20 17 new medical insurance policy
The State Council recently issued the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents, proposing to integrate urban residents' medical insurance and the new rural cooperative medical system, and appropriately increase the proportion of individual contributions. Migrant workers and flexible employees will participate in the basic medical insurance for employees. What practical information is mentioned in the Opinions? Bian Xiao has combed a lot of dry goods for you. Let's have a look!
1, which people are covered?
The coverage of the medical insurance system for urban and rural residents includes all the insured persons in the existing medical insurance for urban residents and the new rural cooperative medical system, that is, all urban and rural residents except those who should be insured in the basic medical insurance for employees. Migrant workers and flexible employees shall participate in the basic medical insurance for employees according to law, and may participate in the medical insurance for urban and rural residents in accordance with local regulations if they have difficulties.
2. The proportion of individual contributions will increase.
In areas where there is a big gap between the existing medical insurance for urban residents and the individual payment standard of the new rural cooperative medical system, we can adopt a differentiated payment method and gradually transition in 2-3 years. The actual per capita financing and individual contributions after integration shall not be lower than the existing level.
Gradually establish a link mechanism between individual payment standards and per capita disposable income of urban and rural residents. Reasonably divide the financing responsibilities of the government and individuals, and appropriately increase the proportion of individual contributions while raising the standard of government subsidies.
3. How to raise funds?
Adhere to multi-channel financing, continue to combine individual contributions with government subsidies, and encourage collectives, units or other social and economic organizations to give support or funding. Reasonably divide the financing responsibilities of the government and individuals, and appropriately increase the proportion of individual contributions while raising the standard of government subsidies.
4. How to determine the financing standard?
All localities should consider the needs of urban and rural residents for medical insurance and serious illness insurance as a whole, and reasonably determine the unified financing standards for urban and rural areas in accordance with the principle of fund balance. In areas where there is a big gap between the existing medical insurance for urban residents and the individual payment standard of the new rural cooperative medical system, we can adopt a differentiated payment method and gradually transition in 2-3 years. The actual per capita financing and individual contributions after integration shall not be lower than the existing level.
5. How to ensure balanced treatment?
Follow the principle of moderate security and balance of payments, balance urban and rural security benefits, and gradually unify the scope of protection and payment standards. The medical insurance fund for urban and rural residents is mainly used to pay the medical expenses incurred by the insured in hospitalization and outpatient service. Stabilize the level of hospitalization security, and maintain the proportion of hospitalization expenses within the policy range at around 75%. Further improve outpatient co-ordination and gradually improve the level of outpatient support. Gradually narrow the gap between the payment ratio within the scope of the policy and the actual payment ratio.
6. How much can medical insurance pay after hospitalization?
The medical insurance fund for urban and rural residents is mainly used to pay the medical expenses incurred by the insured in hospitalization and outpatient service. Stabilize the level of hospitalization security, and maintain the proportion of hospitalization expenses within the policy range at around 75%. Further improve outpatient co-ordination and gradually improve the level of outpatient support. Gradually narrow the gap between the payment ratio within the scope of the policy and the actual payment ratio.
7. How to manage the medical insurance fund?
Medical insurance for urban and rural residents shall implement a unified national fund financial system, accounting system and fund budget and final accounts management system. The medical insurance fund for urban and rural residents shall be included in the financial special account, and the management of "two lines of revenue and expenditure" shall be implemented. Fund independent accounting, account management, no unit or individual may misappropriate.
Promoting the total payment control in an all-round way by combining the capital budget management. The use of the fund follows the principle of fixed income and expenditure, balance of payments and slight balance, to ensure that the payable expenses are paid in full and on time, and to reasonably control the fund's current balance rate and accumulated balance rate. Establish and improve the early warning mechanism of fund operation risk, prevent fund risks and improve the efficiency of use.
8, clear the scope of payment of medical insurance drugs and medical services.
