Interpretation of relevant policies on application conditions and insurance ratio of Guangdong's 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 settlement platform of the new rural cooperative medical system, with stable capital investment, * * * using the service platform, * * * enjoying information resources, synchronizing settlement and payment, standardized management and operation, obvious relief effect, fast service for people with difficulties and scientific coverage of urban and rural areas. So what are the policies and regulations for serious illness relief in Guangdong? What is the proportion and scope of reimbursement for serious illness assistance in Guangdong? The following contents are for reference only!

Your bureau's "Proposal on Optimizing the Serious Illness Relief Mechanism and Accurate Poverty Alleviation" has been received. After the comprehensive opinions of the Provincial Department of Human Resources and Social Security and the Provincial Health and Family Planning Commission, the results are hereby replied as follows:

I. Verification means and audit procedures for serious illness relief.

The traditional means of identifying families applying for serious illness relief by grass-roots civil affairs staff are mainly household survey and verification of medical bills. At the end of 20 17, the checking system of the financial situation of families applying for assistance in our province was launched, which provided a powerful information tool for staff to accurately identify the recipients of serious illness assistance. At the same time, all business processes are automatically transferred in the system, and the current status and progress are clear at a glance, which greatly improves the efficiency of rescue approval. The verification system covers eight social assistance business data specified in the Interim Measures for Social Assistance, and is structurally connected with eight business system modules. Relying on the government information resource sharing platform of the provincial information center and the e-government cloud platform, it is an integrated information system that vertically connects the ministries, provinces, cities, counties and towns, and horizontally connects various government departments and financial institutions in a big data centralized mode. The system is functionally divided into two modules. One is an inspection module to solve the identified problems. Systematic and comprehensive integration of government departments, banks, securities, insurance and other information resources about citizens' income and property status, through the integration and calculation of various data, according to different business standards, identify the objects of various rescue businesses, and strive to achieve "no good insurance, no omissions, all insurance should be guaranteed"; The second is eight rescue business management modules to solve the problems of management and enjoyment. This module is used vertically by the rescue departments at all levels below the provincial level, which makes the whole process of application, review, approval and fund distribution of rescue business electronic, and realizes the filing, card building and information management of rescue objects; Horizontal information sharing and interconnection with poverty alleviation office, human society, housing construction, education and other departments.

In order to further accurately identify the difficult objects that meet the conditions for serious illness relief, according to the notice of the General Office of the National Health and Family Planning Commission, The General Office of the Ministry of Civil Affairs and the Comprehensive Department of the Office of the Leading Group for Poverty Alleviation and Development of the State Council issued the Work Plan for Special Treatment of Rural Poor People (No.Han Yi [2065 438+07] 154 of the State Council), the Provincial Health and Family Planning Commission, the Provincial Civil Affairs Department, the Provincial Department of Human Resources and Social Security, the Provincial Poverty Alleviation and Development Office, and jointly formulated the Implementation Plan for Special Treatment of Serious Diseases of Rural Poor People in Guangdong Province with the Provincial Bureau of Traditional Chinese Medicine (Han [ Kloc-0/8] 195), starting from 20 18, Guangdong Province poverty alleviation big data platform was established and Guangdong Province set up a file card. The plan requires strengthening clinical pathway management, controlling the total medical expenses, giving full play to the guarantee functions of basic medical insurance, serious illness insurance, medical assistance and other systems, and reducing the actual out-of-pocket expenses of patients.

Two, on the serious illness relief fund raising channels

(1) Improve the system and mechanism. First, the Notice of Guangdong Provincial Civil Affairs Department on Strengthening the Implementation of Medical Assistance Policies and Doing a Good Job in Medical Assistance for People in Need was issued, so as to effectively raise the awareness of civil affairs departments at all levels in doing a good job in medical assistance and fully implement the medical assistance policies; Guide all localities to improve the examination and approval mechanisms such as outpatient assistance, "secondary assistance" and poverty alleviation due to illness; Strengthen the connection between basic medical insurance and basic medical insurance and serious illness insurance, and give full play to the joint efforts of policies. Second, in conjunction with the Provincial Department of Finance, the Provincial Health and Family Planning Commission, the Provincial Department of Human Resources and Social Security, the Provincial Poverty Alleviation Office and other departments, the "Implementation Plan for Special Treatment of Serious Illness of Rural Poor People in Guangdong Province" was issued to do a good job in special treatment of seriously ill people in rural areas, give full play to the guarantee role of basic medical insurance, serious illness insurance, medical assistance and other systems, control the total medical expenses, and reduce the actual medical expenses of people in need. Third, our office will work with the Provincial Department of Finance, the Provincial Department of Human Resources and Social Security, the Provincial Health and Family Planning Commission, the Provincial Poverty Alleviation Office and other departments to draft and issue the "Guiding Opinions on Doing a Good Job in Poverty Alleviation for Three Years" to guide all localities to conscientiously implement relevant social assistance policies, and do a good job in linking poverty alleviation with subsistence allowances and medical assistance, so as to provide a strong guarantee for winning the battle against poverty. The fourth is to improve the information system platform and share it with medical insurance information and poverty alleviation information; Carry out medical assistance policy and business training to improve the policy level and business ability of leaders and managers at all levels; Strengthen policy propaganda and raise people's policy awareness.

