In order to implement the decisions and deployments of the CPC Central Committee and the State Council, deepen the reform of direct settlement of basic medical insurance for cross-provincial medical treatment in different places, and strive to solve the problems of inconvenient registration of medical treatment in different places, the National Medical Insurance Administration and the Ministry of Finance jointly issued the "About Further Doing a Good Job" today. Notice on Direct Settlement of Basic Medical Insurance for Cross-province Medical Treatment in Different Places.
Promoting the direct settlement of medical expenses across provinces for basic medical insurance is an important reform measure to improve the medical insurance system and address the outstanding concerns of the people.
Since the establishment of the National Medical Insurance Bureau, on the basis of fully realizing the direct settlement of hospitalization expenses across provinces, it has made every effort to promote the online filing of off-site medical treatment and the direct settlement of general outpatient expenses across provinces in all coordinating regions. A pilot program of direct settlement across provinces for 5 types of outpatient chronic and special diseases such as outpatient radiotherapy and chemotherapy for malignant tumors.
In recent years, the direct settlement policy for cross-provincial and remote medical treatment has expanded from hospitalization, to general outpatient clinics, and then to outpatient clinics for chronic and special diseases. In the early stage of the pilot, most policies were promoted in the way of "patching". This "Notice" reviews the previous policies. The system has been systematically sorted out and integrated, and on this basis, the top-level design has been strengthened to solve the narrow scope and short time limit of filing personnel, long-term residents living across provinces cannot enjoy treatment in both the filing location and the insurance location, and inter-provincial temporary outpatient medical personnel filing Problems such as the low reimbursement rate afterward.
In response to the problem that some regions do not support the direct settlement of emergency rescue expenses, trauma expenses, out-of-hospital inspection and treatment purchases during hospitalization, and medical expenses after re-filing, a unified national standard has been formulated.
The "Notice" requires that local medical insurance departments should adjust policies and measures that are inconsistent with this notice in a timely manner to ensure that they are connected with national policies before the end of December 2022; in light of local actual conditions, further clarify and refine policy management regulations, streamline handling materials, and simplify Handling procedures and optimizing management services; synchronously adjust information systems as required to ensure a smooth transition of direct settlement for medical treatment across provinces.
The "Basic Medical Insurance Cross-provincial Direct Settlement Regulations for Medical Treatment in Different Places" will be officially implemented from January 1, 2023.
The main content of the "Notice"
Clarify the goals and tasks at the end of the 14th Five-Year Plan
That is, before the end of 2025, the direct settlement system and handling management service system for inter-provincial medical treatment in different places will be more complete, the supporting role of the unified national medical insurance information platform will continue to be strengthened, and the national medical treatment settlement capacity will be significantly improved; the rate of inter-provincial direct settlement of hospitalization expenses will increase to Over 70%, the number of cross-provincial networked designated medical institutions for general outpatient clinics has doubled, and outpatient chronic and special disease-related treatment expenses that are widely in demand and widely carried out in various regions are gradually included in the scope of direct inter-provincial settlement. Reimbursement online and offline can be handled across provinces.
Unified cross-provincial direct settlement policy for inpatient, general outpatient and outpatient chronic diseases
It is clarified that in principle, the fund payment policy of "directory of medical treatment places and policies of insured places" shall be implemented in cross-provincial direct settlement; "Prepayment and post-clearing" requirements for the management of funds for medical treatment in different places.
Focus on solving the three problems of remote medical treatment filing, settlement and coordination
Further improve the filing policy for medical treatment in other places.
The scope of people seeking medical treatment in different places has been extended to cross-provincial emergency rescue personnel and non-emergency personnel who have not been referred.
The validity period of the unified filing is valid. During the validity period, you can visit the doctor multiple times in the medical treatment place and enjoy the direct settlement service.
Support the insured personnel to enjoy treatment in both the place of record and the place of insured.
Guide localities to reasonably determine the reimbursement policy for inter-provincial medical personnel temporarily going out for medical treatment.
Further clarify the scope of direct settlement services of designated medical institutions.
Include emergency rescue expenses, out-of-hospital inspection, treatment, and drug purchase expenses during hospitalization, and non-third-party liability trauma expenses that comply with the management regulations of the place of medical treatment.
Allow insured persons to make up for the record of medical treatment in other places and enjoy inter-provincial direct settlement services before discharge settlement.
Further standardize the cross-regional collaboration process of agencies.
Establish a mechanism for co-handling problems between places where medical treatment and insurance are involved, and improve the efficiency of co-handling problems between regions.
Promote the sharing of information such as medical insurance policies and shutdown announcements.
Compact the large medical expenses (30,000 yuan and above) to assist in the investigation of the responsibility for medical treatment.
Relying on designated medical institutions to upload information on medical expenses for self-funded personnel, explore the provision of online processing services for cross-provincial manual reimbursement.
Strengthening the management of medical funds across provinces and other places
The responsibilities of medical insurance departments and financial departments at all levels have been strengthened, the adjustment of the annual prepayment amount of medical funds for inter-provincial and non-local medical treatment and the process of emergency adjustment within the year have been standardized, and the fund settlement mode, realization path and time limit requirements have been clarified.
Improve the standardization support of medical insurance informatization
It is required to continue to deepen the application of the national unified medical insurance information platform and the whole process of medical insurance information business coding standards, promote the optimization and improvement of the national cross-provincial and remote medical treatment management subsystem, and strengthen system operation and maintenance management and security.
Strengthen the supervision of direct settlement funds for medical treatment across provinces and other places
It is required to improve the supervision mechanism of the direct settlement fund for cross-provincial and non-local medical treatment, and improve the working systems such as regional cooperation and joint inspection; implement the supervision responsibility of the medical treatment place and the insured place, and make the direct settlement of inter-provincial and non-local medical treatment as the focus of daily supervision, special inspection, unannounced inspection, etc. At the same time, it clarifies the treatment methods of medical insurance funds and deductions recovered by cross-provincial and remote medical supervision.