Establishing and improving the outpatient mutual assistance security mechanism of basic medical insurance for employees is an important task in deepening the reform of the medical security system. At the end of September this year, the "Implementation Measures for Improving the Outpatient Mutual Aid Mechanism for Employee Basic Medical Insurance" (hereinafter referred to as the "Implementation Measures") was reviewed and approved by the 16th executive meeting of the Suzhou Municipal Government and issued by the Municipal Government Office (Su Fu Ban [2022] No. 207), and will be implemented from January 1, 2023.
The implementation of the "Implementation Measures" will provide multiple reform "dividends" for insured persons. Let's take a look at ten questions and answers on the employee medical insurance outpatient mutual aid security policy!
Ten questions and answers will help you understand Suzhou City Employees Basic Medical Insurance Outpatient Mutual Aid Security Policy
01 What are the national and provincial deployment requirements for the establishment and improvement of the employee basic medical insurance outpatient mutual aid security mechanism?
In April last year, the General Office of the State Council issued the "Guiding Opinions on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Employee Basic Medical Insurance" (Guobanfa [2021] No. 14, hereinafter referred to as the "Guidance Opinions"), and the National Medical Insurance Administration issued the "Three-Year Action Plan for Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Employee Basic Medical Insurance (2021-2023)" (hereinafter referred to as the "Three-Year Action Plan"). In December 2021, the General Office of the Provincial Government issued the "Implementation Opinions on Establishing and Improving the Outpatient Mutual Aid Guarantee Mechanism for Employee Basic Medical Insurance" (Su Zhengbanfa [2021] No. 108, hereinafter referred to as the "Implementation Opinions"). The main spirit is to use about three years to adjust the overall fund and personal account structure. The increased overall fund will be mainly used for outpatient mutual aid protection, improve the outpatient benefits of insured personnel, promote the shift of employee medical insurance outpatient protection from an individual accumulated security model to a social mutual aid security model, and reduce the outpatient medical cost burden of the masses, especially retirees.
02 What time schedule has Suzhou City’s “Implementation Measures” made to implement the national and provincial deployment requirements?
In accordance with the requirements of the national "Guiding Opinions" and the provincial "Implementation Opinions", our city issued the "Implementation Measures" at the end of September 2022, which has improved the outpatient coordination and mutual aid policy currently being implemented in our city. Our city's "Implementation Measures" will be implemented from January 1, 2023. At that time, the overall outpatient treatment level will be increased, and the personal accounts of active employees will be adjusted. The personal account adjustment policy for retirees will be reformed in place by the end of 2023 in accordance with provincial regulations and will be implemented from January 1, 2024.
03 What kind of outpatient co-ordination benefits can participants in employee medical insurance enjoy after the reform?
Outpatient co-ordination covers all insured persons in employee medical insurance. The ordinary outpatient expenses incurred by insured persons at designated medical institutions that are within the scope of basic medical insurance policies and exceed the deductible standard (deductible line) shall be included in the payment scope of the outpatient co-ordination fund. The first is to maintain the current deductible payment standard (deductible payment line). Current employees still receive 600 yuan per year, and retirees still receive 400 yuan per year. The second is to increase the maximum payment limit (capping line). The maximum payment limit (capping line) will be uniformly increased from 4,000 yuan per year for current employees and 4,800 yuan per year for retirees to 13,000 yuan per year. The third is to optimize the payment sequence of medical insurance funds. The order in which the personal account funds can be used up first, and then the " payment threshold " can be used before the overall fund can be used is adjusted to: after the " payment threshold" is reached, the unified fund can be used. The fund uses a three-stage formula of personal account, threshold and overall fund to a two-stage formula of threshold and overall fund. At the same time, with the gradual adjustment of personal account credits and the increase in the affordability of the overall fund, the outpatient overall benefits will be gradually improved.
For example,
small insurance, an employed employee, the personal account amount in the medical insurance card is 2,000 yuan, and the medical expenses total 3,000 yuan when he goes to a tertiary hospital , of which 2,800 yuan is within the scope of the medical insurance policy and 200 yuan is outside the scope of the policy.
