural Cooperative Medical Care in Jiangsu Province, the Measures for the Administration of New Rural Cooperative Medical Care Fund in Jiangsu Province and the Provincial Health Department's Regulations on Standardization and
The Notice on Perfecting the Compensation Scheme of the New Rural Cooperative Medical System requires that the Administrative Measures for the New Rural Cooperative Medical System in Suqian City for 20 12 years (hereinafter referred to as the Measures) be formulated in combination with the actual situation of our city.
I. Basic Principles and Work Objectives
(1) Basic principles: individual contributions, social assistance and government support shall be implemented in fund raising; Fund management in urban areas (including suyu district, Sucheng District) and counties as a whole; The use of the fund is based on income and expenditure, balance of payments, and a slight balance; The operation process is open, fair and just.
(II) Work objectives: The population coverage rate of the new rural cooperative medical system (hereinafter referred to as the new rural cooperative medical system) will reach more than 98% in 20 12, of which the population coverage rate of the recipients will reach100%; Outpatient co-ordination fund accounts for
20% of the total fund raised in that year, and the hospitalization pooling fund accounted for 70% of the total fund raised in that year; The annual balance rate of the fund shall be controlled within 10% (including risk funds), and the cumulative balance rate shall be controlled within 20% (including risk base)
Within gold). The reimbursement rate of hospitalization expenses within the scope of county and township policies reached about 75%.
Second, the participants
Rural residents (including rural primary and secondary school students) participate in the new rural cooperative medical system in the overall planning area where the household registration is located.
Babies and retired soldiers born between the last payment period and the next payment period of the new rural cooperative medical system can participate in the new rural cooperative medical system in the current year according to the normal participation procedures. If the parents apply to participate in the new rural cooperative medical system within fifteen working days from the date of birth, the medical expenses incurred from the date of birth shall be included in the compensation scope of the new rural cooperative medical system fund.
III. Funding criteria
The financing level of the new rural cooperative medical system is about 300 yuan per person per year. Counties (districts) in the fight for the provincial finance to give subsidies to the participating personnel, on the basis of the county (district) finance according to the participating personnel per person per year not less than 240 yuan. Rural minimum living security object, five-guarantee object, key entitled groups and other medical assistance objects are all included in the new rural cooperative medical system by the people's governments in the overall planning area, and their individual contributions are fully funded by the medical assistance fund.
Fourth, medical treatment and referral
(a) all the first-level and above medical institutions in the city, abide by the provisions of the new rural cooperative medical system management, approved by the administrative department of health and signed a service agreement with the joint management office, can be used as the designated medical institutions of the new rural cooperative medical system. Develop the countryside
Village clinics with integrated management of health institutions can carry out outpatient compensation for new rural cooperative medical care. Urban participants can choose their own doctors in all designated medical institutions in urban areas; County participants can be in the county where all designated doctors.
Medical institutions choose their own doctors and need to be referred outside the county. The county-level hospitals put forward opinions on the application for referral, and after the county joint management office has approved it, they will give priority to Suqian People's Hospital of Nanjing Gulou Hospital Group and Suqian Branch of Shanghai Oriental Hospital (special)
Refers to cardiovascular and orthopedic diseases), municipal infectious disease hospital referral.
Participants in urban areas who need to be referred for treatment outside the city must obtain a written certificate from Suqian People's Hospital of Nanjing Gulou Hospital Group, Suqian Branch of Shanghai Oriental Hospital (especially cardiovascular and orthopedic diseases) and Municipal Infectious Disease Hospital, and the referral can only be made after the approval of the Municipal Joint Management Office.
(2) Critical, urgent and severe patients can be referred first, and the formalities will be completed within 15 working days; Referral procedures are valid once, and re-referral is required.
V. Scope and standard of compensation
(a) the new rural cooperative medical system cost compensation is divided into fixed compensation and piecewise proportional compensation.
(two) in the first-class and above medical institutions, the scope of drug use is based on the "Jiangsu Province new rural cooperative medical care essential drugs directory (2009 revision)"; In the village clinic, the scope of medication is based on the national basic drug list.
(3) outpatient compensation standards. Township (town) designated medical institutions outpatient medicine fee according to the proportion of 40% compensation, approved by the administrative department of health village clinics outpatient medicine fee according to the proportion of 45% compensation. countryside
(town) Designated medical institutions per person per day outpatient prescription drug fee limit 100 yuan; The village clinic outpatient prescription drug fee limit is 30 yuan per person per day, and the maximum amount of compensation is 60 yuan per person per year. After the implementation of the basic drug system in village clinics,
In accordance with the regulations, patients are charged the general medical treatment fee of 6 yuan, of which patients pay 1 yuan, and the rest of 5 yuan is paid from the new rural cooperative fund, which is not included in the cumulative maximum compensation per person per year. The general medical expenses are based on the participating population and the village.
