It’s about medical insurance! Five major aspects and multiple optimization adjustments!

The "Foshan Urban and Rural Residents Basic Medical Insurance Outpatient Financial Security Implementation Rules" and the Foshan Employee Basic Medical Insurance Outpatient Financial Security Implementation Rules (hereinafter referred to as the "Details") have been It will be officially implemented on November 1, 2022. The "Detailed Rules" have been improved and optimized in five aspects including expenditure scope, benefit guarantee, medical treatment management, personal account management, and settlement management to ensure that they are in step with and connected with national and provincial reform policies. The issuance and implementation of the "Detailed Rules" have optimized the city's basic medical insurance outpatient financial security system, responded to citizens' actual medical needs and social concerns, optimized and improved the level of basic medical insurance general outpatient co-ordination benefits, and played a vital role in improving the city's multi-level It is of great significance to establish a medical security system, reduce the burden of medical treatment on the masses, help build a policy system for talents from near and far, create a first-class business environment, and enhance Foshan's "soft power." PART 1 Expand the scope of expenditures and effectively increase the inclusion ratio 01 Expand the scope of medical insurance payment The scope of payment shall be implemented in accordance with the provisions of the Guangdong Province Basic Medical Insurance Drug Catalog, the Catalog of Diagnostic and Treatment Items and the Catalog of Medical Consumables. Color B-ultrasound items and medical consumables that citizens are concerned about are included in the scope of medical insurance payment. . 02 Increase the inclusion ratio of expenses in the medical insurance catalog (1) The inclusion ratio of Class A drugs remains at 100, and the inclusion ratio of Class B drugs is increased from 60 to 95. (2) The inclusion ratio of diagnosis and treatment items is increased from 60 to 100. Among them, the "Guangdong Province Basic Medical Insurance Diagnosis and Treatment Item Catalog" stipulates that the inclusion rate of items that require individuals to pay first is 90%. (3) The inclusion ratio of medical consumables is increased from 0 to 90. Among them, if the unit price of dialysis treatment materials is 500 yuan or less, the inclusion ratio is 100. PART 2 Optimize the remuneration policy and provide stronger outpatient financial protection. 03 Increase the reimbursement ratio of general outpatient clinics under the employee medical insurance. The reimbursement ratio for general outpatient clinics under the employee medical insurance will be increased from 40% to 50%, while the resident medical insurance will remain unchanged at 40%. 04 New outpatient referral benefit protection provisions: The insured person who is referred by a selected medical and health institution and seeks medical treatment at a non-selected medical and health institution within 30 days will enjoy benefits according to the reimbursement ratio of the corresponding level of the medical and health institution to which he is transferred. 05 Improve outpatient first aid and rescue benefits to protect insured persons’ medical expenses within the policy scope due to first aid and rescue: (1) Reimbursement according to the reimbursement ratio of the corresponding level of the medical and health institution where first aid and rescue are located; (2) Medical insurance expenses are not included in the calculation The annual maximum payment limit for general outpatient clinics is directly included in the annual cumulative maximum payment limit for employee medical insurance; (3) In this case, there are no site selection requirements, and all qualified expenses incurred by medical and health institutions in the city and outside the city can be reimbursed. 06 The limit on the number of reimbursements for general outpatient clinics has been lifted. Multiple medical consultations in a single day can be reimbursed by medical insurance in accordance with regulations. 07 Those who meet the conditions for medical treatment in other places can enjoy the same treatment. The reimbursement limit for general outpatient medical treatment in other places during the transition period has been cancelled. After the insured person registers for medical treatment in another place in accordance with the regulations, the medical expenses incurred by the medical and health institution in the registration place within the policy scope will be reimbursed according to the reimbursement ratio of the same type of benefits in the insured place, and the cumulative maximum payment limit of the same type of benefits in the insured place and the registration place Combined calculations. 08 The annual maximum payment limit for general outpatient clinics is moderately increased. Provincial documents stipulate that the annual maximum payment limit for general outpatient medical insurance for employees shall not be less than 2.5% of the average annual salary of urban employees on duty at or above the local level in the previous year. Foshan City shall implement it at 2.5%. The maximum annual payment limit for general outpatient services under resident medical insurance is 80% of the current employees. In this way, the maximum payment limit for residents and employees can be realized as the average wage level rises. 09 Benefit standards are tilted towards employee medical insurance retirees. The maximum annual payment limit for ordinary outpatient services for retirees is increased by 10% on the basis of active employees. 10 Support the medical reform and family doctor contract service work. For insured persons who only select one primary medical and health institution as the designated outpatient clinic and sign a family doctor service agreement with it, the annual maximum payment limit will be increased by 10 based on the aforementioned standards.

