Chinanews.com, February 10th. Wuhan Medical Insurance Bureau's official WeChat public account "Wuhan Medical Insurance" released a policy interpretation of the "Wuhan City Employee Basic Medical Insurance Outpatient Mutual Aid Security Implementation Rules" on the 9th.
On December 31, 2022, the "Wuhan City Employee Basic Medical Insurance Outpatient Mutual Aid Implementation Rules" was officially issued. The relevant policies are interpreted as follows:
Question 1: Why is it necessary to carry out the reform of outpatient medical insurance for employees?
Answer: Like cities across the country, the employee medical insurance in our city implements a protection mechanism that combines pooled funds and individual accounts.
Prior to this, the overall planning fund covered hospitalization and outpatient serious illnesses, and personal accounts covered outpatient minor illnesses. There was a situation where the insured employees "are not able to spend enough if they are sick, and can't use it if they are not sick".
On the one hand, more than 60% of the personal account deposits in the city lie in the accounts of young and healthy people; on the other hand, the personal account balances of retired and sick people are not enough to use, and the burden of outpatient personal expenses is heavy.
In accordance with the "Guiding Opinions of the General Office of the State Council on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Basic Medical Insurance for Employees" (Guobanfa [2021] No. 14) and "The General Office of the Provincial People's Government on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Basic Medical Insurance for Employees" Implementation Opinions" (Ezhengbanfa [2022] No. 25), the city has formulated and implemented the "Wuhan City Employees' Basic Medical Insurance Outpatient Mutual Aid Security Implementation Rules", the main purpose is to solve the problem of outpatient security for insured employees, and effectively Reduce the burden of their medical expenses.
The main features of this reform: First, the personal account setting and some functions of employee medical insurance are retained, and its cumulative effect will continue to be played.
The second is to give full play to the guarantee function of the overall planning fund, include ordinary outpatient expenses in the scope of reimbursement of the overall planning fund, and effectively help the insured employees who need medical treatment.
For example, the general outpatient payment limit for in-service personnel is 3,500 yuan, and that for retirees is 4,000 yuan. Before that, they did not enjoy this guarantee.
The third is to strengthen the supporting capacity of the overall planning fund, which is more conducive to protecting the rights and interests of insured employees under the general trend of population aging and continuous growth in medical demand.
Question 2: Implementing the reform of outpatient security methods, what aspects are reflected in the improvement of security for insured employees?
Answer: First, the mutual assistance function of employee medical insurance has been improved.
The insured employees who have a lot of outpatient needs and diseases have obviously benefited, and outpatient medical expenses for common diseases and frequently-occurring diseases that could not be reimbursed before are included in the scope of payment of the overall planning fund.
Especially for insured employees who suffer from chronic diseases, the actual benefit amount far exceeds the reduction amount of personal accounts.
Second, the family mutual aid of individual accounts of employee medical insurance has been realized.
Before the reform, individual accounts could only be used by the insured employees themselves.
After the reform, the scope of use of personal accounts has expanded from the insured employees themselves to themselves, their spouses, parents, and children.
In particular, insured employees who are in good health can use their own accounts to pay for their children and parents' medical expenses. On the basis of the overall planning fund "social mutual aid", a personal account "small family mutual aid" has been added.
Third, the scope of use of personal medical insurance accounts for employees has been expanded.
After the reform, in addition to using personal accounts to pay for medical treatment at designated medical institutions and drugstores, insured employees can also use personal accounts to pay for urban and rural residents' medical insurance for spouses, parents, children, etc., which is more efficient , the coverage will be wider.
Question 3: Some insured employees said that after the reform, "there are fewer transfers to personal accounts, and they suffer losses." What do you think of this?
Answer: After the reform, in the current period, most of the insured employees will have less personal account transfers; in the long run, all insured employees have increased the ordinary outpatient treatment that they did not have before, especially the sick people and the elderly benefit more. many.
It is equivalent to using the personal account to reduce the transfer of money to increase the general outpatient treatment for the insured employees, and the insured employees themselves will benefit in the end.
Not only that, after the reform, the scale of the overall planning fund is larger, the ability to pay for insured employees is stronger, and the protection for diseases is more complete.
For example: the insured person Li, a working employee, 30 years old, with an annual income of 100,000 yuan, suffers from cervical spondylosis, and seeks medical treatment in a secondary hospital. The reimbursement expenses incurred this year are 3,600 yuan. 700 yuan, according to the reimbursement rate of 60% of the secondary hospital, (3600-700) yuan * 60% = 1740 yuan can be reimbursed.
