Chinanews client, Beijing, April 8th (Reporter Li Jinlei) The employee medical insurance will usher in major changes.
The executive meeting of the State Council held on April 7 decided to establish and improve the measures to establish and improve the mutual aid guarantee mechanism of basic medical insurance for employees, broaden the use of personal account funds, and reduce the medical burden of the masses.
Specifically, there are four main changes in employee medical insurance.
Data map: outpatient building of a hospital.
Photo by China News Agency reporter Yin Liqin
Incorporate more outpatient expenses into medical insurance reimbursement
The meeting pointed out that my country's new round of medical reform has established the world's largest basic medical insurance network that benefits more than one billion people, which has played an important role in reducing the burden of medical treatment and alleviating the cost of medical treatment.
In recent years, outpatient chronic diseases such as hypertension and diabetes involving many patients have been included in medical insurance reimbursement.
The next step is to deepen the medical reform, enhance the mutual assistance and mutual assistance function of basic medical insurance for employees, and include more outpatient expenses in medical insurance reimbursement to further reduce the burden on patients.
The meeting determined that part of the general outpatient expenses for chronic, frequently-occurring, and common diseases that are harmful to health and costly will be gradually included in the overall planning fund.
Within the scope of the policy, the payment ratio will start from 50%, with an appropriate preference for retirees. In the future, the level of protection will be gradually increased as the capacity of the fund increases.
According to data from the National Medical Insurance Administration, as of the end of 2020, the number of people participating in basic medical insurance for employees was 34.23 million, an increase of 14.98 million or 4.6% over the same period of the previous year. Among the people participating in basic medical insurance for employees, 253.98 million were employed and retired. 90.25 million employees.
Previously, the basic medical insurance system focused on hospitalization. In 2019, the reimbursement rate of medical expenses within the hospitalization policy of employee medical insurance reached more than 80%, but outpatient insurance was relatively weak, and most outpatient expenses were mainly paid through personal accounts.
However, the money in the personal account is relatively small, and the cost of some common diseases is very high, which cannot be paid by the personal account alone.
Therefore, including more outpatient expenses into medical insurance reimbursement will help reduce the medical burden of the insured.
Data map: Photograph by Cai Jun when the patient enters the hospital for treatment
Unit payments are no longer included in personal accounts
The meeting decided to improve the method for crediting personal accounts.
The individual contributions of the employees are still included in their personal accounts, and all the unit contributions are included in the pooling fund; the personal accounts of retirees are included in the pooling fund according to a fixed amount, and the amount of the transfer is gradually adjusted to the average level of the basic pension in the year when the reform was implemented in the pooling area. Around 2%.
Before the reform, all personal medical insurance payments and 30% of unit payments were included in personal accounts.
After the reform, for in-service employees, all unit contributions are included in the pooling fund instead of personal accounts, and only individual contributions are included in personal accounts.
As a result, the money that goes into the personal account becomes less, so where is this part of the money used?
The “Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Assistance Mechanism (Draft for Comment)” issued by the National Medical Insurance Administration in August 2020 pointed out that the reduction of funds allocated to personal accounts after the adjustment of the unified account structure is mainly used for support Improve mutual aid protection in outpatient clinics and increase outpatient treatment.
Zhang Yinghua, an executive researcher at the World Social Security Research Center of the Chinese Academy of Social Sciences, previously told a reporter from Chinanews.com that the cancellation of the part of unit payment and transfer to personal accounts means that the social pooling part of the medical insurance fund has been increased, and the mutual aid of healthy people to the sick has been enhanced. For healthy people, getting sick in the future can also get more mutual aid from members of the society.
Data map: People swipe their cards to pay at the window of a hospital in Qinghai.
Photo by Zhang Tianfu
Personal accounts can be used by family members
The meeting decided to broaden the scope of use of personal accounts and allow family members to help each other. It can be used to pay for medical treatment in designated medical institutions and the expenses incurred by individuals for purchasing drugs, medical equipment and medical consumables in designated retail pharmacies. Explore the use of family members to participate in urban and rural areas. Resident basic medical insurance and other personal payment.
This means that less money goes into personal accounts, but the use of personal accounts has expanded.
Previously, personal accounts could only pay for the medical expenses of the employees themselves. Most of the healthy people had a large balance in their personal accounts, while a small number of the elderly and frail people could not make ends meet with their personal accounts and their personal burden was heavy.
After the reform, it will be expanded to cover the personal expenses of the employee’s spouse, parents, and children.
Yang Yansui, a professor at the Institute of Hospital Management of Tsinghua University, believes that medical insurance is essentially social mutual aid, but the personal account mutual aid ability is poor, young and healthy people cannot use it, and the elderly are not enough. The expansion of the use of personal accounts will help strengthen the family. Mutual aid, one person participates in insurance to protect the whole family.
Data map: Citizens line up for registration in the outpatient hall of the hospital.
Photo by China News Agency reporter Yang Di
Strengthen the supervision and management of medical insurance funds
The meeting decided to strengthen the supervision and management of the medical insurance fund, improve the audit and internal control systems, seriously investigate and deal with false hospitalizations, fraudulent insurance fraud and other violations of laws and regulations, and improve the payment mechanism compatible with outpatient mutual aid guarantees.
The medical insurance fund is the common people’s money for medical treatment and life-saving, but some people regard the medical insurance fund as "tang monk meat" and try to "drip and leak" from it to defraud the medical insurance fund.
Data shows that in 2020, more than 600,000 designated medical institutions were inspected, more than 400,000 medical institutions that violated laws and regulations were dealt with, and 22.31 billion yuan of medical insurance funds were recovered.
More than half of the designated medical institutions had problems with the use of funds to varying degrees.
With the strengthening of the supervision and management of medical insurance funds, illegal activities such as insurance fraud will be subject to greater "strong supervision".
The reporter noted that the 2021 government work report proposed to establish a sound outpatient mutual aid guarantee mechanism, and gradually include outpatient expenses into the overall planning fund for reimbursement.
According to the "Opinions on Implementing the Division of Key Tasks in the "Government Work Report"" issued by the State Council, this work is led by the National Medical Insurance Administration, and the Ministry of Finance is responsible for division of responsibilities. Relevant policies will be promulgated by the end of May and continued throughout the year.
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