In order to further improve the new rural cooperative medical system in our city (hereinafter referred to as the "new rural cooperative medical system"), improve the multi-level medical security system, improve the level of serious illness security for participating patients, and alleviate the outstanding problems of poverty caused by illness and returning to poverty due to illness. According to the "Notice of the General Office of the State Council on the Full Implementation of Serious Illness Insurance for Urban and Rural Residents" (No.438+05 [2065] of Guo Ban Fa) and relevant documents of our province, combined with the actual situation of our city, this scheme is formulated.
I. Basic principles and objectives
(1) basic principles
1. Adhere to the people-oriented principle and make overall arrangements. Efforts will be made to safeguard the health rights and interests of the people and effectively solve the outstanding problems of poverty caused by illness and returning to poverty due to illness. Strengthen the system convergence, form a joint force, and constantly improve the people's medical security level and health level.
2. Adhere to government-led and professional contractors. The government is responsible for the basic policy formulation, organization and coordination, fund-raising management of serious illness insurance, and strengthens supervision and guidance. Take the way of undertaking serious illness insurance by commercial insurance institutions, give play to the role of market mechanism and the professional advantages of commercial insurance institutions, and improve the operation efficiency, service level and quality of serious illness insurance.
3. Adhere to the * * * responsibility and continue to implement it. The level of serious illness insurance should be compatible with economic and social development, medical insurance financing ability and medical consumption level. Strengthen social mutual assistance, form a mechanism that the government, individuals and insurance institutions share the risk of serious illness, and realize the stable operation and sustainable development of serious illness insurance.
4. Adhere to the balance of payments, and guarantee the meager profit. Serious illness insurance shall be managed by special accounts and accounted independently. In that year, the fund's income and expenditure were basically balanced, the financing standard and guarantee level were calculated reasonably, and it started steadily, standardized operation, ensured the safety of funds, and the insurance institutions guaranteed the capital and made small profits.
(ii) Objectives
Comprehensively carry out the serious illness insurance of the new rural cooperative medical system, and further protect the high medical expenses of rural residents due to serious illness on the basis of the basic medical security system. Continuously improve and perfect the municipal serious illness insurance system covering rural residents, closely link with medical assistance and other systems, and play a role in service guarantee, and the level of medical security for rural residents has been significantly improved.
Second, the financing mechanism
(1) funding criteria. Combined with the financing capacity of the new rural cooperative medical system in our city, the medical expenses for serious illness and the basic medical compensation level, the financing standard of the new rural cooperative medical system for serious illness insurance is 25 yuan per person per year. According to the city's economic and social development level, financing ability of medical insurance, high medical expenses caused by serious illness, compensation level of basic medical insurance, protection level of serious illness insurance and other factors, the financing standard of new rural cooperative medical insurance will be adjusted in a timely manner.
(2) Sources of funds. According to the determined financing standard, the serious illness insurance funds are co-ordinated from the new rural cooperative medical fund in counties and districts, and the participants do not pay separately. Before the end of March of that year, all counties and districts will remit funds to the financial special account of NCMS serious illness insurance.
(3) Overall planning level. The serious illness insurance of the new rural cooperative medical system is implemented at the municipal level, with unified standards, unified implementation and unified management, so as to improve the fund's ability to resist risks.
Third, the content of protection.
(1). All participants who participate in the full payment of the new rural cooperative medical system in our city are included in the new rural cooperative medical system serious illness insurance (in the year of birth, rural newborns enjoy the basic medical insurance and serious illness insurance benefits with their mothers who participate in the new rural cooperative medical system, and pay the participation fee according to the regulations from the second year).
(2) Warranty period. The guarantee time of the serious illness insurance of the new rural cooperative medical system is in accordance with the natural year. In principle, the annual starting and ending time is 65438+ 10 month 1 to 65438+February 3 1.
(3) scope of protection. The coverage of serious illness insurance of the new rural cooperative medical system is connected with the basic policies of the new rural cooperative medical system. The new rural cooperative medical system participants in our city incurred high medical expenses due to hospitalization. After the basic medical care of the new rural cooperative medical system was subsidized according to the policy, if the compliance medical expenses to be borne by individuals reached the conditions and standards of compensation for serious illness insurance, they were given compensation for serious illness insurance.
