Major reform of medical insurance outpatient reimbursement! The medical insurance outpatient expenses of employees shall be included in the reimbursement.

Guide: On August 26, 2020, the State Health Insurance Administration issued the Guidance on establishing and improving the mechanism for the protection of basic medical insurance outpatients for workers (draft for comments), and publicly solicited opinions from the community.
26, 2020, the State Administration of Health Insurance issued the Guidance on establishing and improving the mechanism for the protection of basic medical insurance outpatient co-care for workers (draft for comments) and publicly solicited opinions from the public.
opinions proposed to provide that the general outpatient co-ordination covers all staff medical insurance insured personnel, the proportion of payment from 50%.
request to improve the way individual accounts are credited.
In principle, the standard for the accounting of active employees shall be controlled within 2% of the contribution base of my insured contributions, and all the basic medical insurance fees paid by the unit shall be included in the co-ordination fund;
In addition, personal accounts may be used to cover the medical expenses borne by individuals in medical institutions where employees themselves and their spouses, parents and children seek medical treatment in designated medical institutions for medical insurance, as well as the expenses borne by individuals in the purchase of medicines and medical supplies at designated retail pharmacies.
Guidance on establishing and perfecting the mechanism of medical insurance outpatient co-assistance for workers (draft for comments) For the further improvement of the universal medical insurance system of mutual assistance and shared responsibility, to better solve the problem of outpatient medical insurance for workers (hereinafter referred to as "employee medical insurance"), to effectively reduce the burden of medical expenses of workers, in accordance with the central deepening of the reform of the medical security system related tasks, the following views are put forward.
, guiding ideology and basic principles (i) guiding ideology.
Guided by Xi Jinping's thoughts on socialism with Chinese characteristics in the new era, we will fully implement the spirit of the 19th National Congress of the Communist Party of China and the Second, Third and Fourth Plenary Sessions of the 19th Central Committee of the Communist Party of China, do our best and do our best, adhere to the principle of due diligence for all, enjoy everyone, improve the system, guide expectations and speed up Reform of the key areas and key links of basic medical insurance, through the inclusion of outpatient medical expenses in the scope of payment of the basic medical insurance co-ordination fund, reform of the individual accounts of basic medical insurance for employees, and the establishment and improvement of the mechanism for the protection of outpatient assistance, improve the efficiency of the use of the medical insurance fund, gradually reduce the burden of medical expenses of insured personnel, and achieve a more equitable and sustainable system.
(ii) basic principles.
the basic protection, carry out overall co-ordination and help, and effectively safeguard the rights and interests of the insured personnel.
maintain a smooth transition, maintain policy continuity and achieve a smooth convergence of treatment before and after the reform.
to coordinate the linkage, to improve the personal account system and improve the outpatient guarantee mechanism to promote and gradually transform.
adhere to local conditions, on the basis of the overall design, from the practical point of view, classification of measures to encourage local actively explore effective ways to enhance the health insurance outpatient protection of workers.
, the main measures and content (i) to enhance the function of outpatient co-care protection.
to establish and improve the general out-patient medical expenses co-ordination guarantee mechanism, starting with high blood pressure, diabetes and other people's heavy burden of outpatient chronic diseases, and gradually the incidence of frequent, common diseases of general out-patient medical expenses into the scope of co-ordination fund payment.
general outpatient co-ordination covers all employees of health insurance insured personnel, the proportion of payment from 50%, with the fund to enhance the affordability of gradually improve the level of protection, treatment payment can be appropriately tilted towards retirees.
for the characteristics of outpatient medical services, scientific measurement of the starting standard and maximum payment limit, and do a good job with the hospital payment policy.
According to the fund's affordability, localities can explore the gradual expansion of the scope of outpatient chronic diseases paid for by the co-ordination fund, and include some of the outpatient chronic diseases and special diseases with long treatment cycles, great health damage and heavy economic burden into the scope of payment of the co-ordination fund.
of special treatment that needs to be carried out in outpatient clinics and is more economical than inpatient treatment can be managed by reference to inpatient treatment.
with the gradual improvement of the outpatient co-care guarantee mechanism, explore the transition from disease protection to cost protection.
(ii) improve the method of accounting for individual accounts.
