Interpretation of the application conditions and insurance ratio of Hubei serious illness relief scope

medical assistance for serious illness refers to a new medical assistance system that relies on the basic medical insurance for urban residents (employees) and the new rural cooperative medical care settlement platform, with stable capital investment, * * * use of service platform, * * * enjoyment of information resources, synchronous settlement and payment, standardized management and operation, and obvious relief effect, and can provide fast services for people in need and cover scientific norms in urban and rural areas. So what are the policies and regulations for serious illness relief in Hubei? What is the proportion and scope of reimbursement for serious illness relief in Hubei? The following contents are for reference only!

in may, 218, the general office of Hubei provincial government issued the notice on improving the relevant policies for ensuring the basic medical care for the rural poor, which indicated that it would ensure that the actual reimbursement rate of hospitalization medical expenses for the rural poor would be increased to about 9%, the actual reimbursement rate of outpatient medical expenses for serious illness and special chronic diseases would be increased to about 8%, and the annual actual medical expenses borne by individuals would be controlled within 5, yuan.

in terms of the basic medical insurance policy for urban and rural residents, the individual contributions required by the rural poor to participate in the basic medical insurance for urban and rural residents are subsidized by the finance at the same level, and the specific subsidy standards are determined by the municipal (state) people's governments according to relevant policies and regulations to ensure that they are all included in the scope of protection. The qifubiaozhun for hospitalization in the first-level medical institutions within the county of rural poor population is not higher than that in 1 yuan, and the qifubiaozhun for hospitalization in the second-level and third-level medical institutions within the county is uniformly determined by the municipal (state) people's governments. If the rural poor are hospitalized in the county, the reimbursement rate within the basic medical insurance (excluding serious illness insurance) policy is not less than 9% for the first-level medical institutions, 8% for the second-level medical institutions and 7% for the third-level medical institutions.

In terms of serious illness insurance for urban and rural residents, the minimum threshold for serious illness insurance is lowered, and the minimum threshold for serious illness insurance for rural poor people is reduced to 5, yuan; In an insurance year, the rural poor people are hospitalized several times and only deduct the minimum payment of serious illness insurance once. At the same time, increase the proportion of reimbursement for major illness insurance. The accumulated amount of personal burden that meets the coverage of serious illness insurance shall be reimbursed by 6% for the part above the threshold to 3, yuan (inclusive), 7% for the part above 3, yuan to 1, yuan (inclusive), and 8% for the part above 1, yuan. Increase the maximum payment limit of serious illness insurance. The annual maximum payment limit of serious illness insurance for the rural poor is not less than 35 thousand yuan.

Original content of the attached notice:

Notice of the General Office of the Provincial People's Government on improving the relevant policies for ensuring basic medical care for the rural poor

Municipal, state and county people's governments and provincial government departments:

In order to ensure the basic medical care for the rural poor (hereinafter referred to as "rural poor") and promote health and poverty alleviation, according to the principle of doing our best and doing what we can, We will implement the "four in one" working mechanism of basic medical insurance, serious illness insurance, medical assistance and supplementary medical insurance, and ensure that the actual reimbursement rate of hospitalization medical expenses for rural poor people will increase to about 9%, and the actual reimbursement rate of outpatient medical expenses for serious illness and special chronic diseases will increase to about 8%, and the annual actual burden of medical expenses will be controlled within 5, yuan. The relevant policies are hereby notified as follows.

1. About the basic medical insurance policy for urban and rural residents

1. Subsidize individual insurance expenses. The individual contributions required by the rural poor to participate in the basic medical insurance for urban and rural residents are subsidized by the finance at the same level, and the specific subsidy standards are determined by the people's governments of cities (prefectures) according to relevant policies and regulations, so as to ensure that they are all included in the scope of protection.

2. Adjust hospitalization Qifubiaozhun. The qifubiaozhun for hospitalization in the first-level medical institutions within the county of rural poor population is not higher than that in 1 yuan, and the qifubiaozhun for hospitalization in the second-level and third-level medical institutions within the county is uniformly determined by the municipal (state) people's governments.

3. Increase the reimbursement rate within the policy scope. If the rural poor are hospitalized in the county, the reimbursement rate within the basic medical insurance (excluding serious illness insurance) policy is not less than 9% for the first-level medical institutions, 8% for the second-level medical institutions and 7% for the third-level medical institutions.

