Explain the medical insurance "family account": getting through urban and rural areas is just around the corner, and hospital prescription pharmacies can be reimbursed for medicines bought
The reform uses two percentage points of the individual payment in the personal account to do family mutual aid, the purpose is to gradually open up employees and residents, and finally realize family insurance.
This reform will also lay the foundation for the unification of the urban and rural systems in the future.
Personal account funds can be shared and used within the family. This is a major breakthrough in the reform of the basic medical insurance outpatient service for employees. It means that my country's medical insurance "family account" system has basically taken shape.
On April 22, the State Council issued the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism" (hereinafter referred to as the "Opinions").
The "Opinions" stated that personal accounts can be used to pay for medical expenses incurred by the insured person, his spouse, parents, and children who seek medical treatment in designated medical institutions, as well as the purchase of drugs, medical equipment, and medical consumables in designated retail pharmacies. The expenses borne by the individual.
Although relevant documents have been issued, there are still a large number of issues that are of concern to insured persons, such as how to share family accounts between family members living in different places, and whether parents in rural areas can share the personal accounts of urban employees' children.
Experts interviewed by CBN said that all family members, whether in remote or rural areas, can enjoy the family account. This principle is certain. However, due to the large local differences in medical insurance policies, the next step will be to combine medical insurance departments in various regions. The actual situation in various places has introduced specific plans at the operational level.
The "Opinions" require that the provincial governments to issue implementation measures before the end of December this year to guide the coordinated areas to combine local conditions and refine policies and regulations. A transition period of about three years can be set to gradually achieve the reform goals.
Another highlight of the "Opinions" is the introduction of measures to support the development of designated retail pharmacies, clearly supporting prescriptions out of hospitals. In the future, insured persons can not only use the money in their personal accounts to buy medicines in pharmacies, but also take them. For common diseases and chronic diseases prescribed by the hospital, go to the pharmacy to buy medicines, and enjoy the same reimbursement treatment as the medicines bought in the hospital.
This new policy not only facilitates the general public, but also alleviates the worries of designated retail pharmacies about shrinking medical insurance accounts.
"Family Account" to open up urban and rural areas
Employee medical insurance was established in 1998. It implements a security model that combines social pooling and personal accounts. "The pooled fund guarantees hospitalization and outpatient major illnesses, and the personal account guarantees outpatient expenses for minor illnesses and medicines."
In recent years, the limitations of personal accounts have gradually become prominent, mainly manifested in insufficient protection functions, insufficient mutual aid, insufficient use of those who are ill, and no use of those who are not.
Chen Jinfu, deputy director of the National Medical Insurance Bureau, said at the press conference of the State Council that the core of this system reform is the transformation from the original personal accumulation insurance model for outpatient medical expenses to the mutual fund insurance model.
The expansion of the use of personal accounts. The personal accounts of children participating in employee medical insurance can be used by their parents. The implementation of mutual aid within the family is a major innovation of this reform.
Fan Weidong, head of the Treatment Protection Department of the National Medical Insurance Administration, said that personal accounts have been expanded to three aspects.
First, the funds in the personal account can only be used for personal use. Now, the medical expenses incurred by individuals and their spouses, parents, and children when they seek medical treatment at designated medical institutions can be paid by personal accounts.
The second is to buy medicines at designated pharmacies, which used to be for personal use only. Now, at designated pharmacies, medicines, medical equipment, and medical consumables can all be paid in the personal medical insurance accounts of family members and employees.
Third, it can be used for individual payment of social insurance such as the basic medical insurance for urban and rural residents by their spouse, parents, and children.
"The personal out-of-pocket expenses after the reimbursement of the overall fund can be paid in cash or through a personal account. In the future, when the personal account is paid, you can pay not only to yourself, but also to your family members and your spouse living with you. , Children, parents, this is what we call personal account family mutual aid this small-scale mutual aid." Fan Weidong said.
Zhang Xiao, director of the Medical Insurance and Social Security Research Center of Southeast University, told a reporter from China Business News that one of the goals of this reform is to establish a family account system for medical insurance. The principle "all family members can enjoy" is certain.