Scientifically and reasonably determine the method and level of accounting for individual accounts, the basic medical insurance premiums paid by individual employees shall be included, the standard shall be controlled in principle within 2% of the contribution base of my participation in insurance, and all the basic medical insurance fees paid by the unit shall be included in the co-ordination fund;
individual accounts are specifically to the proportion or standard, the provincial health insurance departments in accordance with the above principles, guide the overall planning of the region combined with local reality, the overall study to determine.
to reduce the amount of funds allocated to individual accounts after adjusting the overall account structure is mainly used to support the sound protection of outpatient assistance and improve the treatment of outpatients.
(iii) regulate the scope of use of personal accounts.
accounts are mainly used to pay out-of-pocket expenses of insured employees within the policy of a fixed-point medical institution or a fixed-point retail pharmacy.
may be used to cover the medical expenses borne by individuals in medical institutions designated for medical insurance for employees themselves and their spouses, parents and children, as well as the expenses borne by individuals in the purchase of medicines and medical supplies at designated retail pharmacies.
to explore individual contributions for spouses, parents and children to participate in basic medical insurance for urban and rural residents.
personal account shall not be used for other expenses such as public health expenses, sports fitness or health care consumption that are not covered by basic medical insurance.
improve and improve the use of personal account management methods, do a good job of income and expenditure information statistics.
(iv) strengthen supervision and management.
improve management service measures, innovate the operating mechanism of the system, guide the rational utilization of medical resources, and ensure the stable operation of the medical insurance fund and the effect of system guarantee.
strict implementation of the fund budget management system, strengthen the fund audit system, internal control of the construction.
establish a dynamic management mechanism for the whole process of individual accounts, strengthen the use of personal accounts, settlement and other aspects of the audit.
strengthen the supervision of outpatient medical behavior and medical expenses, establish a fund security prevention and control mechanism, crack down on fraud and insurance fraud, and ensure the safe, efficient and rational use of the fund.
innovative management methods for outpatient medical services, improve the monitoring, analysis and assessment system of medical services, and guide medical institutions to control the cost of medical services.
to speed up the construction of information technology in accordance with the requirements of the construction of a unified medical insurance information platform, and explore the way to realize the settlement of outpatient medical treatment in different places.
to promote the construction of primary health care system, improve the family doctor contract service, long-term prescription system, etc., to guide the insured personnel to seek medical treatment at the grass-roots level for the first time.
improve the management measures of outpatient chronic diseases and special diseases, and standardize the diagnosis and treatment and referral of primary medical institutions.
(v) improve the payment mechanism suitable for the characteristics of outpatient care.
Primary health care services can be paid per head, actively explore the combination of pay-per-head and chronic disease management, day surgery and eligible outpatient special diseases, the implementation of by disease and disease diagnosis-related sub-groups, not suitable for packaging and payment of outpatient fees, can be paid by project.
to speed up the development of medical insurance drug payment standards, to guide medical institutions and patients to take the initiative to use the efficacy of accurate, affordable drugs.
, organizational leadership (1) seriously organize the implementation.
the work of improving the medical insurance outpatient guarantee mechanism for workers involves the vital interests of the vast number of insured persons, and the medical security and financial departments everywhere should attach great importance to it, and study and formulate the detailed rules for the implementation of the work in the light of local realities.
areas where relevant exploration has been carried out, we should further refine and improve policies and standardize system standards in accordance with this opinion.
areas where relevant work has not yet been carried out, we should actively and steadily study the program and start implementation as soon as possible.
(ii) to strengthen overall coordination.
work to improve the medical insurance outpatient guarantee mechanism for workers is complex, involving a wide range of issues, policy and technical strong, medical security at all levels, financial departments should be integrated arrangements, scientific decision-making, carefully organized and implemented.
properly handle the interface between outpatient security policies before and after the reform to ensure a smooth transition in the treatment of insured persons during the reform period.
should take the initiative to strengthen contacts with the departments of development reform, health and trade unions, establish coordination mechanisms and work together.
to do a good job of policy publicity and interpretation, do a good job of planning, resolve contradictions.
(iii) to actively and steadily promote.
this Opinion will be implemented from the beginning of the year.
to issue provincial documents by the end of this year to guide the overall implementation of the region.
in accordance with the spirit of this opinion, combined with local reality, further clarify the policy adjustment interval, make unified and detailed provisions, clean up the revision of the policy provisions inconsistent with this opinion.
in the process of advancing the work, in the face of new situations, new problems, timely report to the State Health Insurance Administration.
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