(4) Protection level. The threshold of NCMS' serious illness insurance compensation is 1 1,000 yuan. The individual pays part of the hospitalization compliance medical expenses that exceed the deductible standard, and the compensation shall be made in proportion. The compensation ratio is: 50% of 654.38+0000 yuan to 20,000 yuan (inclusive), 60% of 20,000 yuan to 30,000 yuan (inclusive), 70% of 30,000 yuan to 50,000 yuan (inclusive), 80% of 50,000 yuan to 654.38+000 yuan (inclusive), and 654.38+000 yuan.
(5) Guarantee method. The compensation for serious illness insurance of the new rural cooperative medical system adopts two ways: single settlement and annual cumulative settlement. After the participants enjoy the basic medical subsidy of the new rural cooperative medical system, they can apply for serious illness insurance compensation when their out-of-pocket expenses meet the standard of serious illness compensation for a single hospitalization. After the participants enjoyed the basic subsidy of the new rural cooperative medical system for many times in the same year, and the accumulated out-of-pocket compliance medical expenses reached the standard of serious illness compensation, and the compliance out-of-pocket expenses and deductible lines were not calculated repeatedly, they could also apply for serious illness insurance compensation.
Fourth, the way of undertaking.
(1) Organizer. Take public bidding to purchase the serious illness insurance service of the new rural cooperative medical system from commercial insurance institutions. Led by the Municipal Health Planning Bureau, with the participation of the municipal finance, medical reform, financial office and other departments, the commercial insurance institutions undertaking serious illness insurance were selected through government bidding. Commercial insurance institutions undertaking serious illness insurance must meet the following basic conditions: they meet the necessary conditions for operating health insurance stipulated by the China Insurance Regulatory Commission; Engaged in special health insurance business in China for more than 5 years; Have a sound medical insurance service network and strong professional ability, and provide business, financial, information technology and other support; Equipped with a certain number of full-time staff with medical and other professional backgrounds; It can realize independent accounting of serious illness insurance business. The Municipal Health and Family Planning Bureau shall, jointly with the Municipal Finance Bureau and the Financial Office, formulate the bidding access conditions and contract model. After the bidding results are submitted to the municipal government for examination and approval, the Municipal Health Planning Bureau will sign a contract with the winning insurance company.
(2) Standardize bidding. The city's new rural cooperative medical insurance for serious illness should be based on the principles of openness, fairness and impartiality, and standardize the bidding work. The bidding content mainly includes the specific financing standard, compensation ratio, management rate, contractor and management force of serious illness insurance. Commercial insurance institutions that meet the access conditions voluntarily participate in bidding, and undertake serious illness insurance in the form of insurance contracts after winning the bid.
(3) Contract management. To undertake a contract, the responsibilities, rights and obligations of both parties shall be clearly defined, and the contract term shall not be less than 3 years in principle. Commercial insurance institutions shall enjoy rights, perform obligations and bear business risks in accordance with the contents determined in the serious illness insurance contract. According to the principle of balance of payments and guaranteed profit, the management expenses and profit rate of commercial insurance institutions are generally controlled within 3% of the total actual compensation funds of the new rural cooperative medical system in that year, and the relevant funds are borne by the municipal finance. Due to breach of contract, or other acts that seriously damage the rights and interests of participants, the contract may be terminated or dissolved in advance as agreed, and the responsibilities shall be investigated according to law.
(4) Insurance services. Commercial insurance institutions should strengthen handling services and cooperate with the new rural cooperative medical institutions to carry out all aspects of serious illness insurance. It is necessary to equip a professional team, provide "one-stop" instant settlement service, simplify reimbursement procedures, and ensure that people can enjoy serious illness insurance benefits conveniently and in time. Give full play to the advantages of the national network of commercial insurance institutions and provide services such as off-site settlement for participants. Commercial insurance institutions should strengthen management, control risks, reduce management costs, improve service efficiency, speed up settlement, and timely and reasonably pay compensation fees for serious illness insurance to the insured according to regulations.
Verb (abbreviation for verb) supervision and management
(1) Standardize fund management. In accordance with the principle of "balance of payments, guaranteed profit", strengthen the supervision of the serious illness insurance fund of the new rural cooperative medical system, and implement special account, special account and closed operation for the serious illness insurance fund. The Municipal Finance Bureau and the Municipal Health Planning Bureau shall formulate measures for the management of the serious illness insurance fund of the new rural cooperative medical system. The serious illness insurance fund is raised by the Municipal Finance Bureau on an annual basis to the financial special account of serious illness insurance in the city, and the serious illness insurance premium is allocated to commercial insurance institutions on schedule, in time and in full according to the serious illness insurance contract. Serious illness insurance contractors should strictly follow the management measures determined by the financial, health and family planning departments, strengthen the management of serious illness insurance funds, implement separate accounting for serious illness insurance premiums, and directly subsidize households to ensure the safety of funds and ensure solvency. Audit departments should conduct regular audits as needed to ensure the safety of the fund.
