Research on Reimbursement System of New Rural Cooperative Medical System in Gaozhou in 2009
2009-08-05 Reading: 1853 Editor: [large, medium and small]
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Research on Reimbursement System of New Rural Cooperative Medical System in Gaozhou in 2009
According to the requirements of relevant documents from higher authorities, combined with the actual situation of our city, the new rural cooperative medical security system in Gaozhou City in 2009 was formulated. Adhere to the principle of serious illness protection, incorporate a small number of chronic diseases and endemic diseases into serious illness planning, and establish a family-based outpatient medical expense reimbursement system. In that year, the maximum line of hospitalization reimbursement was 30,000 yuan (the cumulative maximum line of subsidies for patients with chronic diseases who were hospitalized and had a large number of outpatients was 30,000 yuan).
The first is to standardize the conditions and methods of participation.
Insurance conditions: All rural registered population who have not participated in other medical security systems organized by the government in our municipal area can participate in the new rural cooperative medical system. Farmers take households as the unit to participate in the cooperative medical care, and the payment amount is 20 yuan per person for the whole year (the elderly with sons must participate in the cooperative medical care with a son's family alone). Rural five-guarantee households and low-guarantee households are funded by the civil affairs department and pay all the funds that individuals should bear.
How to participate: pay money in the village Committee or the town joint management office and get the cooperative medical certificate.
Payment period: cooperative medical care is based on the principle of paying first and then enjoying. Those who participated in the cooperative medical system in 2009 must pay the fee before the end of June 2008, 1 1, and will not be processed after the expiration.
Second, outpatient instant reimbursement:
1. The outpatient medical expenses of each farmer are within 22 yuan. Where the staff of this household go to the designated medical institutions in this town for outpatient service and health examination with the valid cooperative medical certificate of this household in the current year, the outpatient expenses that can be reimbursed by this household in the current year can be directly deducted from the expenses payable. Outpatient medical expenses reimbursement funds are limited to outpatient or physical examination consumption in designated medical institutions in this city in that year. The balance of outpatient consumption fund in that year or the outpatient consumption fund not consumed by the insured family is not carried forward to the next year.
2, examination and approval of hospitalization medical expenses compensation. In Gaozhou City: the reporting line of hospitalization expenses of designated medical institutions in towns (streets) is 200 yuan, and the hospitalization expenses above deductible line are reimbursed by 60%; The reporting line of hospitalization expenses of municipal designated medical institutions is 400 yuan, and the hospitalization expenses above deductible line are reimbursed by 50%; Outside Gaozhou: Participating farmers are hospitalized in non-profit hospitals outside Gaozhou, and the referral system is implemented. Referral management is carried out according to the provisions of Maofu [2007] 17 (i.e. ① diseases that cannot be diagnosed by designated medical institutions in our city; (2) diseases unconditionally treated by designated medical institutions in our city; (3) Dangerous, serious and urgent patients need to be transferred to hospital for rescue. Referral requires patients to apply, and after the approval of designated medical institutions, it will be reported to the Municipal Cooperative Medical Office for approval). If the referral is approved, the reporting line of hospitalization expenses is 600 yuan, and 40% of the hospitalization expenses above the deductible line will be reimbursed. Without the approval of the referral, medical expenses deductible 1000 yuan, 30% of hospitalization expenses above deductible.
Third, the way of hospitalization reimbursement
1, instant reimbursement. Participants must show their ID cards. If the cooperative medical care certificate proves that they have been treated in designated medical institutions in Gaozhou, Maoming Agricultural Reclamation Hospital, Guangdong Unity Farm Hospital, Guangdong Mars Farm Hospital and Guangdong Shengli Farm Hospital, the medical expenses will be reimbursed immediately.
2. Non-immediate reimbursement scope. Patients hospitalized in designated medical institutions without immediate compensation and without approval for referral should report to the village committee or town (street) and cooperative medical office within 48 hours before or after admission, and apply for reimbursement within one month after discharge. The reimburser holds the disease diagnosis certificate, legal hospitalization receipt (printed by computer), hospitalization expense list (printed by computer), cooperative medical certificate and a copy of my ID card, and the passbook of rural credit cooperatives, and goes to the town (street) cooperative medical office or village committee to receive the Report on Reimbursement of Rural Cooperative Medical Expenses, fill in it according to the regulations, and provide the telephone number of medical expenses to send it to the town (street) cooperative medical office. After verification, the town (street) financial settlement center will directly transfer the reimbursement to the passbook of the patient himself or his relatives [if the passbook is not the patient himself or his relatives, the agent shall submit the patient's power of attorney (if the patient dies, his family will handle it on his behalf), the patient's ID card (or household registration book), and the reimbursement voucher shall be accompanied by a copy of the client's ID card].
Note: Except for farmers who participate in medical insurance and rural cooperative medical care at the same time, because the original hospitalization certificate is kept by the insurance company, the copy of the bill stamped by the insurance company (and the inquiry phone number of the insurance company is provided at the same time) can be used as the reimbursement voucher, and other circumstances cannot be reimbursed by the copy.
