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Gaozhou City’s 2009 New Rural Cooperative Medical Care Reimbursement System

2009-08-05 Reading: 1853 Editor: [Large, Medium and Small]

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Gaozhou City’s 2009 New Rural Cooperative Medical Care Reimbursement System

Based on According to the requirements of relevant documents from superiors and combined with the actual conditions of our city, Gaozhou City's 2009 new rural cooperative medical security system was formulated. We will insist on focusing on covering major diseases, include a small number of chronic diseases and endemic diseases into the overall planning of major diseases, and establish a household-based outpatient medical expense reimbursement system. The cap for hospitalization reimbursement for the year is 30,000 yuan (for patients with chronic diseases who are both hospitalized and have large outpatient services, the cumulative cap for subsidies during the year is 30,000 yuan).

1. Standardize the participation conditions and methods

Participation conditions: All rural residents in our city’s jurisdiction who have not participated in other government-sponsored medical security systems can participate in the new rural cooperation Medical. Farmers are required to participate in cooperative medical care on a household basis, and the payment amount is 20 yuan per person throughout the year (old people with sons living alone must participate together with families with one son). For rural five-guarantee households and low-income households, the civil affairs department is responsible for subsidizing and paying all the funds that individuals should bear.

How to participate: Pay the fee at the village committee or the town joint management office and receive the "Cooperative Medical Care Certificate".

Payment period: Cooperative medical care adopts the principle of paying first and enjoying later. Those who participate in the cooperative medical care in 2009 must pay before the end of November 2008, and the payment will not be processed after the expiration date.

2. Immediate outpatient reimbursement:

1. The outpatient medical expenses of participating farmers on a household basis are 22 yuan per person within the year. Any person in the household who goes to the designated medical institution for outpatient service or health examination with the household's valid cooperative medical certificate for the current year can directly deduct the household's reimbursable outpatient expenses for the current year from the fees payable. The reimbursement funds for outpatient medical expenses are limited to outpatient or physical examination consumption at the designated medical institution within the current year. The balance of outpatient consumption funds in the current year or the unspent outpatient consumption funds of the insured households will not be carried forward to the next year.

2. Approval of hospitalization medical expense compensation. In Gaozhou City: the minimum reimbursement for hospitalization medical expenses in designated medical institutions in each town (street) is 200 yuan, and 60% of the hospitalization expenses above the threshold are reimbursed; the minimum reimbursement for hospitalization medical expenses in municipal designated medical institutions is 400 yuan, with a minimum of 400 yuan. 50% of hospitalization expenses above the payment line will be reimbursed; outside Gaozhou City: a referral system will be implemented for participating farmer patients to be hospitalized in non-profit hospitals outside Gaozhou City. Referral management is implemented in accordance with the regulations of Maofu [2007] No. 17 (i.e.: ① diseases that cannot be diagnosed by designated medical institutions in our city; ② diseases that are unconditionally treated by designated medical institutions in our city; ③ critical, serious, and urgent patients must be transferred to another hospital For rescue. The patient needs to submit an application for transfer, and after approval from the designated medical institution, it must be reported to the Municipal Cooperative Medical Office for approval). For approved referrals, the minimum reimbursement for hospitalization medical expenses is 600 yuan, and 40% of the hospitalization expenses above the threshold are reimbursed. For unapproved referrals, the minimum reimbursement for medical expenses is 1,000 yuan, and 30% of the hospitalization expenses above the minimum are reimbursed.

3. Hospitalization reimbursement methods

1. Immediate reimbursement. If a participant is admitted to a designated medical institution in Gaozhou City, Maoming Agricultural Reclamation Hospital, Guangdong Tuanjie Farm Hospital, Guangdong Mars Farm Hospital, or Guangdong Province Shengli Farm Hospital with his or her ID card (or household registration book) or cooperative medical certificate, the medical expenses Implement immediate reimbursement.

2. Non-immediate reimbursement scope. Patients who are hospitalized in designated medical institutions with non-immediate compensation and have not been approved for transfer should report to the village committee or town (street) or cooperative medical office before admission or within 48 hours after admission, and apply for reimbursement within one month after discharge. Reimbursers must hold a disease diagnosis certificate, legal hospitalization receipt (computer printout), hospitalization expense list (computer printout), cooperative medical certificate, personal ID card (or household registration book), and a copy of the Rural Credit Union's passbook (either that of the person or a relative). Yes, go to the town (subdistrict) Cooperative Medical Care Office or the village committee to receive the "Rural Cooperative Medical Care Expense Reimbursement Form", fill it out as required, provide a telephone number for medical expense inquiry, and send it to the town (subdistrict) Cooperative Medical Care Office.

After verification, the town (subdistrict) financial settlement center will directly transfer the reimbursement to the patient's or the patient's relative's bankbook [If the bankbook is not the patient's own or the patient's relative, the agent needs to submit the patient's power of attorney (if the patient dies, his/her The family member shall apply on behalf of the patient,) and the patient’s ID card (or household register), and the reimbursement voucher must be accompanied by a copy of the trustee’s ID card].

