The Provincial Medical Insurance Bureau issued the ＂Questions and Answers on the Publicity of Mutual Aid for Workers’ Medical Insurance Outpatients in Shanxi Province＂
On February 14th, Shanxi Provincial Medical Insurance Bureau made extensive publicity to the society on the related issues of mutual aid security for workers’ medical insurance clinics in Shanxi Province.
Why should we establish a mutual aid guarantee mechanism for employees’ medical insurance outpatient service?
Medical insurance for employees has been established since 1998, and it is a security model combining social pooling with individual accounts. The pooling fund is used to guarantee serious illness in hospital and out-patient, and individual accounts are used to guarantee expenses for minor illness and medicines in out-patient. With the development of social economy, the limitations of personal accounts have gradually become prominent. Because of the personal accumulation, there is a big gap between the personal accounts of healthy people and non-healthy people, and family members cannot share them. The sick ones are not enough and the sick ones cannot be used. On the other hand, there is the phenomenon that criminals cheat insurance. The core of this reform is to change from the original individual accumulation guarantee mode of outpatient medical expenses for insured employees to the mutual fund guarantee mode.
What is the basis for establishing mutual aid for employees’ medical insurance clinics?
"Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of Medical Security System" clearly puts forward that outpatient medical expenses should be gradually included in the payment scope of the basic medical insurance pooling fund, individual accounts of employees’ basic medical insurance should be reformed, and the outpatient mutual aid guarantee mechanism should be established and improved. The Guiding Opinions of the General Office of the State Council on Establishing and Perfecting the Outpatient Mutual Aid Security Mechanism for Employees’ Basic Medical Insurance has made clear arrangements for establishing the outpatient mutual aid security mechanism for employees’ medical insurance. The first is to strengthen the function of outpatient mutual aid guarantee. Establish and improve the overall guarantee mechanism for the general outpatient expenses of employee medical insurance, and gradually include the general outpatient expenses of frequently-occurring and common diseases into the scope of payment of the overall fund. The general outpatient service covers all the insured personnel of employee medical insurance as a whole, and the payment ratio within the policy scope starts from 50%, and the treatment payment can be appropriately tilted to retirees. The second is to improve the method of counting personal accounts. Personal accounts of employees are included in the basic medical insurance premiums paid by individuals, and the inclusion standard is controlled at 2% of the base of my insured payment in principle, and all the basic medical insurance premiums paid by the unit are included in the overall fund; In principle, the individual accounts of retirees are allocated by the overall fund according to the quota, and the allocated amount is gradually adjusted to about 2% of the average basic pension level in the year when the reform was implemented in the overall planning area according to this opinion. The third is to standardize the use of personal accounts. Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies. It can be used to pay the medical expenses borne by the insured person and his spouse, parents and children in designated medical institutions.And the expenses incurred by individuals in purchasing drugs, medical devices and medical consumables at designated retail pharmacies. Explore personal accounts for personal contributions for spouses, parents and children to participate in basic medical insurance for urban and rural residents.
What does "mutual aid" mean?
The employee medical insurance fund is divided into two parts: one is the overall fund, which is the big pool; The second is personal account. This reform is a mutual aid, a big mutual aid and a small mutual aid. Great mutual aid is to establish a guarantee mechanism for outpatient mutual aid and implement mutual aid guarantee within the scope of all insured people; Small mutual aid is the implementation of personal account family mutual aid, and the implementation of mutual aid protection among family members.
What impact does the reform have on outpatient reimbursement?
The core of this reform is to bring the general outpatient expenses into the overall fund reimbursement:
The first is to establish general outpatient co-ordination. The frequently-occurring and common diseases in outpatient department will be included in the employee medical insurance co-ordination fund for reimbursement, and the reimbursement ratio within the policy scope will reach more than 50%. These expenses were originally settled by personal accounts.
The second is to expand the coverage of outpatient chronic and special diseases. 45 diseases, such as outpatient treatment of malignant tumor with high cost and long treatment cycle, anti-rejection treatment of organ transplantation, hemophilia and uremia dialysis, are uniformly included in the scope of protection for chronic and special diseases in employee outpatient clinics, and the medical expenses incurred in outpatient clinics are included in the overall fund for reimbursement, and the reimbursement rate within the policy scope is over 70%. It turns out that there are an average of 29 diseases in the overall planning areas of the province.
The third is to implement personal account family mutual aid. Personal accounts can be used to pay medical expenses incurred by individuals in designated medical institutions or retail pharmacies, as well as medical expenses incurred by their spouses, parents and children in designated medical institutions or retail pharmacies. At the same time, it can also be used for personal contributions such as basic medical insurance for urban and rural residents, large medical expenses subsidies for employees and long-term care insurance for themselves, their spouses, parents and children. The original personal account can only be used for my own medical expenses or personal contributions.
What is the specific treatment of co-ordination of medical insurance outpatient service for employees in our province?
