What is the role of community medical insurance?

Guiding Opinions of the State Council on Launching the Pilot Program of Basic Medical Insurance for Urban Residents

Guofa [2007] No. 20

Provinces and Autonomous Regions , Municipal People's Governments, ministries and commissions of the State Council, and agencies directly under the State Council:

The Party Central Committee and the State Council attach great importance to solving the medical security problems of the broad masses of the people and constantly improve the medical security system. In 1998, my country began to establish a basic medical insurance system for urban employees. Later, it launched a pilot project for a new rural cooperative medical system and established an urban and rural medical assistance system. Currently, those who do not have a medical insurance system are mainly urban non-employed residents. In order to achieve the goal of basically establishing a medical security system covering all urban and rural residents, the State Council decided to launch a pilot project of basic medical insurance for urban residents (hereinafter referred to as the pilot) starting this year. All regions and departments must fully understand the importance of this work, regard it as an important task in implementing the Scientific Outlook on Development and building a harmonious socialist society, attach great importance to it, make overall plans, regulate and guide it, and advance steadily.

1. Goals and principles

(1) Pilot goals. In 2007, 2 to 3 cities in qualified provinces were selected to launch the pilot program. In 2008, the pilot program was expanded to reach more than 80% of the pilot cities in 2009. In 2010, it was fully rolled out across the country and gradually covered all urban non-employed residents. It is necessary to explore and improve the policy system of basic medical insurance for urban residents through pilot projects, form a reasonable financing mechanism, a sound management system and a standardized operating mechanism, and gradually establish a basic medical insurance system for urban residents focusing on overall planning of serious illnesses.

(2) Pilot principles. The pilot work must start at a low level, reasonably determine the financing level and security standards based on the level of economic development and the affordability of all aspects, focus on ensuring the serious medical needs of urban non-employed residents, and gradually improve the security level; adhere to the principle of voluntariness and fully respect the will of the people ; Clarify the responsibilities of the central and local governments. The central government determines the basic principles and main policies, and the local governments formulate specific measures to implement territorial management of insured residents; adhere to overall planning and coordination, and implement basic policies, standards and management measures between various medical security systems etc. connection.

2. Insurance coverage and financing level

(3) Insurance coverage. Students in primary and secondary schools (including students in vocational high schools, technical secondary schools, and technical schools), children, and other non-employed urban residents who are not covered by the urban employee basic medical insurance system can voluntarily participate in the urban resident basic medical insurance.

(4) Financing level. Pilot cities should appropriately determine the financing level based on the local economic development level and the basic medical consumption needs of different groups such as adults and minors, and consider the affordability of local residents' families and finances; explore the establishment of financing levels, payment years and benefits Horizontally linked mechanism.

(5) Payment and subsidies. The basic medical insurance for urban residents is mainly based on family contributions, and the government provides appropriate subsidies. Insured residents pay basic medical insurance premiums in accordance with regulations and enjoy corresponding medical insurance benefits. Employers with qualified conditions can provide subsidies for the insurance premiums of employees' family members. The state formulates tax incentive policies for individual contributions and unit subsidy funds.

For insured residents in pilot cities, the government will provide an annual subsidy of no less than 40 yuan per capita. Among them, the central government will provide a subsidy of 20 yuan per capita to the central and western regions through special transfer payments every year starting from 2007. subsidy. On this basis, in principle, the government will provide a subsidy of not less than 10 yuan per capita every year for the family contribution required for students and children who are eligible for subsistence allowances or who are severely disabled to participate in the insurance. Among them, the central government will provide subsidies to the central and western regions A subsidy of 5 yuan per capita will be provided; for the family contributions required for the insurance of other needy residents such as other subsistence allowance recipients, severely disabled people who have lost the ability to work, elderly people over 60 years old from low-income families, etc., the government will provide a subsidy of not less than 60 yuan per capita every year. A subsidy of RMB 30 per capita will be provided, of which the central government will provide a subsidy of RMB 30 per capita to the central and western regions. The central government will provide appropriate subsidies to the eastern region based on the new rural cooperative medical subsidy method. The specific plan for financial subsidies shall be studied and determined by the financial department in consultation with the labor and social security, civil affairs and other departments, and the subsidy funds shall be included in the financial budgets of governments at all levels.

