Compared with 2020, what changes have taken place in the focus of medical insurance management in 2021?

At the end of February 2021, the Medical Security Management Center of the National Medical Security Administration (hereinafter referred to as the "National Medical Insurance Center") issued the "Key Points of Medical Security Handling and Management Services in 2021" (hereinafter referred to as "Key Points of Work in 2021"), which clarified The overall requirements and specific work priorities of medical security handling management services in 2021.

1.

(1) Epidemic prevention and control medical insurance management work: from "optimizing services" to "special affairs and special handling.

The main points of work in 2020 and 2021 emphasize the importance of putting people's life safety and health first, and doing a good job in epidemic prevention and control medical insurance management.

(2) Medical insurance system style construction: from "comprehensive" to "in-depth".

The main points of work in 2020 and 2021 have emphasized the implementation of the requirements for the construction and deployment of the medical security system, and the full implementation of the "good and bad" system.

2.

(1) Medical insurance fund supervision: from "special governance" to "daily management".

Strengthening the management of the medical insurance fund is an important task for the medical insurance management in 2020.

In 2021, the daily management of the medical insurance fund will continue to be strengthened.

(2) Agreement management between the two designated institutions: implement the management measures for the two designated institutions.

The management methods of the two institutions are the latest summary and concrete manifestation of the practical experience in the management of medical insurance agreements.

At the beginning of 2020, the two-designated institution management measures were publicly solicited for comments, and the official draft was released at the end of December.

(3) Medical insurance payment reform: Promote pilot work related to DRG and DIP.

In 2020, the National Medical Insurance Administration will carry out DRG-paying national pilot work in 30 cities.

3.
Comprehensively optimize medical security services

(1) Construction of the management service system: from "establishment" to "improvement".

2020 is the process of comprehensively launching the construction of the medical insurance management system at all levels, from "none" to "existence".
With the basic formation of the national medical insurance management system and the continuous improvement of related guarantee mechanisms, the construction of this year's management service system will continue to develop in a more unified and sinking direction, and strive to build a national unity covering provinces, cities, and counties.
, Township (street), village (community) service network.
At the same time, continue to strengthen the construction of the handling team, carry out the promotion of refined management service cases, build a medical insurance public service brand, and enhance the sense of responsibility, mission and honor of the handling team.

(2) Standardization and standardization of handling services: deeper and more innovative.

In 2020, the medical insurance handling service system has not yet been established, and the standardization of handling services is in its infancy.
2021 is a year of comprehensive and in-depth standardization.
First, the "National Medical Security Management Government Service Items List" released in May 2020 provides a clear direction for the standardization and standardization of management services.
This year, the government service items operation specifications will be formulated; second, special demonstration projects will be launched to develop The establishment of medical insurance management halls and service standards, and the construction of standardized windows and demonstration sites; third, steadily promote the construction of the national medical insurance service hotline center; in addition, for the first time, innovative service delivery methods are proposed to encourage and support social forces to participate in medical insurance management services.

(3) Participation management: from "checking for omissions and filling vacancies" to "improving and optimizing.
"

The focus of the insurance management work in 2020 is mainly to clean up duplicate insurance, and to do a good job in the transfer of fund collection and collection management responsibilities.
On this basis, in 2021, we will establish and improve the insurance participation database covering the whole people, and maintain the overall stability of the insurance participation rate; improve the payment methods for flexible employees to participate in the insurance, promote convenient and convenient participation in the vicinity; optimize the insurance payment service, and adhere to the online and online Combine the following to explore a convenient, efficient and effective way to participate in insurance.

4.
Promote the "cross-provincial administration" of high-frequency medical insurance services

In 2020, the “Cross-provincial General Administration” of medical insurance services is mainly carried out around the direct settlement of medical treatment in different places.
On the basis of further improving the standardization, it is basically realized that eligible patients of inter-provincial and remote medical treatment can be directly settled in all designated hospitals in hospitals.
Direct settlement of outpatient expenses for medical treatment in different places in regional integration areas.
In 2021, it will be further improved on this basis, mainly including: First, formulate a unified national cross-provincial direct settlement management method for medical treatment in different places, and establish a collaborative management work mechanism; Second, all coordinated areas will rely on the national medical insurance service platform to realize online filing services.
We will expand the pilot program of self-service direct settlement for medical treatment in different places in a timely manner; the third is to basically realize direct settlement of ordinary outpatient expenses across provinces nationwide.

In addition, with regard to the "cross-provincial administration" of other matters, rules and standards will be unified, the level of informatization will be improved, and data sharing will be strengthened.
Before the end of the year, the "cross-provincial administration" of changes in insurance information, registration of resident medical insurance participation, transfer and continuation of basic medical insurance relationships, and basic information changes in medical insurance designated medical institutions will be basically realized.

Fifth, coordinate the implementation of key medical insurance work

(1) Medical insurance for poverty alleviation: further consolidate the results.

In 2020, our country has completed the mission of poverty alleviation in the new era as scheduled.
The medical insurance agency is mainly responsible for improving the poor population’s insurance enrollment account, doing a good job in the dynamic verification of information with the poverty alleviation department, and grasping the real-time insurance policy for the newly added poor population; implementing the basic medical insurance, critical illness insurance, and medical assistance in the city’s “one-stop shop” "Real-time settlement, do a good job of data collection, filling, and maintenance, dynamically monitor the progress of medical insurance and poverty alleviation in the jurisdiction; do a good job in ensuring the outpatient use of "two diseases" for urban and rural residents.
This year, the medical insurance management office will further cooperate to consolidate and expand the achievements of medical insurance in poverty alleviation, implement the three-tier system comprehensive guarantee, "one-stop" settlement and other policies in accordance with the regulations; at the same time, effectively link the rural revitalization strategy and do a good job in transitional policy continuation.

(2) National medicine policy: coordinate and promote implementation.

In 2020, the National Medical Insurance Bureau made a comprehensive adjustment to the basic medical insurance drug catalog, and ensuring the implementation of the new version of the catalog has become one of the key tasks in 2021.
In addition, it will also study the addition of functional modules of the catalog adjustment information system, strengthen the construction of the backbone of drug negotiations and fund calculations, and lay a solid foundation for the future "dynamic adjustment of the national medical insurance drug catalog" and "every advance must be discussed".

In addition, on the basis of the state-organized central drug procurement related handling and supporting work in 2020, in 2021, the focus will be on the connection of medical insurance payment and the selected price, and the policy of retaining the balance of medical insurance funds will be implemented.

(3) Mutual assistance in staff medical insurance clinics: coordinated advancement.

At this year’s National Medical Security Work Conference, it is clearly necessary to establish and improve an outpatient mutual aid guarantee mechanism for basic medical insurance for employees, and relevant policy documents will also be formally issued this year.
Medical insurance agencies should also coordinate relevant work to ensure the smooth implementation of policies and measures.
For example, in combination with the reform of the head-to-head payment method, budget management, agreement management and other tools are used to help promote the establishment of general outpatient medical insurance for employees, improve employee medical insurance personal accounts, standardize the use of personal accounts, and strengthen supervision and management.