Fourth, large outpatient reimbursement for chronic diseases.
1. The scope of reimbursement for chronic diseases in outpatient department: liver cirrhosis, cancer, chronic renal failure (uremia), systemic lupus erythematosus, mental disorder, rheumatic heart disease, leukemia, tuberculosis, diabetes, sequelae of cerebrovascular accident (cerebral infarction, cerebral hemorrhage and cerebral thrombosis) and follow-up treatment of myocardial infarction.
2. Provisions on identification of chronic diseases: The signature identification of two deputy chief physicians in Gaozhou (or above) shall prevail; The appraisal of mental illness shall be subject to the appraisal of Maoming Third People's Hospital.
3. The application procedure for large-scale outpatient reimbursement of chronic diseases is the same as that for non-immediate reimbursement.
4. During the year, the cumulative deductible line for large-scale outpatient medical expenses for chronic diseases is 500 yuan; The reimbursement ratio is: seek medical treatment in the outpatient department of the town-level designated medical institution in this city, and the outpatient expenses above the deductible line are reimbursed by 40%; In the outpatient clinics of designated medical institutions in Gaozhou and Maoming Third People's Hospital, 30% of the outpatient expenses above the deductible line are reimbursed, and the outpatient expenses of hospitals outside Gaozhou are not reimbursed. The ceiling line of large outpatient expenses for chronic diseases in the year is 10000 yuan.
Verb (abbreviation for verb) Maternity allowance:
1. Each patient hospitalized in a designated medical institution will be given a one-time subsidy to 300 yuan. Caesarean section is subsidized according to the proportion of hospitalization expenses reimbursement.
2, to participate in the new rural cooperative medical system of farmers suffering from cataract intraocular lens implantation surgery, each side of the highest one-time subsidy 800 yuan.
6. Non-reimbursement scope: all expenses required for fighting, traffic accidents, alcoholism, drug abuse, intentional self-injury, medical accidents (disputes) and family planning; Expenses incurred for cosmetic surgery, plastic surgery, bodybuilding and correction of physical defects; Medical consultation, medical appraisal, health prediction, examination and treatment fees for male and female infertility and sexual dysfunction; Other expenses not covered by the Interim Measures for the Administration of Medical Insurance for Urban Workers in Guangdong Province.
Note: 1. All injured inpatients must be admitted to the hospital (signed by the doctor and sealed by the hospital), and those who are not in the "non-reimbursement scope" can be included in the reimbursement scope after being confirmed by the Materials Committee and verified by the town (street) cooperative medical office.
Note 2. The participating farmers in Baoguang, Shan Mei, Shizailing and Panzhou went to the Second People's Hospital of Gaozhou City and the Maternal and Child Health Hospital of Gaozhou City for hospitalization and outpatient service, and were reimbursed according to the standards of designated medical institutions at the town level.
This reimbursement system has been implemented since June 65438+ 10/2009.
Gaozhou village cooperation medical treatment work leading team office
December 28th, 2008
Notice on Adjusting the Compensation System of Rural Cooperative Medical Care in Gaozhou City in 2009
Towns (streets) cooperative medical office, finance office, town-level designated medical institutions in the city:
According to the spirit of "Maoming New Rural Cooperative Medical System Management Measures" (Mao Fu [2008] No.91), combined with the actual situation of our city, after the study of the meeting of the members of the leading group of the new rural cooperative medical system in our city, it is decided to make the following adjustments to some contents of "Gaozhou 2009 Rural Cooperative Medical System Compensation Measures", please implement them carefully.
First, raise the reimbursement ceiling line standard during the year. For those discharged from hospital in April 1, the upper limit of reimbursement during the year was raised from "accumulated 30,000 yuan" to "accumulated 50,000 yuan".
Two, improve the proportion of hospitalization reimbursement of designated medical institutions at the town level. The participating farmers in our city were hospitalized in the designated medical institutions at the town level, and were discharged on April 1 day, and the reimbursement rate of hospitalization medical expenses increased from 60% to 70%. (Note: See the attached table for the township-level designated medical institutions that improve the reimbursement standard. )
Three, the city's participating farmers to Maoming Agricultural Reclamation Hospital hospitalization, reimbursement deductible line for 600 yuan, reimbursement ratio of 40%; Go to Gaozhou Chronic Disease Prevention Station, Guangdong Shengli Farm Hospital, Guangdong Mars Farm Hospital and Guangdong Unity Farm Hospital for hospitalization. The reimbursement deductible line is 200 yuan, and the reimbursement ratio is 60%.
The rest of the policies are implemented according to the original Compensation System of Rural Cooperative Medical Care in Gaozhou City in 2009.