If the cost of treatment is 2,800 yuan within the scope of the medical insurance policy in 2022, 2,000 yuan will be paid first from the personal account, and the remaining 800 yuan will be included in the local supplementary threshold and paid by the individual. The 200 yuan exceeding the threshold will be paid by the local supplementary fund at a rate of 60%. The 200 yuan for expenses outside the scope of the medical insurance policy will be borne by the small insurance company at its own expense. In the end, of the 3,000 yuan in medical expenses, 2,000 yuan is paid to the individual account, and 200×60% is paid to the local supplementary fund = 120 yuan. The personal out-of-pocket expense is the sum of the threshold fee and the proportional out-of-pocket expense, which is 600+200×40%=680 yuan. The personal out-of-pocket expense is 200 yuan, that is, the small insurance needs to pay 880 yuan in cash, and the personal account amount is 0.
If the same expenses occur in 2023, the medical expenses within the scope of the medical insurance policy will be 2,800 yuan, of which 600 yuan will enter the minimum payment line and be paid by the individual. The remaining 2,200 yuan does not need to use personal account funds first, but will be paid directly by the outpatient overall fund at a ratio of 60%. In the end, of the 3,000 yuan in medical expenses, the overall fund paid 2,200 × 60% = 1,320 yuan. The out-of-pocket expense is the sum of the starting line self-payment and the proportional out-of-pocket expense, which is 600 + 2,200 × 40% = 1,480 yuan. The personal out-of-pocket expense is 200 yuan, and the self-payment and self-pay expenses of 1,680 yuan will all be paid by the personal account. That is, the small insurance does not require cash payment, and the personal account balance is 320 yuan.
It can be seen from this that for the same two total expenses and the same personal account amount, after the implementation of the new policy of mutual aid for medical insurance outpatient clinics in 2023, the outpatient benefits of insured persons have been significantly improved!
04 How to adjust the special treatment for outpatient chronic diseases after the reform?
On the premise of ensuring that the overall level of comprehensive outpatient protection for insured employees does not decrease, the city’s employee medical insurance outpatient special disease and chronic disease protection policy will be adjusted and optimized. In accordance with the requirements of the "Notice of Jiangsu Provincial Medical Security Bureau on Unifying Basic Medical Insurance Outpatient Special Disease Protection Policies", the scope of outpatient special disease protection will be standardized and expanded. Standardize and simplify the outpatient security policy system, and integrate outpatient chronic diseases that meet the regulations into the outpatient mutual aid security mechanism, so as to achieve fairness, standardization and uniformity of employee medical insurance outpatient benefits within the city under the municipal coordination of basic medical insurance.
05How to improve the personal account crediting method?
Starting from January 1, 2023, the personal account of active employees will be included in the basic medical insurance premium paid by the individual every month, and the inclusion standard will be 2% of the insured payment base. All basic medical insurance premiums paid by the unit will be included in the overall fund; starting from January 1, 2023, retirees' personal accounts will be allocated a fixed amount according to the allocation scale of their personal accounts in 2022. From January 1, 2024, the amount transferred to retirees' personal accounts will be uniformly adjusted to 2.5% of the average basic pension level in the year when the overall planning area implements the reform based on opinions.
Example 1
Small insurance, for active employees, the monthly insurance payment base is 5,000 yuan, then the monthly credit standard for personal accounts is 5,000 × 2% = 100 yuan, and the 5,000 × 7% = 350 yuan paid by the unit will all be included in the overall fund. The monthly arrival time of the employee's personal account amount is based on the actual arrival time of the tax deduction for the monthly payment amount, from the 12th to the end of each month.
Example 2
Uncle Li, 65 years old, is a retiree. In 2023, his personal account will still be transferred according to the transfer limit of his personal account in 2022, which is 1,350 yuan, which will be credited on January 1, 2023.
