Employee medical insurance ushered in major changes-the
mutual
aid use of personal accounts benefited family members
Our reporter Wu Jiajia
Recently, the General Office of the State Council has issued the "Guiding Opinions on Establishing and Improving the Mechanism for Establishing and Improving the Mutual Aid Guarantee Mechanism of Basic Medical Insurance for Employees."
The opinions put forward that the outpatient expenses should be included in the payment scope of the employee medical insurance overall fund, reform the employee medical insurance personal accounts, and establish and improve the outpatient mutual aid guarantee mechanism.
How to realize family mutual aid in personal accounts of insured employees?
What conditions need to be met?
Will the treatment of the insured person be affected?
The Economic Daily reporter interviewed experts and relevant department heads.
Personal accounts can be used by the whole family
The opinion is clear that the personal account can be used to pay for medical expenses incurred by the insured person, his spouse, parents, and children in the designated medical institution for medical treatment, and for the purchase of drugs, medical equipment, and medical consumables in designated retail pharmacies. Personally borne expenses.
"Family mutual aid is for personal accounts." Fan Weidong, head of the Treatment Protection Department of the National Medical Security Administration, said that the employee medical insurance fund is divided into two parts, namely the overall fund and the personal account.
After this reform, the scope of use of employee personal accounts will be expanded. The main use is the "small pool" of personal accounts, which can be said to be "small mutual aid."
The personal out-of-pocket expenses after the reimbursement of the overall fund can be paid in cash or through a personal account.
At present, many families generally have family members participating in different types of insurance.
Parents participate in medical insurance for urban and rural residents, and children participate in employee medical insurance.
Personal accounts allow families to use for mutual aid, which will reduce the family’s burden of medical expenses.
"Outpatient mutual aid guarantee will help the insured to realize the risk of intergenerational transfer." Chen Jinfu, deputy director of the National Medical Insurance Bureau, said that the insured was not ill when he was young, and tended to get sick when he was old, but relying solely on personal accumulation is limited and social accumulation It can solve the public's medical needs on a larger scale.
At the same time, outpatient mutual aid protection can also further release the effectiveness of medical insurance funds.
"According to the relevant statistics of the overall fund and personal accounts in 2020, the cumulative balance of personal accounts is 1 trillion yuan. Before the reform, this money was not available to others. The new guarantee mechanism is generally the balance transfer of funds and is used for real The purchase of medical services is conducive to the mutual aid of crowd funds, and it is also conducive to the sustainable development of the system." Chen Jinfu said.
Expansion of reimbursement
The opinion puts forward that the general outpatient expenses for frequently-occurring and common diseases shall be gradually included in the payment scope of 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%.
In addition, gradually expand the scope of outpatient chronic diseases that are paid by the overall fund, and include some outpatient expenses for diseases that have long treatment cycles, great health damage, and heavy cost burdens into mutual aid protection. Economical and convenient special treatment can be managed with reference to hospitalization treatment.
This means that in the future, employee insured persons can be reimbursed for more general outpatient expenses.
Chen Jinfu said that the past system had an adverse regulatory effect on hospitalization. The problem caused by minor illnesses and large-scale care was that it not only increased fund expenditures, but also wasted high-end medical resources.
Expanding the scope of outpatient reimbursement not only improves the treatment level of insured persons, but also eliminates the phenomenon of "small illness and large-scale care".
Not only that, but you can also be reimbursed by medical insurance when you buy medicines in pharmacies and see a doctor online.
Fan Weidong said that in addition to the original personal account that can continue to be used to purchase drugs in pharmacies, qualified retail pharmacies are included in the settlement scope of the overall fund. The cost of purchasing medical equipment and medical consumables at designated pharmacies can be paid by personal accounts. +"Medical services can also be included in the scope of basic medical insurance.
Does not affect the level of protection
According to opinions, the personal accounts of employees are included in the basic medical insurance premiums paid by the individual, and the accounting standard is in principle controlled at 2% of the insurance payment base of the individual, and all the basic medical insurance premiums paid by the unit are included in the overall planning fund.
In principle, the personal accounts of retirees are allocated from the overall planning fund according to a fixed amount, and the allocated amount is gradually adjusted to about 2% of the average level of the basic pension in the year when the reform is implemented in accordance with this opinion.
After adjusting the pooling fund and personal account structure, the increased pooling fund is mainly used for outpatient mutual aid protection and improving outpatient benefits of insured persons.
"By adjusting the personal account crediting method, the unit payment will no longer be credited to the personal account." Chen Jinfu said that basically the new credits to the personal account will be reduced, but the reduction of the new credits to the personal account does not mean that the protection function is reduced. It is the formation of a new guarantee mechanism in the "big pool" of mutual aid guarantee.
This new guarantee mechanism generally transfers funds in a balanced way, and the guarantee efficiency is significantly enlarged.
This part of the funds is not only used to purchase medical services, but also conducive to the mutual aid of funds, and is more conducive to the sustainable development of the long-term system.
The opinion also stipulates that the use of personal accounts shall be regulated and shall not be used for expenditures that are not covered by basic medical insurance, such as public health expenses, sports fitness or health care consumption.
Experts said that based on the funds designed by the Social Insurance Law and related laws, the medical insurance fund is used for social insurance and is used for targeted use to prevent disease risks.
At the same time, limited by economic and social development and fund support capabilities, guarantees cannot be separated from the current stage of development and can only guarantee basics.
In other words, the level of protection and the scope of protection must be adapted to the level of economic development to achieve sustainable development of the system.
Wu Jiajia
Wu Jiajia