(1) Qifubiaozhun: The insured employees see a doctor in a medical institution with a charging price of Class III or below, a medical institution with a charging price of Class II and a medical institution with a charging price of Class I, and the outpatient co-ordination Qifubiaozhun is 30 yuan/visit, 50 yuan/visit and 80 yuan/visit respectively.
(2) Annual payment limit: In a natural year, the maximum annual payment limit for on-the-job employees is 1,800 yuan and that for retired employees is 2,000 yuan. The payment limit is not carried forward or accumulated to the next year.
(3) Payment ratio: 50% of the outpatient expenses that meet the requirements in the first-class designated medical institutions shall be paid by the on-the-job employee pooling fund and 55% by the retired employee pooling fund; In accordance with the provisions of the outpatient expenses occurred in the second-class medical institutions, the on-the-job staff and workers’ overall fund paid 55%, and the retired staff and workers’ overall fund paid 60%; In accordance with the provisions of the outpatient expenses occurred in the designated medical institutions with three types of charges and below, the on-the-job staff and workers’ overall fund paid 60%, and the retired staff and workers’ overall fund paid 65%.
Can my employee medical insurance be used by my family? How to use it?
(a) family mutual aid is for personal accounts, not a big pool of overall mutual aid. Personal account implements family mutual aid, which expands the use scope of employee personal account:
First, it used to be for my own use, but now the medical expenses borne by me, my spouse, parents and children in designated medical institutions can be paid by personal accounts;
Second, when purchasing medicine at designated pharmacies, it used to be for personal use. Now, when purchasing medicine, medical equipment and medical consumables at designated pharmacies, it can be paid by personal accounts of family members and employees’ medical insurance;
Third, it can be used for personal contributions for me, my spouse, parents and children to participate in basic medical insurance for urban and rural residents, large medical expenses subsidies for employees and long-term care insurance.
(2) Personal out-of-pocket expenses after the reimbursement of the overall fund can be paid in cash or through a personal account. When the personal account is paid, not only the expenses of the person but also the expenses of family members can be paid.
First, the part of the authorized person’s personal account balance exceeding 1000 yuan can be used as a mutual aid fund for the use of the authorized person. Second, the licensor can set different payment quotas/times for different licensees. Third, the authorized person needs to use the mutual aid funds in the designated medical institutions of medical insurance by virtue of the authorized person’s social security card or medical insurance electronic certificate.
What changes have taken place in personal accounts after the reform?
First, reform the accounting method. The individual contributions of on-the-job employees are still included in my personal account, according to 2% of my payment base, and all the basic medical insurance premiums paid by the unit are included in the overall fund; For retirees, because individuals don’t pay fees, individual accounts are allocated by the overall fund according to the quota, and the amount is 2% of the average basic pension in the province in the year of reform;
Second, appropriately broaden the scope of use, allowing family members to help each other to use personal accounts to pay for medical expenses borne by family members (children, spouses and parents), personal contributions for family members to participate in residents’ medical insurance, and expenses for family members to purchase medicines, medical devices and medical consumables at designated retail pharmacies;
The third is to improve the management measures for the use of personal accounts. Personal accounts should not be used for public health, physical fitness or health care consumption, and at the same time, fraud and insurance fraud should be severely cracked down.
Will the money in personal accounts decrease after the reform? Will it affect the treatment?
After the reform, from the current point of view, most of the insured employees’ personal accounts are reduced; In the long run, all insured workers have increased the general outpatient treatment that they did not have before, especially the sick people and the elderly. It is equivalent to using personal accounts to reduce the amount of money transferred, which increases the general outpatient treatment for the insured employees, and ultimately benefits the insured employees themselves. The first is mutual aid guarantee. After the reform, the scale of the overall fund is larger, the ability to pay for the insured employees is stronger, and the protection of diseases is more comprehensive. The second is intergenerational transfer. I didn’t get sick when I was young, but I used it when I was old, but personal accumulation is limited, and social accumulation can meet everyone’s treatment needs in a wider range. The third is fund efficiency. The medical insurance department takes this money not only to pay the insured, but also to play a game with medical institutions and pharmaceutical companies to improve the management performance of medical insurance funds. In short, the rights and interests of personal accounts have not been eroded, and the accumulation is still for their own use; The new institutional function transformation has achieved the institutional results of mutual aid guarantee, intergenerational guarantee and improvement of management efficiency.
What guarantees does the establishment of outpatient mutual aid mechanism have for the elderly?
When improving the outpatient mutual aid guarantee mechanism in our province, the general outpatient co-ordination treatment payment is appropriately tilted to retirees, the annual payment limit is higher than that of on-the-job employees, and the reimbursement ratio is 5 percentage points higher; Further increase the inclusion of chronic and special diseases in outpatient clinics will benefit the elderly to a greater extent and a wider range. At the same time, the personal accounts of children who participate in employee medical insurance can also be used by their parents. (Qian Long)