Although 1,100 yuan was less credited to Li's personal account, he enjoyed 640 yuan more in treatment.
The insured person Wang, a working employee, is 51 years old and has an annual income of 80,000 yuan. He suffers from chronic cholecystitis and seeks outpatient treatment in a certain level of hospital. The reimbursement expenses incurred this year are 4,900 yuan. 700 yuan, according to the reimbursement rate of 80% of the first-level hospitals, (4900-700) yuan * 80% = 3360 yuan can be reimbursed.
Although 1,360 yuan was less credited into Wang's personal account, he enjoyed 2,000 yuan more in treatment.
The insured person Zhou, a retiree, is 68 years old and has an annual pension income of 50,000 yuan. Before the reform, his personal account was allocated 2,400 yuan per year.
Suffering from cerebral infarction, I went to a tertiary hospital for outpatient treatment, and the reimbursement expenses incurred this year were 7,150 yuan. If I am reimbursed according to the outpatient overall policy, excluding the threshold fee of 500 yuan, I can be reimbursed according to the 60% reimbursement ratio of the tertiary hospital (7150- 500) yuan * 60% = 3990 yuan.
Although 1,404 yuan less was transferred to Zhou's personal account after the reform, his treatment was 2,586 yuan more.
Question 4: After the reform of outpatient insurance, is it convenient for insured employees to buy medicines in pharmacies?
Answer: After the reform, insured employees will not be affected to purchase medicines in pharmacies.
The reform proposes to include qualified designated retail pharmacy drug guarantee services into the scope of outpatient guarantee, the purpose is to facilitate the reimbursement of patients nearby and reduce the burden of expenses.
First, the personal account balance of the insured employees, as before, can purchase drugs in the medical insurance catalog at any designated pharmacy.
Second, insured employees can also enjoy reimbursement when they purchase state-negotiated drugs at qualified designated pharmacies with external prescriptions from designated hospitals.
Third, after the supporting system is completed, the insured employees can also enjoy the reimbursement treatment of the overall planning fund in qualified designated pharmacies with the out-of-pocket prescriptions of designated hospitals.
Question 5: After the establishment of the employee medical insurance outpatient mutual aid security system, what convenient services will medical institutions provide?
A: First, open convenience clinics.
In order to cooperate with the reform, 544 designated medical institutions in the city have set up convenient outpatient clinics, exempting registration fees, diagnosis and treatment fees and personal payment of general diagnosis and treatment fees in grassroots medical institutions.
Second, optimize the treatment measures.
On the basis of exempting general outpatient registration fees for the elderly over the age of 65, medical institutions at all levels have set up green channels for the elderly to see a doctor, and can issue 3-month prescriptions for eligible chronic disease patients.
Third, promote online diagnosis and treatment.
Encourage doctors to issue online prescriptions for some common diseases and chronic diseases for returning patients.
Fourth, do a good job in health management.
Promote family doctor services, incorporate patients with chronic diseases such as hypertension and diabetes into health management, and comprehensively improve the level of health services for key populations.
Question 6: What supporting medical insurance policies will be issued in Wuhan in the future?
Answer: First, increase the number of designated medical institutions for outpatient co-ordination of employee medical insurance, and include more qualified designated medical institutions into the scope of outpatient co-ordination, so that insured employees have more choices of medical institutions.
Second, increase the coverage of special diseases for chronic diseases in outpatient medical insurance, increase the types of special diseases for chronic diseases such as hypertension and diabetes from 28 to 37, and increase the types of basic diseases from 32 to 70.
Third, improve the medical insurance reimbursement policy for day surgery. At present, 23 outpatient day surgeries can be reimbursed by medical insurance, and the number of reimbursed diseases will continue to increase in the next step.
Fourth, promote the circulation of electronic prescriptions. Insured employees can directly purchase medicines at designated outpatient pharmacies with electronic prescriptions issued by designated medical institutions, and enjoy the treatment of outpatient overall planning funds.
In the next step, the departments of medical insurance, health care, market supervision, and finance will continue to deepen the supporting measures for the reform of the employee medical insurance outpatient mutual aid guarantee mechanism to ensure that the insured employees can see a doctor more conveniently, have more adequate medical expense protection, and have a stronger sense of gain.
(China New Finance and Economics)
Screenshot of the WeChat public account information of "Wuhan Medical Insurance".