Second, the policy of serious illness insurance for urban and rural residents

4. Reduce the threshold of serious illness insurance. The minimum threshold for serious illness insurance for the rural poor is reduced to 5 yuan. In an insurance year, the rural poor people are hospitalized several times and only deduct the minimum payment of serious illness insurance once.

5. increase the reimbursement rate of serious illness insurance. The accumulated amount of personal burden that meets the coverage of serious illness insurance shall be reimbursed by 6% for the part above the threshold to 3, yuan (inclusive), 7% for the part above 3, yuan to 1, yuan (inclusive), and 8% for the part above 1, yuan.

6. increase the maximum payment limit of major illness insurance. The annual maximum payment limit of serious illness insurance for the rural poor is not less than 35 thousand yuan.

III. Policies on medical assistance

7. Make overall use of social assistance funds and give full play to the role of medical assistance. Implement the main responsibility of the county (city, district) people's government for medical assistance, and define the scope and conditions of medical assistance according to the actual situation on the basis of the medical information of the rural poor. Increase the overall use of social assistance funds, in addition to rural subsistence allowances, five-guarantee precision poverty alleviation subsidies, get through the use of social assistance funds at all levels for medical assistance, and subsidize the medical expenses that the recipients meet the requirements. Strengthen the connection between medical assistance for serious diseases and serious illness insurance, and give medical assistance for serious diseases to the poor people in rural areas in accordance with relevant regulations. All localities carry out outpatient assistance according to the actual situation.

IV. About the policy of all-out guarantee

8. Establish all-out guarantee system. In principle, the people's governments of cities (states) and counties (cities, districts) shall provide the basic medical insurance, serious illness insurance and medical assistance for urban and rural residents first, and supplementary medical insurance (or bottom-up security funds) later, and provide bottom-up security for the rural poor by purchasing supplementary medical insurance or setting up bottom-up security funds.

take the city (state) as the unit, scientifically calculate and reasonably determine the annual financing standard of supplementary medical insurance (or bottom-up guarantee funds) according to the principle of "fixed income by expenditure, balanced income and expenditure, and bottom-up guarantee".

9. Unified supplementary insurance agencies. Municipalities (prefectures) people's governments shall, in accordance with the principles of safety, economy, convenience and efficiency, determine the supplementary medical insurance agencies by themselves, and give priority to the major illness insurance underwriting institutions for urban and rural residents in principle.

1. control the medical expenses beyond the scope of the policy. The medical expenses beyond the policy scope of rural poor population are shared by supplementary medical insurance (or all-out guarantee funds), rural poor individuals and medical institutions.

the proportion of medical expenses outside the hospitalization policy of the rural poor in the total medical expenses is not more than 3% in the first-class medical institutions within the county, 8% in the second-class and third-class medical institutions within the county, and 1% in the third-class medical institutions outside the county. The medical expenses borne by individuals within the specified proportion shall be shared by the rural poor individuals and the supplementary medical insurance (or the guarantee funds), and the specific measures shall be formulated by the municipal (state) people's government; Medical expenses exceeding the prescribed proportion shall be borne by medical institutions in principle.

V. Relevant policies and regulations

11. Define the scope and time limit of protection. For all rural poor people identified by the poverty alleviation department since 214 (including those who have been lifted out of poverty, those who have not been lifted out of poverty, and those who have newly increased poverty), they will enjoy the insurance subsidy and the "four-in-one" medical security treatment until the end of 22. Among them, for the newly-increased rural poor, the "four in one" medical security treatment will be implemented according to the time when they are identified as poor people.

12. Insist on advocating diagnosis and treatment within the county. The rural poor enjoy the "four-in-one" medical security treatment in the county, and the medical expenses for medical treatment outside the county are reimbursed according to the current medical insurance policy for urban and rural residents.

The rural poor can be compensated for their out-of-pocket medical expenses when they go to medical institutions outside the county, but they need to go through relevant procedures before referral. Specific compensation measures shall be formulated by the municipal (state) people's governments.

13. If the rural poor who participated in the employee medical insurance did not reach the treatment level of the rural poor after enjoying the employee medical insurance benefits according to regulations, the supplementary medical insurance (or all-out guarantee funds) will make up the treatment to ensure that their medical insurance treatment level reaches the work goal.

