* * * Detailed Rules for the Implementation of Economic Security Mechanism

Chapter I General Principles

Article 1 In order to further improve the basic medical insurance system for employees (hereinafter referred to as employee medical insurance), optimize the use structure of medical insurance funds, improve the use efficiency of medical insurance funds, and better solve the problem of outpatient insurance for insured persons, According to the Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients (Guo Ban Fa [202 1] 14) and the Notice of the General Office of Shandong Provincial People's Government on Printing and Distributing the Implementation Plan for Establishing and Perfecting the Economic Security Mechanism for Employees' Basic Medical Insurance Outpatients in Shandong Province (Lu Zhengban Fa [202 1

Second, adhere to the responsibility of ensuring basic and mutual aid, and earnestly safeguard the rights and interests of insured workers; Adhere to a smooth transition and properly handle the policy convergence before and after the reform; Adhere to collaborative linkage, establish a general outpatient medical insurance system for employees, reform personal accounts simultaneously, and optimize the internal structure of the fund; Adhere to local conditions, proceed from reality, actively explore effective ways to enhance the outpatient medical insurance for employees, scientifically formulate the payment policy for the general outpatient treatment of employees, steadily improve the level of outpatient medical insurance, and promote a fairer and more sustainable medical insurance system.

Article 3 The medical insurance department shall take the lead in establishing and improving the economic security mechanism for medical insurance outpatient service for employees; The financial department shall cooperate with the supervision and management of the medical insurance fund; The tax authorities should do a good job in the collection of medical insurance premiums; The health department strengthens the supervision and assessment of medical institutions and promotes the standardized diagnosis and treatment behavior of designated medical institutions; Market supervision departments should strengthen supervision over the circulation and use of drugs and severely crack down on illegal activities such as purchasing drugs through illegal channels.

Chapter II Medical Insurance for General Outpatient Workers

Fourth, establish a general outpatient service guarantee mechanism. From June, 5438 to February, 2022, the general outpatient medical insurance system for employees will be established in an all-round way, policies will be improved, management measures will be standardized, and the medical needs of general outpatients will be guaranteed fairly and universally. Combined with the implementation of the province's unified medical security treatment list system, to ensure that the city-wide general outpatient security system is unified in the security content and treatment payment, and to do a good job in the convergence of outpatient chronic diseases and hospitalization payment policies.

Fifth, determine the payment policy for general outpatient treatment of employee medical insurance. Scientifically set the unified annual Qifubiaozhun, payment ratio and maximum payment limit of outpatient co-ordination fund in the city, set differentiated Qifubiaozhun and payment ratio for designated medical institutions at different levels, and appropriately tilt to primary medical institutions to promote graded diagnosis and treatment.

(1) Qifubiaozhun. In a natural year, the Qifubiaozhun for general outpatient medical insurance for employees is calculated cumulatively in that year. The Qifubiaozhun for first-class and below (including village clinics and community health service stations under integrated management, the same below), second-class and third-class designated medical institutions are 200 yuan, 400 yuan and 800 yuan respectively. Insured persons seek medical treatment in outpatient clinics of designated medical institutions at the first and lower levels, at the second and third levels. The qifubiaozhun for general outpatient service of employee medical insurance is calculated according to the cumulative makeup.

(2) payment ratio. The medical expenses within the scope of the general outpatient policy of the insured, the above part of the Qifubiaozhun, and the proportion paid by the employees of the first-level and lower, second-level and third-level designated medical institutions from the overall fund are 70%, 60% and 50% respectively; The payment ratio of retired workers in designated medical institutions at level 1 and below, level 2 and level 3 is 75%, 65% and 55% respectively.

(3) the maximum payment limit. In a natural year, the maximum payment limit of the medical insurance pooling fund for the general outpatient medical expenses incurred by the insured employees within the policy scope is 1500 yuan. The payment limit is not carried forward or accumulated to the next year.

Article 6 The general outpatient service security policy covers all employees who participate in the medical insurance of our city and enjoy normal treatment (including retirees and flexible employees). The expenses incurred by the insured in the outpatient service of all designated medical institutions in this Municipality within the policy scope may be paid with reference to these provisions. The insured persons who seek medical treatment in different places will be included in the scope of general outpatient service, and long-term residents in different places will be treated according to these rules; For those who go out for medical treatment temporarily, the individual shall pay 10% first, and then pay according to the prescribed proportion.