Following the principles of clinical necessity, safety, effectiveness, reasonable price, appropriate technology and affordable fund, and on the basis of the current urban residents' medical insurance and the new rural cooperative medical system, and taking due consideration of the changes in the needs of the insured, the types are basically complete and the structure is generally reasonable. At the same time, improve the management methods of medical insurance catalogue, and implement hierarchical management and dynamic adjustment.
9. What are the payment methods of medical insurance?
We will systematically promote the reform of composite payment methods that combine various payment methods, such as paying by head, paying by disease type, paying by bed day, and prepaying the total amount, establish and improve the negotiation mechanism and risk sharing mechanism between medical insurance agencies and medical institutions and drug suppliers, promote the formation of reasonable medical insurance payment standards, guide designated medical institutions to standardize service behavior, and control unreasonable growth of medical expenses.
By supporting insured residents to carry out contract services with primary medical institutions and general practitioners, we will formulate differentiated payment policies, promote the construction of graded diagnosis and treatment system, and gradually form a new medical order of primary diagnosis, two-way referral, rapid division and treatment, and linkage up and down.
When will 10 be implemented?
All provinces (autonomous regions and municipalities) should make plans and arrangements for the integration of medical insurance for urban and rural residents before the end of June 2065438+2007, define the timetable and road map, and ensure that all policies and measures are put in place. Each overall planning area shall formulate specific implementation plans before the end of 20 17 and 12.
17 province realizes the unified management of universal health insurance.
Since the issuance of the State Council's Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents, eight provinces (autonomous regions and municipalities directly under the Central Government) such as Hebei, Hubei, Inner Mongolia, Jiangxi, Xinjiang, Beijing, Hunan and Guangxi have officially issued documents, making arrangements and arrangements for the integration of the medical insurance system for urban and rural residents in this province, and fulfilling the task requirements of the State Council in the first half of the year as scheduled.
The above-mentioned eight provinces have made arrangements and arrangements for comprehensively promoting the integration system from the overall consideration of straightening out the system, integrating the system and improving the efficiency. First, it is clearly stated that the management functions of the new rural cooperative medical system undertaken by the health and family planning departments and the medical insurance management functions of urban residents managed by the human and social departments should be merged and unified by the human and social departments. Second, according to the requirements of "six unifications" in the State Council document, it is required to establish a unified basic medical insurance system for urban and rural residents by integrating the two systems of urban residents' medical insurance and the new rural cooperative medical system. The third is to clarify the task division, timetable and road map of the integration work, and put forward specific requirements to ensure the smooth and orderly progress of the integration work.
Up to now, among the 32 provinces, autonomous regions and municipalities (including Corps), 8 provinces (Hebei, Hubei, Inner Mongolia, Jiangxi, Xinjiang, Beijing, Hunan and Guangxi) have issued integration plans, and 9 provinces (Tianjin, Shanghai, Zhejiang, Guangdong, Chongqing, Ningxia, Qinghai and Corps) have fully realized system integration before the release of the the State Council document. The above/kloc Clearly handing over the integrated and unified basic medical insurance system for urban and rural residents to the human and social departments to realize the unified management of the universal basic medical insurance system and even the whole social insurance system, fully embodies the high consensus of local party committees and governments on the unified medical insurance management system and their profound understanding of the social security system with China characteristics.
From the practice of various places, the system integration has achieved remarkable results: First, the masses have generally benefited and the sense of reform has been enhanced. In practice, all localities have adopted the idea of "low payment is not high, high treatment is not low, and the directory width is not narrow", and the fairness of residents' medical insurance system has been obviously enhanced, especially the utilization level and security level of rural residents' medical services have been generally improved. The second is to improve the efficiency of public services and reduce administrative costs. Relying on the social insurance public service system, the integrated management services such as enrollment registration, fund collection, rights and interests record and treatment payment have been realized, avoiding repeated investment and multi-head construction, and reducing repeated enrollment and subsidy payment. Only the integration of Shandong Province eliminated 2.5 million duplicate insured persons, saving more than 800 million yuan of financial duplicate subsidy funds in that year. Third, the mutual aid ability of the medical insurance fund has been enhanced, which is conducive to giving play to the basic role of medical insurance in medical reform. All localities pay attention to the laws of social medical insurance system, promote the external incentives and constraints of medical insurance on medical services, and provide a solid foundation for the linkage reform of the three medical services.