For example, for parents and children in the same employee medical insurance system, my country is implementing a reform of inter-provincial settlement of outpatient expenses. There will be no technical obstacles to the use of family accounts in different places in the future.
Zhang Xiao said that parents who participated in the medical insurance for urban and rural residents shared the personal account funds of their children participating in the medical insurance for urban employees, which was also within the scope allowed by the policy. Extend and expand.
Yang Yansui, a professor at the Institute of Hospital Management of Tsinghua University, told China Business News that from an international perspective, medical insurance involves one employee participating in the insurance for the whole family. The situation in my country where only one person is insured and family members cannot enjoy the same medical insurance benefits are internationally There is no precedent.
The reform uses two percentage points of the individual payment in the personal account to do family mutual aid, the purpose is to gradually open up employees and residents, and finally realize family insurance.
This reform will also lay the foundation for the unification of the urban and rural systems in the future.
The "Opinions" specifically proposes to simultaneously improve the outpatient coordination of basic medical insurance for urban and rural residents, and gradually increase the level of protection.
Zhang Xiao also said that due to the large differences in the medical insurance system between regions and the level of treatment, the specific time for the implementation of the "Opinions" depends on the situation of the local formulation of the plan. The next step should be to address the problems faced by the past personal accounts and the use of personal accounts. The needs of insured persons are sorted out and evaluated, and then detailed reform plans in various regions are formulated in accordance with the spirit of the "Opinions" to achieve a smooth transition as much as possible.
Good for designated retail pharmacies
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.
Zhu Minglai, director of the Research Center for Health Economics and Medical Security of Nankai University, told a reporter from China Business News that after the release of the draft for comments, the response of designated retail pharmacies was relatively strong. A large part of the retail pharmacy market is based on personal account funds to buy in pharmacies. The reduction of personal accounts will affect their interests.
The officially issued "Opinions" comprehensively consider the opinions of retail pharmacies, and include qualified retail pharmacies into the scope of outpatient protection.
Fan Weidong said that as of the end of 2020, there are about 390,000 designated medical pharmacies across the country, and the annual expenditure of personal accounts for designated pharmacies is more than 200 billion yuan.
This reform also places great emphasis on continuing to play the positive role of designated retail pharmacies in medical security services.
In addition to the original personal account that can continue to be used for drug purchases in pharmacies, the "Opinions" also clarified three support measures.
First, include eligible retail pharmacies into the settlement scope of the overall fund.
It used to be that personal accounts can be used in pharmacies, but now the overall settlement of funds has been extended to pharmacies.
Specifically, the insured person can purchase medicines in the pharmacy with the prescription issued by the medical institution after outpatient visits at the designated medical institution, and the incurred expenses in compliance with the regulations enjoy the same reimbursement treatment as the medical institution.
Second, the "Opinions" also broadened the scope of use of personal accounts, implemented family mutual aid, and further expanded the scope of payment for personal accounts to the cost of purchasing medical equipment and medical consumables at designated pharmacies.
Third, eligible "Internet +" medical services can also be included in the scope of basic medical insurance.
For eligible online medical services, funds can also be paid in accordance with regulations.
Zhu Minglai said that due to the large number of designated pharmacies, there were often illegal acts of defrauding medical insurance funds in the past. Effective supervision of retail pharmacies is an issue that must be paid attention to in the next step.
Zhang Xiao said that some young people’s accounts have accumulated as much as tens of thousands of dollars. Since these money cannot be used elsewhere, they have a strong impulse to find ways to "cash out". Therefore, after personal accounts are opened to families, they must strengthen their fraudulent practices. And the identification of fraudulent insurance.
Moreover, "blocking" alone will not work, and the relevant departments must design and perform the functions of the account well.
The "Opinions" proposed that the budget management system of the medical insurance fund should be strictly implemented, and the fund audit and internal control system should be strengthened.
Strengthen the review of personal account use and settlement.
Strengthen the supervision of medical behavior and medical expenses, and crack down on fraudulent insurance fraud.