Chapter III Management of Personal Account Use

Seventh, improve the personal account of employee medical insurance. The adjustment of personal account charging method is implemented simultaneously with the establishment of outpatient service guarantee mechanism. Continue to keep personal accounts, and the historical balance of personal accounts is still owned by the insured.

(a) adjust the personal account of the basic medical insurance for employees. From June 5438 to February 2022, the basic medical insurance premium paid by the unit was reduced to 50% of the current standard, that is, 2.25% of the individual contribution base was included in the personal account. From June 5438+ 10, 2024, the basic medical insurance premiums paid by employees will no longer be included in individual accounts, but will all be included in the overall fund. The basic medical insurance premiums paid by employees are all included in personal accounts, and the standard is 2% of my base payment.

(two) adjust the personal account of the basic medical insurance for retirees included in these measures.

1. Retirees who are normally insured by the unit. From June 5438+ 10, 2024, the individual accounts of retirees will be allocated by the overall fund according to the quota, and retirees under the age of 70 will be allocated by 2% of the average basic pension in 2023, and retirees over the age of 70 will be allocated by 2.5% of the average basic pension in 2023.

2. Retirees who are insured by flexible employees. From June 5438+ 10, 2023, flexible employees who are eligible for medical insurance retirement benefits (including other retirees who are eligible for medical insurance retirement benefits and have not established personal medical insurance accounts) will establish individual medical insurance accounts for employees, which will be allocated by the overall fund according to the quota. Retirees under 70 years old will be included in 2% of the city's average basic pension in 2022, and retirees over 70 years old will be included in 2.5% of the city's average basic pension in 2022. From June 5438+ 10, 2024, the inclusion criteria are consistent with the retirees who are normally insured by the unit.

3. On-the-job retired workers shall be included in their personal accounts according to the standards of retirees from the month when they enjoy retirement medical insurance benefits.

(three) adjustment of civil servants Medicaid personal accounts included in the method. From June 5438+0, 2023, the medical assistance part of the on-the-job and retired civil servants' personal accounts will be included in the quota, and the standard is 2.5% of the personal contribution base (pension) in February 2022. Before and after graduation, the newly hired personnel will be included in the quota according to 2.5% of their first month's probation salary; New retirees are included in the amount of 2.5% of the pension for the first month after retirement. According to the civil service Medicaid fund income and expenditure situation timely adjustment.

Eighth regulate the use of personal accounts. Personal account funds are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions. It can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, the expenses incurred in purchasing medicines, medical devices and medical consumables in designated retail pharmacies, and the personal contributions of participating in basic medical insurance for urban and rural residents, long-term care insurance and government-guided inclusive commercial medical insurance. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance.

Article 9 Individual account funds can be carried forward and inherited. Except for trans-regional relationship transfer, resettlement in different places, settlement abroad and death, individual accounts of employees' basic medical insurance shall not be cashed out or cashed out in disguised form.

Chapter IV Cohesion of Relevant Systems

Tenth standardize and improve the basic medical insurance payment policy for employees. The employer shall pay 7% of the payment base (excluding maternity insurance), and the individual shall pay 2% of the payment base; From June 5438+ 10, 2023, individual industrial and commercial households without employees, part-time employees who have not participated in employee medical insurance in the employer and other flexible employees will pay 7% of the payment base (excluding maternity insurance), and no personal medical insurance account will be established during their employment.

Eleventh unified medical insurance payment scope. The basic medical insurance general outpatient service guarantees the implementation of a unified medical insurance drug catalogue, diagnosis and treatment catalogue, medical consumables catalogue and medical service facilities scope catalogue. The general outpatient medical expenses incurred during the hospitalization period of the insured workers and during the period of enjoying the long-term care insurance medical preferential treatment are not included in the scope of payment of the general outpatient co-ordination fund; Enjoy the general outpatient medical expenses during the long-term care and home care treatment of insurance institutions, and include them in the payment scope of the general outpatient co-ordination fund. You can enjoy the general outpatient medical insurance benefits and the outpatient medical insurance benefits for chronic diseases and special diseases at the same time.