14. If the rural poor suffer accidental injuries (except the third party's liability) and give birth in hospital, and they are reimbursed by basic medical insurance, serious illness insurance and medical assistance in the county according to the current urban and rural residents' policy, they will be compensated by supplementary medical insurance (or all-out guarantee funds) to ensure that their medical security treatment level reaches the work goal.

15. The current medical security policy for rural destitute dependents, family members with minimum living security, orphans and impoverished disabled people will remain unchanged.

VI. About handling management services

16. Improve the accuracy of personnel identification. Poverty alleviation departments should clarify the criteria for identifying the rural poor, carry out data verification according to the criteria, clarify the basic information of the rural poor in the national poverty alleviation and development information system, fill in the core data such as ID numbers, strengthen the comparison and connection with the urban and rural residents' medical insurance information system, the residents' health file management system, and the civil and social assistance information system, and do a good job in dynamic management of rural poor data. Before October of each year (before the start of medical insurance collection for urban and rural residents), the information of rural poor people will be officially informed to the local tax authorities and social security agencies.

17. implement the system of "pay after treatment". The rural poor are hospitalized in the designated medical institutions in the county, and go through the admission procedures with social security cards, valid identity documents and poverty certificates issued by poverty alleviation departments, and sign the agreement of paying after diagnosis and treatment. When they are admitted to the hospital, they only need to pay the basic medical insurance hospitalization Qifubiaozhun fee without paying the hospitalization deposit.

all localities should establish a fund pre-allocation system, speed up the examination, settlement and disbursement of funds, shorten the advance period of medical institutions, and reduce the advance pressure of medical institutions. The specific measures shall be formulated by the municipal (state) people's governments.

18. Implement "one-stop" instant settlement. The people's governments of counties (cities, districts) make overall plans for "one-stop" instant settlement. Health planning, human society, civil affairs, poverty alleviation, insurance supervision and other departments should strengthen communication and cooperation, connect various medical security information systems, and build a "one-stop, one-vote system" information exchange and instant settlement platform in designated medical institutions within the county to ensure that rural poor people can handle and settle in one window when they leave the hospital.

VII. On departmental responsibilities

19. Implement departmental responsibilities and strengthen coordination. Health and family planning departments should take the lead in health poverty alleviation, do a good job in health poverty alleviation, establish a supplementary medical security mechanism for rural poor people, control the unreasonable increase of medical expenses, and implement "first diagnosis and treatment, then payment" and "one-stop service, one-vote settlement". The human and social departments should take the lead in basic medical insurance and do a good job in accurate poverty alleviation through medical insurance. Agencies to provide poverty alleviation departments of rural poor population data (including midway adjustment data), according to the receipt, the individual insurance information is complete and accurate, timely completion of insurance registration procedures, input of urban and rural residents medical insurance information system. The poverty alleviation department is responsible for strengthening the dynamic management of the rural poor population, providing basic information on the dynamic changes of the rural poor population in a timely manner, organizing and ensuring the full participation of the rural poor population, supervising the implementation of their individual payment subsidies, and strengthening the supervision and assessment of health poverty alleviation work. The civil affairs department is responsible for identifying the poverty alleviation targets such as the family members of the minimum living guarantee, the destitute dependents and orphans, organizing and ensuring that the poverty alleviation targets such as the family members of the minimum living guarantee, the destitute dependents and orphans participate in the basic medical insurance for urban and rural residents, and implementing the policy of individual contributions for the insured; Do a good job in connecting medical assistance with basic medical insurance and serious illness insurance. The financial department shall, according to the needs of the work and the division of powers, provide financial support for health poverty alleviation through existing channels, and urge all localities to implement various security funds. The local tax department is responsible for the collection of individual contributions for basic medical insurance for urban and rural residents, and cooperates with relevant departments to ensure that the subsidies for the rural poor are paid into the state treasury in full and on time to avoid repeated payments by the rural poor. The insurance regulatory department should strengthen the supervision and management of underwriting commercial insurance companies and urge them to realize immediate settlement. Other relevant departments should do their respective duties, and do a good job in ensuring basic medical care for the rural poor. ;