(2) Overwrite all objects. Establish a database of people with difficulties, improve the active discovery mechanism, and effectively bring all the people with difficulties, such as destitute dependents, low-income households, poverty-stricken people who set up a file, and people who are poor due to illness, into the scope of medical assistance to ensure that every insured person is not missed, and hospitalization (slow door) assistance should be saved.

(3) Simplify expense settlement. Do a good job in data statistics and real-time updates of needy people such as destitute dependents, low-income households, and poverty-stricken people with established files, treat special diseases and chronic diseases in inpatient and outpatient clinics of designated medical institutions within the county, and realize "one-stop" settlement services for medical assistance and basic medical insurance. Led by the Provincial Department of Human Resources and Social Security, a medical assistance module was built in the provincial centralized medical insurance system to realize real-time docking with the medical assistance system. At the end of 20 18, medical assistance, basic medical insurance and serious illness insurance in the province will be settled in different places gradually, so as to improve the reimbursement efficiency of medical assistance and facilitate the needy people to see a doctor.

(4) Improve capital efficiency. Carry out the "second aid" of medical assistance in an all-round way, and urge all localities to formulate specific rules for the "second aid" before June 2065438+2008, and include the expenses outside the scope of the policy into the scope of medical assistance, so as to minimize the burden of medical expenses for people in need; Give full play to the role of the coordination mechanism of basic living security for people in need, and do a good job in medical assistance for people with special difficulties who have high medical expenses due to serious diseases. Innovative payment methods of funds, the "one-stop" instant settlement fees in designated medical institutions, after being audited and countersigned by the civil affairs department, will be allocated to designated medical institutions by the social security fund account "urban and rural medical assistance fund account"; Other aid recipients and "second aid", the "special account for urban and rural medical assistance fund" of the special account for social security fund will issue medical assistance reimbursement funds through social security cards. Establish a quarterly notification system, inform all localities about the use of funds every quarter, strengthen the supervision and inspection of policy implementation and the use of funds, effectively improve the efficiency of the use of funds, and use every penny in places where people in need need.

Three, about the construction of primary health care system

At present, our province is vigorously promoting the construction of graded diagnosis and treatment system. First, increase financial input and comprehensively improve the ability of primary health care services from hardware and software. The second is to increase basic medical security. We will steadily improve the level of hospitalization for urban and rural residents, and gradually narrow the gap between the actual reimbursement ratio and the reimbursement ratio within the policy scope. Actively promote the reform of urban-rural integration of medical insurance. Accelerate the provincial overall planning of medical insurance. Improve the policy of serious illness insurance for urban and rural residents, and give priority to patients with high medical expenses and difficult groups. The third is to improve the medical security and assistance system for serious and serious diseases, improve the emergency assistance system for diseases, and build a solid medical security bottom line. Introduce the charging standard of telemedicine service, incorporate it into the overall medical insurance, and effectively reduce the burden on patients. Fourth, actively develop commercial health insurance. Adhere to the combination of government-led and social participation, support the development of commercial health insurance linked to basic medical insurance, and meet the needs of multi-level health protection.

Fourth, the convergence with the serious illness insurance system

Since 20 16, our province has further improved the serious illness insurance policy, realizing "one extension and two inclinations", extending the coverage from urban and rural residents to employees, and ensuring that the treatment is inclined to the difficult groups and the people with high medical expenses. As of 20 17, the province's serious illness insurance covers101220,000 people, ensuring that the insured, especially the poor, can afford serious illness.

(1) Actively promote the precise poverty alleviation through major illness insurance. Serious illness insurance has lowered the threshold for people in need, increased the proportion of reimbursement, set no annual ceiling, and properly and accurately solved the security needs of people in need. First, the minimum payment standard for the poor has dropped by no less than 80%, and the reimbursement rate has reached more than 80%. Second, the minimum threshold for the poverty-stricken population and the minimum living security target for the establishment of the card has dropped by no less than 70%, and the reimbursement rate has reached more than 70%. In 20 17, there were 69,650 people with serious illness insurance difficulties in the province, including 40,072 inpatients with specific diseases and 29,578 outpatients.

(2) Improve the management service level. First, vigorously promote the direct settlement of medical treatment in different places in the province. At present, there are 657 online medical institutions in the province, with a cumulative settlement of1170,000 person-times, with a settlement amount of 28.2 billion yuan; Accelerate the direct settlement of medical treatment across provinces. There are 772 designated medical institutions across provinces, ranking first in the country, directly settling 33,000 person-times, and the settlement amount is 770 million yuan, ranking third in the country, effectively reducing the burden of the masses to advance and run errands. Second, all localities should optimize and integrate public service resources, promote the integrated settlement and "one-stop" of basic medical insurance, serious illness insurance and medical assistance, and alleviate the problems of "running errands" and "fund payment" of people in need.

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