Twelfth standardize outpatient chronic diseases and medical insurance policies. According to the relevant provisions of the province, unify the name and identification standard of basic diseases in the city. For some chronic diseases and special diseases, according to the fund bearing capacity and the level of general outpatient support, the transition from disease support to cost support is realized through the conversion of outpatient support mechanism.

Thirteenth broaden the channels of outpatient drug use security. Support the external prescription adjustment and settlement of designated retail pharmacies, gradually bring the drug security services provided by qualified designated retail pharmacies into the scope of outpatient security, implement a unified outpatient payment policy with designated medical institutions, and combine the annual Qifubiaozhun and the annual maximum payment limit with designated medical institutions.

Fourteenth to encourage "internet plus" medical services. Explore the inclusion of qualified "internet plus" medical services in the scope of medical insurance payment, and open up online medical insurance payment channels for the follow-up of chronic diseases and special diseases through the media of medical insurance electronic certificate, so as to realize online registration, online follow-up, online prescription dressing change, prescription circulation, medical insurance payment, drug distribution and other service functions.

Fifteenth improve the information management of medical insurance. Establish a unified outpatient information system in the city to realize the interconnection and resource sharing between medical insurance agencies and designated medical institutions. Designated medical institutions should establish information uploading systems such as prescriptions and strengthen the daily audit and supervision of outpatient expenses. The outpatient expenses incurred by the insured in the designated medical institutions shall be settled online in real time, and the insured shall only pay the personal burden, and the rest shall be settled by the medical insurance agency and the designated medical institutions.

Sixteenth improve the payment method of medical expenses settlement. Incorporate outpatient medical services into the agreement management of medical institutions designated by medical insurance, and establish a statistical analysis system for outpatient expenses. Promote the reform of outpatient payment methods. For general outpatient clinics and outpatient clinics with chronic diseases and special diseases, composite payment methods such as paying by head and paying by disease type can be implemented.

Seventeenth do a good job in the convergence of family doctor contract service and general outpatient service, outpatient chronic disease and special disease management measures, guide the insured to the primary medical treatment for the first time, and promote the improvement of the primary medical and health service system.

Eighteenth clear inpatient emergency payment policy. The outpatient and emergency expenses within the scope of the policy before hospitalization of the insured shall be paid according to the general outpatient co-ordination policy; In the emergency rescue invalid death, the medical expenses within the scope of its policy according to a hospitalization reimbursement.

Chapter V Supervision and Administration

Nineteenth improve the supervision and management mechanism. Establish and improve the fund management system and audit and inspection mechanism suitable for outpatient economic security, and implement the main responsibility of designated medical institutions. Designated medical institutions shall strictly abide by the basic medical insurance and medical and health laws, regulations and policies, implement real-name registration system registered medical treatment, strictly control the indications, treat diseases, make reasonable diagnosis and treatment, and actively publicize medical insurance policies and regulations. Seriously investigate and deal with illegal acts and problems such as over-diagnosis and treatment in outpatient service, irrational drug use, and defrauding medical insurance funds by using employees' personal medical insurance accounts and reimbursement quotas in general outpatient service to ensure the safe, efficient and rational use of funds. Improve the monitoring and analysis mechanism of outpatient medical services, and guide designated medical institutions to standardize the provision of medical services.

Twentieth strict implementation of medical insurance fund revenue and expenditure management, strengthen the use of personal accounts, settlement and other aspects of the audit, do a good job in revenue and expenditure information statistics. Improve the intelligent monitoring platform for intra-provincial and inter-provincial settlement of personal accounts, the dynamic maintenance mechanism, normalization inspection mechanism and emergency response mechanism of designated medical institutions with "one card bank". Improve the monitoring and analysis mechanism of outpatient medical services, and guide designated medical institutions to standardize the provision of medical services.

Chapter VI Supplementary Provisions

Twenty-first Municipal Medical Insurance Bureau and Municipal Finance Bureau can adjust the standard of outpatient care according to the superior deployment and the ability of medical insurance fund to pay.

Twenty-second the detailed rules for the implementation by the medical insurance bureau City is responsible for the interpretation of.