11 The benefits for insured persons who enroll in the insurance midway, change their status, or retire midway are “higher rather than lower” (1) Enrollment in the middle: Participants who participate in the resident medical insurance in the middle of the year will receive the maximum general outpatient coordinating fund of the resident medical insurance in that year. The payment limit and the benefit limit are not converted on a monthly basis; insured persons who participate in the employee medical insurance midway in 2 years will be subject to the maximum payment limit of the general outpatient co-ordination fund of the employee medical insurance for that year, and the benefit limit is not converted on a monthly basis; (2) Change of identity (including " Residents to employees" and "employees to residents"): According to the maximum payment limit of the general outpatient medical insurance general outpatient pool fund for active employees, the amount of payment from the general outpatient fund during the year will be deducted; (3) Retirement midway: According to the annual maximum payment limit of the general outpatient pool fund for retirees The amount paid by the unified fund during the year will be deducted. PART 3 Achieve cross-regional outpatient services, smooth and worry-free medical treatment at selected points 12 Achieve cross-regional outpatient visits to enjoy medical insurance benefits. In principle, insured persons can choose designated medical institutions within the city, and are no longer limited to enjoying benefits within the insured area. For example: Insured persons in Shunde District can also enjoy medical insurance reimbursement when they seek medical treatment at the general outpatient clinic of the Municipal New Maternal and Child Hospital! Outpatient reimbursement is no longer restricted by the insured area, and you can choose a medical institution close to your work unit and residence as needed to enjoy it. Outpatient medical insurance benefits. 13 More hospitals can apply for general outpatient designated medical institutions. For example, the Municipal No. 1 Hospital, the Municipal Traditional Chinese Medicine Hospital, etc. can apply for general outpatient designated medical institutions. Insured persons in all districts of the city can choose to seek medical treatment. 14 Support the hierarchical diagnosis and treatment of medical reform. In principle, insured persons can seek medical treatment at selected medical and health institutions within the city and enjoy general outpatient services. The number of designated medical and health institutions selected shall not exceed 3, among which at least 1 primary medical and health institution shall be selected. There are 6 channels for "selecting points", which take effect immediately after selection, making the operation convenient and fast. 15 The selected medical and health institutions can be changed to 3 hospitals per year. Insured persons who really need it can change the selected hospitals no more than 3 times in a year, and one change is counted as one time, and at least one of them must be a primary medical and health institution. Change business can be handled through selected channels. 16. If registered personnel choose to seek medical treatment in other places for retirement, long-term living in other places, or permanent work in other places, insured persons can choose no more than 3 designated medical and health institutions for medical treatment in the place of registration and insured place***, of which at least One is a grassroots medical and health institution. In principle, the registration site must be a designated medical institution that has realized direct settlement of basic medical insurance in different places. PART 4 ??Adjust personal account standards to expand the scope of fund use 17. Increase the monthly transfer standard for retirees’ personal accounts. The monthly transfer limit for retirees’ personal accounts will be 2.8 of the city’s average monthly basic pension amount in 2021, and the monthly transfer standard will increase by 34.57 yuan. /people. 18 Adjustment of transfer standards for employee medical insurance personal accounts. All basic medical insurance premiums paid by individual employees will be included in personal accounts, and all basic medical insurance premiums paid by employers will be transferred to the overall fund and will no longer be transferred to personal accounts. 19 Expand the scope of use of employee medical insurance personal account funds. In addition to paying for myself and my spouse, parents, and children to seek medical treatment at designated medical institutions, purchase medicines at designated retail pharmacies, and pay resident medical insurance premiums, personal account funds can also be used to pay for additional expenses. The following items are included: (1) Personal expenses incurred when purchasing medical equipment and medical consumables at designated retail pharmacies; (2) Payment expenses incurred by insured persons who have not reached the minimum payment period for employee medical insurance when they retire; (3) Others Fees that comply with national and provincial regulations. 20 Further standardize the circumstances that can be transferred to one's bank account and refine the medical insurance relationship, inter-city transfers out of the province, inter-provincial transfers out, inter-provincial placement of retirees in different places, and situations such as enlistment, death, and overseas settlement of insured persons during the insurance period. Below are the rules for handling funds in personal accounts. 21 After retirement, employees’ medical insurance participants can enjoy personal account benefits in accordance with regulations. After the implementation of the new policy, the policy “for participants who participated in basic medical insurance for the first time after January 1, 2017 (inclusive)” will no longer be implemented. Do not enjoy the benefits of personal account".

PART 5 Settlement is more worry-free and benefits are guaranteed 22 Technological innovation Add provisions for supplementary accounting and sporadic reimbursement of medical insurance outpatient medical expenses.