(6) Fee payment. The Urban Resident Basic Medical Insurance Fund is mainly used for inpatient and outpatient serious medical expenses of insured residents. Areas with favorable conditions can gradually implement outpatient medical expense pooling on a trial basis.

The use of the basic medical insurance fund for urban residents must adhere to the principle of determining expenditure according to revenue, balancing revenue and expenditure, and having a slight surplus. It is necessary to reasonably formulate the minimum payment standard, payment ratio and maximum payment limit of the urban residents' basic medical insurance fund, improve payment methods, and reasonably control medical expenses. Explore medical services and payment methods that are suitable for the financial affordability of non-employed residents in difficult towns to reduce their medical expense burden. The Urban Resident Basic Medical Insurance Fund is used to pay for medical expenses within the specified range. Other expenses can be solved through supplementary medical insurance, commercial health insurance, medical assistance and social charity donations.

3. Strengthen management and services

(7) Organizational management. The management of the basic medical insurance for urban residents shall, in principle, refer to the relevant provisions of the basic medical insurance for urban employees. All localities should make full use of the existing management service system, improve management methods, and improve management efficiency. Encourage qualified regions to further integrate basic medical security management resources by combining the actual conditions of urban employee basic medical insurance and new rural cooperative medical management. It is necessary to explore and improve the social supervision organization of medical insurance with the participation of representatives from government agencies, insured residents, social groups, medical service institutions, etc., and strengthen the supervision of the management, services, and operation of basic medical insurance for urban residents. Establish professional technical standards organizations and expert consulting organizations for medical insurance, and improve professional technical standards and business specifications for medical insurance service management. According to the needs of the development of medical insurance industry, we will effectively strengthen the construction of medical insurance management service institutions and teams. Establish and improve management systems, improve operating mechanisms, and strengthen the construction of medical insurance information systems.

(8) Fund management. The basic medical insurance fund for urban residents should be included in the social security fund financial account for unified management and be separately accounted for. Pilot cities must strictly implement financial systems in accordance with relevant regulations on social insurance fund management, strengthen the management and supervision of basic medical insurance funds, explore and establish a sound risk prevention and adjustment mechanism for funds, and ensure fund safety.

(9) Service management. The management of medical services under the basic medical insurance for urban residents shall, in principle, be implemented with reference to the relevant provisions of the basic medical insurance for urban employees. Specific measures shall be formulated by the labor and social security departments of the pilot cities in conjunction with the development and reform, finance, health and other departments. Factors such as the basic medical needs of insured residents and the affordability of the basic medical insurance fund must be comprehensively considered to reasonably determine the scope of medical services. Through the conclusion and performance of designated service agreements, the management of designated medical institutions and designated retail pharmacies will be standardized, and the rights and obligations of medical insurance agencies and designated medical institutions and retail pharmacies will be clarified. Medical insurance agencies should simplify the approval procedures to facilitate residents' insurance participation and reimbursement of medical expenses; clarify the settlement methods for medical expenses, and settle settlements with medical institutions in a timely manner in accordance with regulations. Strengthen the management of medical expenses and explore the establishment of a reward and punishment mechanism for medical insurance management services. Actively promote settlement methods such as payment by disease type and prepayment by total amount, and explore ways to determine medical expense standards through agreement.

(10) Give full play to the role of urban community service organizations. Integrate, enhance, and expand the functions of urban community service organizations, strengthen the construction of community service platforms, and provide basic medical insurance management services. Vigorously develop community health services and include qualified community health service institutions into the designated scope of medical insurance; for the medical expenses incurred by insured residents seeking medical treatment at community health service institutions, the payment ratio of the medical insurance fund must be appropriately increased.