06 Personal account What does family member mutual aid mean?
Personal account funds are mainly used to pay out-of-pocket expenses incurred by insured persons within the policy scope of designated medical institutions.After the reform, personal accounts can mainly help family members in three aspects: first, they can be used to pay for the medical expenses borne by the insured person himself and his spouse, parents, and children at designated medical institutions; second, they can be used to pay for the insured person himself, his spouse, parents, and children to purchase medicines, medical equipment, and medical consumables at designated retail pharmacies. The scope of medical equipment and medical consumables for medical expenses borne by individuals is uniformly formulated by the province; third, it can be used for individual payments by insured persons to participate in employee large medical expense subsidies (or critical illness insurance), long-term care insurance, etc. Personal accounts are used for individual payments by spouses, parents, and children to participate in urban and rural residents basic medical insurance, etc. It is expected that specific implementation rules for personal account family mutual aid will be released as early as the first quarter of 2023.
07 What benefits will the reform bring to insured persons? What special protection will be provided to elderly retirees?
The reform of the outpatient mutual aid security mechanism has taken into consideration the implementation of strategies such as coping with the aging of the population, and has adopted three measures to improve the level of security for retirees. First, it is clear that the overall outpatient benefits can be appropriately tilted towards retirees, which is mainly reflected in the fact that the minimum payment line is 200 yuan lower than that of active employees, and the payment ratio is 10 percentage points higher than that of active employees. Second, personal accounts can be shared with families. When the personal accounts of elderly retirees are not enough, they can use the personal accounts of their children who participate in employee medical insurance to implement family pooling to reduce the burden of medical expenses on the elderly. The third is to improve the outpatient special disease policy. In accordance with the requirements of the Provincial Medical Insurance Bureau on unifying basic medical insurance outpatient special disease protection policies, the city's outpatient special disease protection policies have been unified, and payment policies such as "senile cataract" and "family hospital bed" have been retained. What measures does
08 take to strengthen the use of personal accounts and outpatient medical management?
On the one hand, the "Implementation Measures" clarify that personal accounts shall not be used for public health expenses, sports fitness or health care consumption, etc. that are not covered by basic medical insurance; on the other hand, the "Implementation Measures" clarify that the supervision of medical insurance funds will be strengthened, outpatient medical expenses will be included in the province's unified medical insurance fund intelligent monitoring scope, and laws and regulations such as the "Regulations on the Supervision and Management of the Use of Medical Security Funds" will be strictly implemented to prevent violations such as cashing out of personal accounts and out-of-scope use.
09 What measures will the reform take to improve the accessibility of medical services to insured persons?
First, support the settlement and dispensing of external prescriptions in designated retail pharmacies, include the medication protection services provided by qualified designated retail pharmacies into the scope of outpatient protection, and establish a prescription circulation platform. The payment ratio of the drug cost coordination fund within the scope of the policy is consistent with that of designated medical institutions that dispense external prescriptions, giving full play to the role of designated retail pharmacies in providing convenience and accessibility. Before the prescription circulation platform is deployed and meets the conditions for implementation, the payment ratio of the unified fund for qualified designated retail pharmacies shall be based on the ratio of tertiary medical institutions. The second is to establish and improve the national negotiated drug " dual-channel " medication guarantee mechanism, actively promote the implementation of negotiated drugs, make a good connection between separate payment of drug costs and outpatient coordination policies, and explore the inclusion of qualified " Internet + " medical services into the scope of protection. The third is to guide non-emergency insured persons to seek medical treatment at primary medical and health institutions for the first time by collaboratively promoting the construction of primary medical service systems, improving family doctor contract services, and standardizing long-term prescription management.
10 How does the reform of outpatient payment methods adapt to the requirements of the reform of outpatient mutual aid security mechanisms?
The "Implementation Measures" clarify that the total budget management of the outpatient overall fund will be improved, and the reform of outpatient medical insurance payment methods that is compatible with the outpatient mutual aid guarantee mechanism will be deepened. Based on the characteristics of outpatient medical services, innovate medical insurance payment policies and management.For outpatient services in primary medical institutions, explore payment methods based on capitation; for outpatient chronic diseases, actively explore the combination of capitation payment and chronic disease management; for day surgeries and eligible outpatient special diseases, payment by disease type or by disease diagnosis-related grouping will be implemented; for outpatient fees that are not suitable for package payment, payment can be made by project.
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