Gaozhou village cooperation medical treatment work leading team office
March 2009 18
Notice on Supplementary Provisions of New Rural Cooperative Medical Compensation System in Gaozhou City in 2009
Towns (streets) cooperative medical office, financial office, designated units directly under the rural cooperative medical system:
In order to further strengthen the management of the new rural cooperative medical system in our city and ensure the steady and healthy development of this work. According to the spirit of Mao Fu [2008] No.91Measures for the Administration of New Rural Cooperative Medical System in Maoming City, combined with the actual situation of our city, the following supplementary provisions are made on the relevant issues of new rural cooperative medical system in Gaozhou City in 2009:
First, strictly implement the drug list, diagnosis and treatment scope and medical service charges. The designated medical institutions shall uniformly implement the drug list stipulated in the Medical Insurance Drug List for Urban Employees in Guangdong Province (2004 Edition) and the scope of diagnosis and treatment stipulated in the Interim Measures for the Management of Medical Insurance Treatment Projects for Urban Employees in Guangdong Province, and uniformly implement the service charge standard stipulated in the Medical Service Price of Non-profit Medical Institutions in Maoming City (2007 Edition). If it is not implemented according to the regulations, it will not be audited and reimbursed.
Two, the provisions of the scope of reimbursement for some examination and treatment. Inspection expenses not covered by reimbursement include: CT, DR, CR, magnetic vibration, etc. Other expenses not included in the reimbursement scope include: consulting service fee, education fee, training fee, photocopying fee, production fee, ambulance fee, escort fee, body temperature fee, equipment depreciation fee, etc. The bed fee does not exceed 30 yuan every day, and the color Doppler ultrasound examination does not exceed 70 yuan, and the ICU treatment of severe patients does not exceed 500 yuan every day. See Annex 1, Annex 2 and Annex 3 for the unpaid part of rural cooperative medical care.
Third, responsibility and accountability. (a) the staff of the Municipal Cooperative Medical Office regularly or irregularly conduct spot checks on designated medical institutions. For the designated medical units found to have arbitrary charges such as illegal charges, repeated charges, expanded charges or self-supporting projects, the Municipal Cooperative Medical Office selects the patient data with the highest illegal charges as the calculation standard from the spot check results, calculates the proportion of illegal charges to the total hospitalization expenses, multiplies the proportion by the total expenses of cooperative medical patients in the hospital in the current month, and deducts the compensation expenses of cooperative medical care in the hospital in the current month according to the results. And investigate the responsibility of the responsible person and relevant leaders. If the violation is verified 3 times during the year, the qualification of designated medical institutions will be cancelled. (two) strictly control the growth of medical expenses, reduce the expenditure of cooperative medical fund, and reduce the burden of medical expenses of participating farmers. In principle, the calculation of hospitalization expenses of cooperative medical care is based on the per capita hospitalization expenses in the same period of last year, and the per capita hospitalization expenses in the current month are within the standard range of per capita hospitalization expenses in the same period of last year, and the compensation for cooperative medical care is allocated according to regulations; If the per capita hospitalization expenses in the current month are higher than that in the same period of last year, the cooperative medical compensation shall be calculated and distributed according to the per capita hospitalization expenses in the same period of last year. Settled quarterly, the compensation for cooperative medical care over the same period of last year shall be paid by designated medical institutions (note: except in special circumstances). The specific situation is verified by the Municipal Cooperative Medical Office.
Fourth, strictly control the audit. (1) All relevant units shall check and audit in strict accordance with the regulations, and the unpaid part not set in the system shall be deducted manually according to the relevant regulations. (2) Anyone who fails to declare as required, fails to verify the hospitalization expenses or goes through the illegal declaration procedures will not be reimbursed. (Note: 1. Verification of hospitalization expenses: If you are hospitalized outside Gaozhou City and the total hospitalization expenses are more than 5,000 yuan, you must send it to the Municipal Cooperative Medical Office for verification before you can apply for reimbursement. 2. Hospitalization invoices: legal hospitalization invoices are uniformly printed by the national tax department or the financial department. All hospital invoices printed privately by XX Hospital, XX Company and other departments are regarded as illegal hospital invoices and will not be reimbursed). (3) For farmers who have participated in both commercial insurance and rural cooperative medical care, the calculation method of rural cooperative medical care compensation is: the compensation amount of rural cooperative medical care = [(total hospitalization expenses-commercial insurance compensation expenses)-reporting line] × reimbursement ratio.
Verb (abbreviation of verb) adjusts the proportion of partial reimbursement. Farmers in Panzhou, Shan Mei, Shizailing and Baoguang streets went to Gaozhou Second People's Hospital and Gaozhou Maternal and Child Health Hospital for hospitalization, and the reimbursement ratio was adjusted from "60%" to "70%".
The rest shall be implemented according to the original regulations.
Six, the above supplementary provisions, from June 2, 20091day (point out the hospital time).
Seven, the right to interpret these provisions belongs to Gaozhou rural cooperative medical work leading group.
Gaozhou village cooperation medical treatment work leading team office
June 2009 10