4. Deepen relevant reforms

(11) Continue to improve various medical security systems. Further improve the basic medical insurance system for urban employees, and take effective measures to include employees of mixed ownership, non-public economic organizations, and people with flexible employment into the basic medical insurance for urban employees; vigorously promote the participation of migrant workers in cities to participate in the basic medical insurance for urban employees, focusing on solving The issue of coordinating serious illness; continue to work hard to solve the medical security problem for employees and retirees of state-owned enterprises in difficulty, closed and bankrupt enterprises, etc.; encourage urban residents within the working age who are capable of working to find employment in various ways and participate in the basic medical insurance for urban employees; further standardize The current payment policy of urban employee basic medical insurance strengthens the management of medical services. Accelerate the implementation of the new rural cooperative medical system. Further improve the urban and rural medical assistance system. Improve the multi-level medical security system and ensure the connection between various medical security systems.

(12) Collaboratively promote the reform of the medical and health system and the pharmaceutical production and distribution system.

In accordance with the overall requirements of deepening the reform of the medical and health system, coordinate the reform and institutional connection of medical and health care, drug production and circulation, and medical security systems, and give full play to the role of the medical security system in raising medical funds, improving medical quality, and controlling medical expenses. Further transform government functions, strengthen regional health planning, and improve the medical service system. Establish and improve the health industry standard system and strengthen supervision of medical services and drug markets. Standardize medical service behavior, and gradually establish and improve technical standards such as clinical operating specifications, clinical diagnosis and treatment guidelines, clinical medication specifications, and admission and admission standards. Accelerate the construction of urban community health service systems, give full play to the role of community health services and traditional Chinese medicine services in medical services, and explore ways to implement graded medical care for insured residents in areas with conditions.

5. Strengthen organizational leadership

(13) Establish an inter-ministerial joint meeting system for the State Council’s basic medical insurance for urban residents. Under the leadership of the State Council, the Inter-ministerial Joint Conference on Urban Resident Basic Medical Insurance of the State Council (hereinafter referred to as the Inter-ministerial Joint Conference) is responsible for organizing, coordinating and macro-guiding the pilot work, researching and formulating relevant policies and supervising and inspecting the implementation of the policies, summarizing and evaluating the pilot work, and coordinating Solve problems that arise during the pilot work and make reports and suggestions to the State Council on major issues.

(14) Select and determine pilot cities. The provincial people's government may select 2 to 3 pilot cities based on local conditions and submit them to the inter-ministerial joint meeting for approval. The pilot implementation plan of the pilot cities shall be reported to the inter-ministerial joint conference office for record, and shall be approved and implemented by the provincial (regional, municipal) people's government.

(15) Formulate supporting policies and measures. The labor and social security departments must formulate relevant supporting policies and measures in conjunction with relevant departments such as development and reform, finance, health, civil affairs, education, drug supervision, and traditional Chinese medicine management. All departments must coordinate and cooperate according to their respective responsibilities to accelerate various supporting reforms. Mobilize all aspects of society to create a good environment and provide strong support for promoting the reform of the medical insurance system to ensure the smooth progress of the pilot work.

(16) Carefully organize and implement. Local people's governments at all levels must fully understand the significance of the pilot work and effectively strengthen organizational leadership. Provincial people's governments must make overall plans and actively and steadily advance the pilot work in their respective administrative regions based on the pilot objectives and tasks, basic policies and work steps stipulated in this guidance. Pilot cities must formulate pilot implementation plans and carefully organize their implementation based on full research, careful calculations, and multi-party arguments. Cities that have taken the lead in carrying out basic medical insurance work should sum up experience in a timely manner, improve the system, and further explore more realistic basic medical insurance systems and mechanisms.

(17) Do a good job in publicity and propaganda. The establishment of a basic medical insurance system for urban residents is directly related to the vital interests of the masses. It is a major livelihood project with strong policy implications. All localities must adhere to the correct guidance of public opinion, strengthen the publicity of the significance, basic principles and principles and policies of the pilot work, and strengthen the summary and promotion of good practices and experiences in the pilot, so that this policy of benefiting the people can be deeply rooted in the hearts of the people and truly win the support of the broad masses of the people. The understanding and support from all walks of life have made the pilot work a practice in which the masses actively participate.

All localities should pay attention to studying new situations and new problems that arise during the pilot process, actively explore solutions, and properly handle the relationship between reform, development and stability. Report any important situations to the inter-ministerial joint meeting in a timely manner.

State Council

July 10, 2007

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