The current basic medical insurance system in China
(1) Basic medical insurance for urban workers. It is a social medical insurance system that guarantees the basic medical needs of employees and implements territorial management according to the affordability of finance, enterprises and individuals. The basic medical insurance premium is shared by employers and employees, and the basic medical insurance is combined with social pooling and individual accounts.
(2) Basic medical insurance for urban residents. It is a medical insurance system with urban minors and unemployed urban residents who have not participated in the medical insurance for urban workers as the main participants; The basic medical insurance for urban residents is mainly based on family contributions, and the government gives appropriate subsidies;
(3) New rural cooperative medical system. It is a medical mutual aid system for farmers, which is organized, guided and supported by the government, participated by farmers voluntarily, and raised by individuals, collectives and the government.
The State Council interprets and integrates the basic medical insurance for urban and rural residents.
First, why should the basic medical insurance system for urban residents be integrated with the new rural cooperative medical system?
In 2003 and 2007, China established the new rural cooperative medical system (hereinafter referred to as the new rural cooperative medical system) and the basic medical insurance for urban residents (hereinafter referred to as the medical insurance for urban residents) for rural population and urban unemployed population respectively. Since the establishment of the system, the coverage has been continuously expanded, the security level has been steadily improved, and the operation has been stable, which has played an important role in improving the national basic medical insurance system, meeting the people's basic medical insurance needs, and improving the people's health level.
In recent years, with the rapid development of economy and society, the negative effects of the urban-rural division of the two systems have begun to appear, and there are problems such as repeated participation in insurance, repeated investment and insufficient treatment. On the basis of summing up the operation of urban residents' medical insurance and the new rural cooperative medical system and the practical experience of local exploration, the CPC Central Committee and the State Council clearly put forward to integrate the two systems of urban residents' medical insurance and the new rural cooperative medical system and establish a unified basic medical insurance system for urban and rural residents.
2. At present, how is the local exploration and integration of urban and rural residents' medical insurance system progressing? What is the implementation effect?
At present, some provinces, cities and counties have realized the integration of medical insurance system for urban and rural residents. All localities generally straighten out the administrative system according to the path of "centralized management first, then integration", unify policies according to the principle of "low fund-raising, high treatment and narrow catalogue", and gradually transition by means of "one system with multiple files, linking fund-raising with treatment" to establish a unified basic medical insurance system for urban and rural residents. Integrate handling management resources and implement integrated handling services. Improve the level of information management by improving the medical insurance information management system. Properly handle special problems, do a good job of system connection, and achieve a smooth transition.
Generally speaking, local exploration provides a useful reference for the national overall planning of urban and rural residents' medical insurance system. The integration of some fields has achieved initial results, which has expanded the fund's ability to resist risks and avoided repeated participation in insurance, subsidies and construction to some extent. However, due to the lack of top-level design and system promotion, the coordinated development of medical insurance system and medical service system needs to be further strengthened, and the fairness of financing of medical insurance system needs to be further improved.
3. At present, what is the significance of the central government's decision to comprehensively promote the integration of urban and rural residents' medical insurance system?
Integrating the two systems of urban residents' medical insurance and the new rural cooperative medical system and establishing a unified medical insurance system for urban and rural residents is an important measure to promote the reform of medical and health system, realize the fair enjoyment of basic medical insurance rights and interests for urban and rural residents, promote social fairness and justice, and enhance people's livelihood and well-being, and is of great significance to the coordinated development of urban and rural economy and society and the comprehensive construction of a well-off society. Establishing a medical insurance system for urban and rural residents is conducive to promoting fairer security, more standardized management services, more effective use of medical resources, and promoting the sustained and healthy development of the universal medical insurance system.