The total amount of service is controlled.
Other medical institutions inside and outside the city will not be compensated for outpatient medical expenses.
(4) Compensation standard for hospitalization.
First-class hospitals can report medical expenses for compensation in two stages, with the compensation ratio below 400 yuan being 40% and above 400 yuan being 85%;
Secondary hospitals can report medical expenses for two-stage compensation, the compensation ratio below 400 yuan is 40%, and the compensation ratio above 400 yuan is 70%;
The deductible line of tertiary hospitals in the city is 400 yuan, and the medical expenses can be compensated in two stages. The compensation ratio of 401-20,000 yuan is 50%, and the compensation ratio of more than 20,000 yuan is 60%.
The deductible line of hospitals outside the city is 600 yuan, and the medical expenses can be compensated in two stages. The compensation ratio of 601-20,000 yuan is 45%, and the compensation ratio of more than 20,000 yuan is 55%.
If the participants are hospitalized more than twice in a year, only one deductible line will be set.
Guaranteed compensation is implemented for hospitalization medical expenses. The minimum compensation rate for patients with malignant tumor is 40%, and that for other diseases is 35%. For the participants who go through the referral procedures and go abroad for medical treatment, guaranteed compensation will be taken. For the participants who have not fulfilled the referral procedures, 90% of the normal referral compensation standard will be implemented.
(five) outpatient special disease compensation standard. The outpatient medical expenses such as radiotherapy and chemotherapy for malignant tumor, dialysis treatment for end-stage renal disease, anti-rejection treatment for organ transplantation, aplastic anemia and hemophilia shall be 75%.
Compensation, the maximum limit of 40 thousand yuan per person per year; Chronic hepatitis B complicated with cirrhosis, nephrotic syndrome, systemic lupus erythematosus, Parkinson's disease and other outpatient medical and treatment expenses will be compensated according to the proportion of 75%, per person per year.
The maximum amount is 20,000 yuan. The expenses of outpatient special diseases of participating personnel shall be compensated according to the patient's medical records and actual expenses issued by secondary and above medical institutions.
The outpatient treatment expenses of insulin-dependent diabetes, stage III hypertension, sequelae of stroke, severe psychosis and other diseases shall be compensated according to the proportion of 75%, and the annual compensation limit for each person is 2000 yuan. Outpatient special disease expenses are compensated according to the patient's medical records and actual expenses issued by medical institutions at or above the first level.
If the above special outpatient diseases are treated in outpatient clinics of medical institutions at corresponding levels outside the city, they will be compensated according to 90% of the above compensation standards.
(six) the implementation of price management of maternity hospital delivery costs in medical institutions. Namely: 800 yuan, the first-level hospital for normal delivery, 900 yuan, the first-level hospital for vaginal surgery and midwifery 1250 yuan, and the second-level hospital 1500 yuan; 2,000 yuan for a first-class hospital and 2,450 yuan for a second-class hospital. The part exceeding the price limit shall be borne by the designated medical institutions.
In line with the family planning policy of rural pregnant women in hospital delivery, in accordance with the new rural cooperative medical system in hospital compensation standard subsection compensation, insufficient in 400 yuan according to 400 yuan. The total compensation cost of the new rural cooperative medical system and the financial subsidy for hospital delivery shall not exceed the actual expenses. Prenatal screening compensates 40 yuan for each case.
(7) Compensation standards for infectious diseases. Infectious diseases are treated centrally and hospitalization is encouraged. Infectious patients in urban areas are treated by the municipal infectious disease prevention and control center, and infectious patients in Shuyang, Siyang and Sihong counties are treated by the county health center.
Two medical institutions designated by the health administrative department 1-2 were treated in a unified and centralized manner, and the outpatient reimbursable expenses were compensated according to the proportion of 50%, and the hospitalization reimbursable expenses were compensated according to the proportion of 80%. Infectious diseases in other medical institutions
Hospital expenses will not be compensated.
(eight) to encourage the use of traditional Chinese medicine treatment. The use of traditional Chinese medicine treatment, outpatient and hospitalization expenses according to the "measures" compensation standards, the patient's use of Chinese herbal medicine costs to compensate 30%. Traction, acupuncture and other treatment items are compensated.