(2) Strengthen the supervision of contractors. All relevant departments should perform their duties and cooperate with each other to effectively protect the rights and interests of participants. The Municipal Health and Family Planning Bureau should take the efficiency of capital use and the satisfaction of participants as the core, formulate the assessment methods for the new rural cooperative medical system serious illness insurance, strengthen supervision, inspection and assessment in conjunction with financial and other relevant departments, and urge commercial insurance institutions to improve the service quality and level in accordance with the contract requirements. The municipal medical reform office should play an overall coordination role and do a good job in tracking analysis, monitoring and evaluation, supervision and assessment. Municipal Finance Office should do a good job in qualification examination, service quality and daily business supervision, strengthen solvency and market behavior supervision, and increase the investigation and punishment of illegal and unfair competition behaviors of commercial insurance institutions. Relevant departments and commercial insurance institutions should effectively strengthen the personal information security of insured persons to prevent information leakage and abuse. City, county, district new rural cooperative medical institutions should establish complaint acceptance channels, conduct supervision and inspection through daily spot checks, urge commercial insurance institutions to perform their duties, report and deal with problems in a timely manner.
(3) Strengthen the control of medical institutions and medical expenses. Relevant departments and medical institutions should strengthen supervision and management in various ways to prevent and control unreasonable medical behaviors and expenses and ensure the quality of medical services. Health and family planning departments should strengthen the supervision of medical institutions, medical service behavior and quality. Commercial insurance institutions should give full play to the role of medical insurance mechanism, closely cooperate with health and family planning departments, promote the reform of payment methods, standardize medical behavior, and control medical expenses.
(4) Improve the social supervision mechanism. The serious illness insurance agency shall disclose the signing of the contract with the contractor, as well as the financing standard, treatment level, payment process, settlement efficiency and annual income and expenditure of the serious illness insurance to the public and accept social supervision. City, county, district new rural cooperative medical institutions and serious illness insurance contractors should set up a report mailbox, open the telephone number, smooth social supervision channels.
Implementation steps of intransitive verbs
(1) Policy formulation stage. Introduce the implementation plan, determine the commercial insurance institutions and sign the contract through bidding, and complete the bidding for commercial insurance institutions before the end of February. Municipal Health Planning Bureau, Municipal Finance Bureau, Municipal Medical Reform Office, Municipal Finance Office and other departments study and formulate relevant supporting policies, solve the problem of basic medical insurance and serious illness insurance policies, data and information convergence, and implement serious illness insurance funds.
(2) startup time. On June 65438+1 October1day, the city's new rural cooperative medical insurance for serious illness was launched.
Seven. safeguard measure
(1) Raise awareness and strengthen leadership. Municipal, county, district and county governments and relevant departments should fully understand the importance of carrying out serious illness insurance and make careful arrangements. It is necessary to give full play to the functions of the leading group of the new rural cooperative medical system in the city, establish a working mechanism for coordinating and promoting the serious illness insurance led by the health planning department, with the participation of the municipal development and reform, medical reform, finance, civil affairs, financial office and other departments, improve and perfect the supervision and management institutions of the new rural cooperative medical system, refine supporting policies according to the division of responsibilities, strengthen communication and cooperation, and form a joint effort to ensure the steady and continuous advancement of the serious illness insurance work.
(2) Improve the mechanism and operate effectively. Constantly improve the comprehensive management mechanism of serious illness insurance with industry supervision, social supervision and departmental linkage, do a good job in tracking analysis, monitoring and evaluation, regularly evaluate and summarize the progress and operation of serious illness insurance every year, find and solve existing problems in time, and ensure the further promotion of serious illness insurance. Intensify investigation and punishment, put an end to unreasonable refusal to pay, malicious medical behavior and expenses, abuse of power by management departments, and ensure that serious illness insurance is scientific, standardized, open and transparent from system design to compensation payment, so as to ensure that the people get more benefits.
(3) Do a good job in publicity and create an environment. Relevant departments and commercial insurance institutions should strengthen the publicity and interpretation of serious illness insurance policies and the professional training of handling personnel, so that the masses can widely understand the policies and treat diseases rationally. It is necessary to closely track and analyze public opinions, enhance the public's awareness of insurance responsibility, and create a good social atmosphere for the implementation of serious illness insurance.
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