Personal accounts can be used to pay for the medical expenses incurred by the insured person, his spouse, parents, and children in the designated medical institutions for medical treatment, and for the purchase of drugs, medical equipment, and medical consumables in designated retail pharmacies by individuals. cost.
The largest reform of the employee medical insurance system in more than 20 years was officially unveiled.
The 340 million insured persons will usher in an "enhanced version" of outpatient mutual aid while their personal accounts are shrinking.
After the reform is fully launched, 200 billion yuan of funds can be used to strengthen outpatient protection in the current period, and the elderly are the biggest beneficiaries.
On April 22, the State Council issued the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Assistance Mechanism" (hereinafter referred to as the "Opinions").
The "Opinions" proposed that the outpatient mutual aid guarantee function should be enhanced, and the payment ratio within the general outpatient policy should start from 50%; the personal account accounting method should be improved, and all the basic medical insurance premiums paid by the unit will be included in the overall fund.
Chen Jinfu, deputy director of the National Medical Insurance Bureau, stated at the State Council Information Office's regular policy press conference that the general consideration of the reform is to promote the shift from the personal accumulation insurance model to the social mutual aid and mutual aid insurance model for outpatient medical insurance for employees.
By including ordinary outpatient expenses into the reimbursement of the overall planning fund, the protection function of the medical insurance fund is enhanced, the efficiency of the fund is improved, the accessibility of outpatient medical services is correspondingly improved, and the burden of the masses, especially the elderly, on outpatient medical expenses is reduced.
Compared with the consultation draft published at the end of August last year, the official "Opinions" included the medication protection services provided by qualified designated retail pharmacies into the scope of outpatient protection, supported the settlement and dispensing of external prescriptions in designated retail pharmacies, and proposed explorations. Eligible "Internet +" medical services are included in the coverage.
my country’s medical insurance system has always followed the basic principle of “coordinating funds to manage major illnesses and personal accounts for minor illnesses”. However, many problems have emerged in reality. The scale of personal account accumulation is getting larger and larger, and it will be nearly 1 trillion in 2020. However, the use efficiency of account funds is very low, and the limitations have become increasingly prominent.
Chen Jinfu said that the reform of the outpatient mutual aid guarantee mechanism has greatly activated and improved the efficiency of the fund's use by "vacating the cage and changing the bird" of the medical insurance fund.
After the reform, there will be 200 billion of funds used to strengthen outpatient protection during the current period. This money has become a real fund investment, which can be used for the sick, especially the elderly, and for medical services. Paid.
The outpatient mutual aid policy mainly involves three levels: one is reimbursement of outpatient expenses, the second is personal account reform, and the third is family sharing.
Equity swap is the key word in the reform of personal account of medical insurance.
After the reform, the size of medical insurance personal accounts will be reduced. The basic medical insurance premiums paid by units will no longer be included in the personal accounts of in-service employees. In principle, the personal accounts of retirees will be allocated by the pooling fund at a fixed amount.
The increased overall planning fund after the reduction of individual accounts is mainly used for outpatient mutual aid and to improve outpatient benefits.
The "Opinions" proposes to establish and improve the overall insurance mechanism for general outpatient expenses of medical insurance for employees. On the basis of ensuring medical insurance for outpatient chronic and special diseases, such as hypertension and diabetes, which are heavily burdened by the masses, the common outpatients with frequently-occurring diseases and common diseases shall be gradually reduced. Outpatient expenses are included in the scope of payment by the overall planning fund.
Ordinary outpatient clinics cover all insured employees of employee medical insurance, and the payment ratio within the scope of the policy starts from 50%.
Liao Cangyi, a researcher at the Medical Service Governance Research Center of Tsinghua University, told CBN that the state's promotion of the reform of medical insurance personal accounts and the establishment of an outpatient mutual aid guarantee mechanism can be seen as a reform of the stock of medical insurance funds and expand the use of personal accounts.
This move will not only improve the benefits of insured persons, but also reduce personal account abuse and the resulting regulatory pressure on fraudulent insurance and hedging, and improve the efficiency of the use of medical insurance funds.
Another reform of the "Opinions" in activating the existing medical insurance funds is to expand the scope of use of personal accounts, so that families can help each other.
Personal accounts can be used to pay for the medical expenses incurred by the insured person, his spouse, parents, and children in the designated medical institutions for medical treatment, and for the purchase of drugs, medical equipment, and medical consumables in designated retail pharmacies by individuals. cost.
That is to say, the medical insurance cards of the children participating in the medical insurance of employees can justifiably buy medicines for their parents and use them for medical treatment, make up for the lack of funds in the medical insurance funds of the elderly’s personal accounts, and improve the level of protection for the elderly.
The elderly is the most important system consideration for this reform.
Fan Weidong, head of the Treatment Security Department of the National Medical Insurance Administration, said that on the basis of a 50% start-up level for general outpatient care, it is clearly required that all localities provide additional preferential payments to retired elderly people.
After the reform is implemented, this system can reduce the burden of outpatient expenses for retirees by nearly 100 billion yuan.
This is a great benefit for the elderly.
In the process of reform, this group of people will benefit even greater and wider.
Author: Guo Jinhui