4. What is the general idea of comprehensively promoting the integration of medical insurance system for urban and rural residents? How to grasp the basic principles?
The general idea is to start with policies, make things easy first and then difficult, step by step, and "unify the system, integrate policies, balance levels, improve mechanisms and improve services". Highlight the integration of systems and policies and implement the "six unifications"; Highlight the rationalization of management system, integrate handling institutions, and provide integrated urban and rural handling services; Highlight the improvement of service efficiency, realize gradual transition and smooth integration, and establish a unified basic medical insurance system for urban and rural residents.
Basic principles: First, overall planning and coordinated development. Incorporate the medical insurance system for urban and rural residents into the development of universal medical insurance system and deepen the overall situation of medical reform, highlight the linkage of "medical insurance, medical care and medicine" and strengthen the system convergence. The second is to base on the basics and ensure fairness. Based on the level of economic and social development, the burden of urban and rural residents and the ability to bear funds, fully consider and gradually narrow the urban-rural gap and regional differences to ensure that urban and rural residents enjoy basic medical insurance benefits fairly. The third is to promote it according to local conditions and in an orderly manner. Strengthen the connection before and after integration, ensure the smooth continuity and orderly transition of work, ensure that the basic medical insurance benefits of the people are not affected, and ensure the safety of the fund and the smooth operation of the system. The fourth is to innovate the mechanism and improve efficiency. Adhere to the separation of management and operation, improve the management and operation mechanism, and further promote the reform of payment methods. Give full play to the role of market mechanism and mobilize social forces to participate in basic medical insurance services.
Verb (abbreviation of verb) How to implement "six unifications" in the process of integrating medical insurance system for urban and rural residents?
Starting from the policy, we should integrate the medical insurance system for urban and rural residents, with the focus on integrating its financing and treatment guarantee policies. On the basis of studying and comparing the differences between the original two systems and summing up the practical experience of various places, the policy integration requirements of "six unifications" are put forward.
First, we must unify the coverage. Medical insurance for urban and rural residents covers other urban and rural residents except the urban employed population. Migrant workers and flexible employees who have difficulties in participating in employee medical insurance are allowed to choose to participate in urban and rural residents' medical insurance independently.
Second, we must unify the fund-raising policy. Adhere to multi-channel financing, reasonably determine the unified financing standards for urban and rural areas, improve the dynamic adjustment mechanism of financing, and improve the financing sharing structure. In areas where there is a big gap between urban residents' medical insurance and the new rural cooperative medical system, different payment methods can be adopted to gradually transition. Gradually establish a link mechanism between individual payment standards and per capita disposable income of urban and rural residents.
Third, we must unify protective treatment. Gradually unify the scope of protection and payment standards, keep the proportion of hospitalization expenses within the policy range at around 75%, and gradually improve the level of outpatient protection. Properly handle the convergence of special safeguard policies before and after integration, and gradually narrow the gap between the payment ratio within the policy scope and the actual payment ratio.
Fourth, we must unify the medical insurance catalogue. According to the relevant provisions of the state, all provinces follow the principles of clinical necessity, safety and effectiveness, reasonable price, appropriate technology and affordable funds, and on the basis of the existing urban residents' medical insurance and the new rural cooperative medical system, give due consideration to the changes in the needs of the insured, and formulate a unified catalogue of medical insurance drugs and medical services.
Fifth, we must unify fixed-point management. Unify the management measures of designated institutions, strengthen the management of designated service agreements, improve the evaluation mechanism, and implement dynamic access and exit. Adopt a policy of equal treatment for social medical care.
Sixth, we must unify fund management. Implement a unified fund financial system, accounting system and fund budget and final accounts management system, strengthen internal control management and external supervision system, promote total payment control, improve fund operation risk early warning mechanism, reasonably control fund balance, prevent fund risks and improve efficiency.
Thanks!