(9) The provincial human resources and social security department, the provincial civil affairs department and other five departments "issued the notice of Jiangsu Province on the implementation measures for including some rehabilitation projects into the scope of basic medical security" (Su Ren She Fa [2010] No.479) stipulated that some medical rehabilitation projects, rescue rehabilitation and assistive devices for disabled children aged 0-6 years were included in the scope of hospitalization compensation.
(ten) the full implementation of the reform of payment methods such as payment by disease, and the number of diseases paid by secondary and above medical institutions should reach more than 20.
We will comprehensively promote the protection of eight major diseases, including childhood leukemia, congenital heart disease, end-stage renal disease, women's breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, and opportunistic infection of AIDS, and continuously improve the level of protection. Hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, rectal cancer and other 12 diseases will be included in the pilot scope of major disease protection for rural residents.
(eleven) trauma patients according to the compensation standard of 70% compensation.
(twelve) compensation cap line. The annual cumulative compensation limit for the expenses of the new rural cooperative medical system is140,000 yuan per person, including hospitalization expenses100,000 yuan and outpatient expenses of 40,000 yuan.
(13) Compensation time. In principle, the compensation for the new rural cooperative medical system is completed within a natural year, and the inter-annual compensation for special circumstances does not exceed 6 months.
Six, no compensation scope
The following expenses do not belong to the compensation scope of the new rural cooperative medical fund:
(a) the expenses incurred by the participants in using drugs outside the catalogue shall not be compensated. Designated medical institutions should control the proportion of drug expenses outside the catalogue used by participants. Village clinics must all use medicines in the catalogue.
Products, the cost of using drugs out of the catalogue in first-class medical institutions shall not exceed 5%, the cost of using drugs out of the catalogue in second-class medical institutions shall not exceed 10%, and the cost of using drugs out of the catalogue in third-class medical institutions shall not exceed 15%. Designated medical machine
The construction and use of drugs outside the catalogue must be informed in advance and signed by the participants or immediate family members.
(two) the expenses that should be paid by the industrial injury or maternity insurance fund according to the regulations; Expenses to be paid by medical insurance for urban workers and residents; Expenses to be borne by a third party; Expenses to be borne by public health; Expenses for overseas medical treatment.
(three) the expenses of non-basic medical care (mainly refers to higher wards, special wards, special care, family beds, etc.) in medical institutions at all levels.
(four) the medical service, examination and treatment projects of medical institutions without the approval of the price and health departments, and the expenses incurred by raising the charging standards without authorization.
(five) fighting, alcoholism, drug abuse, sexually transmitted diseases, traffic accidents, intentional self-injury, unproductive pesticide poisoning, medical accidents (disputes), family planning costs.
(VI) Registration fee, medical record fee, house call fee, additional fee for name-calling operation, Chinese medicine decoction fee, medical travel fee, ambulance fee, accompanying bed fee, bed wrapping fee, consultation fee, food (nutrition) fee, daily necessities fee, certificate fee, health care file bag fee, stretcher fee, air conditioning (including heating) fee, TV fee, telephone fee, and personal life cooking fee.
(seven) all kinds of weight loss, bodybuilding and treatment of freckles, pigmentation, white hair and medical beauty expenses; Rhinoplasty, breast augmentation, double eyelid surgery, nevus removal, ear piercing, verruca plana, dental inlay, tooth cleaning, dentition correction and treatment.
Stained teeth, glasses, myopia treatment, and the cost of assembling artificial eyes, wigs and artificial limbs; Expenses for using traction equipment, crutches, leather steel carapace, waistline, deformed insole, medicated pad, medicated pillow and cold and hot compress bag; Massage, magnetic therapy,
The cost of hyperthermia (except for tumor patients).
(eight) all kinds of medical consultation, medical appraisal and health prediction fees, commercial medical insurance fees, physical therapy fees, male and female infertility, sexual dysfunction examination and treatment fees.
(nine) the nominal hospitalization or hospitalization expenses that obviously do not meet the hospitalization conditions; Living in a super-standard ward, which exceeds the cost of ordinary beds.
(ten) the cost of transplanting all kinds of organs or tissues, installing artificial organs and placing materials in the body during the treatment.
(eleven) other circumstances in which no compensation is provided by the state or province.
VII. Compensation Measures
(a) participants need to provide the new rural cooperative medical certificate (card) for outpatient treatment in designated medical institutions in the city, the original and photocopy of the new rural cooperative medical certificate (card) and ID card for hospitalization, and the outpatient medicine fee and hospitalization fee shall be reported on the spot.
(II) The hospitalization expenses incurred by the participants outside the city, and the materials of the participants in Shuyang County, Siyang County and Sihong County shall be reviewed by the county joint management office and the compensation procedures shall be handled; The materials of urban participants shall be reviewed by the municipal joint management office and the compensation procedures shall be handled.
1.Participants should provide the following information when applying for compensation: the new rural cooperative medical certificate (card); Original and photocopy of ID card; City and county joint management office agreed to referral approval form; Valid bills (original) issued by the hospital, computer-printed hospitalization expense settlement list and discharge summary.
2. Participants who go out to work or live outside the city for a long time should provide the following information when applying for compensation for medical treatment abroad: the new rural cooperative medical certificate (card); Original and photocopy of ID card; Proof of the village (neighborhood) committee or work unit with long-term residence; Valid bills (original) issued by the hospital, computer-printed hospitalization expense settlement list and discharge summary.
(III) The township (town) joint management office of Shuyang County, Siyang County and Sihong County shall publicize the compensation for medical expenses in township (town) hospitals and village clinics on a monthly basis. Designated medical institutions in urban areas are responsible for publicizing the compensation for hospitalization of urban participants on a monthly basis.
VIII. Fund Raising, Management and Supervision
(a) Shuyang County, Siyang County, Sihong County, urban new rural cooperative fund into the financial new rural cooperative fund account management, earmarking, the balance transferred to the next year to continue to use.
(two) the township (town) people's government is responsible for raising the fees paid by individual farmers, the county (District) finance and health departments are responsible for striving for provincial funds, and the county (District) finance department is responsible for implementing financial matching funds. County finance
Department is responsible for the new rural cooperative medical fund included in the county new rural cooperative medical account, and the financial departments of suyu district, Sucheng District and Yanghe New Town are responsible for the new rural cooperative medical fund included in the new rural cooperative medical account. The audit department is responsible for the management and use of the new rural cooperative fund on a regular basis.
Conduct a special audit.
(III) The handling institution shall, in accordance with the provisions of the state, withdraw risk funds from the new rural cooperative medical fund to make up for the temporary difficulties in fund turnover caused by abnormal overspending of the new rural cooperative medical fund, and the accumulated risk funds withdrawn shall not exceed 10% of the total fund raised in that year.
(4) In the process of fund raising, it is strictly forbidden to collect fees for hitchhiking, to change the fund-raising standard without authorization, to advance funds for those who have not participated, to avoid discrepancies between accounts and facts, and to intercept, occupy or misappropriate funds.
(5) Designated medical institutions shall pay the service performance bond to the local city and county joint management office, and the city and county joint management office shall deduct the deposit for the violations of designated medical institutions in accordance with the service agreement, and the deducted deposit shall be used for the normal operating expenses of the city and county joint management office.
(VI) Designated medical institutions and their staff shall provide medical services in accordance with the requirements of the agreement, abide by laws and regulations, abide by professional ethics, implement clinical technical operation norms, carry out business training, improve service quality and efficiency, and achieve reasonable examination and treatment, rational drug use, and control medical expenses.
(seven) designated medical institutions to falsify documents and other means to defraud the new rural cooperative medical fund fees, the administrative department of health shall order it to return the defrauded fund fees, and impose a fine of more than two times and less than five times the amount defrauded.
Paragraph, the agency shall terminate the new rural cooperative medical service agreement with it; If the directly responsible person in charge and other directly responsible personnel are qualified to practice, the administrative department of health shall revoke their practice certificates according to law.
(eight) by forging proof materials, using other people's new rural cooperative medical certificate and other means to defraud the new rural cooperative medical fund fees, the administrative department of health shall order it to return the compensation fees defrauded, and impose a fine of more than two times and less than five times the amount defrauded. If the case constitutes a crime, it shall be handed over to judicial organs for handling.
IX. Supplementary Provisions
(1) The Measures shall be implemented as of the date of issuance. "Suqian 20 10 new rural cooperative medical management measures" shall be abolished at the same time. If the relevant provisions of the new rural cooperative medical system are inconsistent with these Measures, these Measures shall prevail.
(two) the "measures" by the Municipal Health Bureau is responsible for the interpretation of.
Key words: notice of measures for the administration of health and rural cooperative medical care △
Cc: the offices of ministries and commissions of the Municipal Party Committee, the Office of the Standing Committee of the Municipal People's Congress and the Office of the CPPCC,
City Court, City Procuratorate, Suqian Military Division.
Suqian Municipal People's Government Office issued on July 20 12 19.
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