Note: Except for farmers who participate in both medical insurance and rural cooperative medical care, since the original hospitalization voucher is kept by the insurance company, a copy of the bill certified by the insurance company's seal (the insurance company's inquiry phone number is also provided) No.) as the reimbursement voucher, in other cases, copies cannot be used as the reimbursement voucher for reimbursement.

IV. Large-amount outpatient reimbursement for chronic diseases

1. Scope of large-amount outpatient reimbursement for chronic diseases: liver cirrhosis, cancer, chronic renal failure (uremia stage), systemic lupus erythematosus , mental disorders, rheumatic heart disease, leukemia, tuberculosis, diabetes, sequelae of cerebrovascular accidents (cerebral infarction, cerebral hemorrhage, cerebral thrombosis), and follow-up treatment of myocardial infarction.

2. Chronic disease identification regulations: The signatures of two medical staff who are deputy chief physicians (or deputy chief physicians or above) in Gaozhou City shall be the subject; the identification of mental illness shall be based on the identification of Maoming Third People's Hospital shall prevail.

3. The procedures for applying for large-amount outpatient reimbursement for chronic diseases are the same as those for non-immediate reimbursement.

4. The cumulative minimum payment limit for large outpatient medical expenses for chronic diseases during the year is 500 yuan; the reimbursement ratio is: 40% of the outpatient expenses above the minimum payment line are reimbursed for outpatient services at town-level designated medical institutions in this city; In the outpatient clinics of designated municipal medical institutions in Gaozhou City and the Third People's Hospital of Maoming City, 30% of outpatient expenses above the threshold are reimbursed. Outpatient expenses in hospitals outside Gaozhou City are not reimbursed. The cap for large outpatient expenses for chronic diseases is RMB 10,000 during the year.

5. Childbirth subsidy:

1. For any normal delivery at a designated medical institution, a one-time subsidy of 300 yuan will be provided for each case. Cesarean section is subsidized according to the hospitalization expense reimbursement ratio.

2. Farmers participating in the New Rural Cooperative Medical System who suffer from cataracts and undergo intraocular lens implantation surgery will receive a one-time subsidy of up to 800 yuan for each affected eye.

6. Non-reimbursement scope: all expenses required for fights, traffic accidents, alcoholism, drug abuse, intentional self-injury, medical accidents (disputes) and family planning; plastic surgery, orthopedics, bodybuilding and correction Expenses incurred for physiological defects; medical consultation, medical appraisal, health prediction, examination and treatment of male and female infertility and sexual dysfunction; other expenses that are not within the scope of reimbursement stipulated in the "Interim Measures for the Management of Diagnosis and Treatment Projects of Urban Employee Medical Insurance in Guangdong Province".

Note 1. Anyone who is injured and hospitalized must obtain a certificate from the hospital (signed by the treating doctor and stamped by the hospital), confirmed by the Materials Committee, and verified by the town (street) Cooperative Medical Office that he or she does not fall into the category of "unauthorized" "Reimbursement Scope" before it can be included in the reimbursement scope.

Note 2. Participating farmers belonging to the four subdistricts of Baoguang, Shanmei, Shiziling and Panzhou who go to Gaozhou Second People’s Hospital and Gaozhou Maternal and Child Health Hospital for hospitalization and outpatient services shall be treated as follows: Standard accounting and reimbursement for town-level designated medical institutions.

This reimbursement system will be implemented from January 1, 2009.

Gaozhou City Rural Cooperative Medical Work Leading Group Office

December 28, 2008

Regarding the adjustment of "Gaozhou City's 2009 Rural Cooperation Notice on the relevant contents of the "Medical Compensation System"

Each town (street) cooperative medical office, financial office, and town-level designated medical institutions in the city:

According to the "Maoming New Rural Cooperative Medical Care System" In accordance with the spirit of the "Administrative Measures" (Maofu [2008] No. 91), combined with the actual situation of our city, and after study by the members of the city's new rural cooperative medical work leading group meeting, it was decided to adjust some of the "Gaozhou City 2009 Rural Cooperative Medical Compensation System" The content has been adjusted as follows, please implement it carefully.

1. Raise the standard for the cap line for reimbursement during the year. For those discharged from hospital from April 1, the reimbursement cap for the year will be increased from "accumulated 30,000 yuan" to "accumulated 50,000 yuan".

2. Increase the hospitalization reimbursement ratio of designated medical institutions at the town level. For farmers in our city who are hospitalized in town-level designated medical institutions in the city and are discharged from April 1, the reimbursement rate for hospitalization medical expenses will be increased from 60% to 70%. (Note: Please see the attached table for details of the town-level designated medical institutions that have increased reimbursement standards.

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3. For farmers in our city who go to Maoming Agricultural Reclamation Hospital for hospitalization, the starting line for reimbursement is 600 yuan, and the reimbursement rate is 40%; for those who go to Gaozhou Chronic Disease Prevention and Treatment Station, Guangdong Province Shengli Farm Hospital, Guangdong Province Mars For hospitalization in Farm Hospital and Guangdong Province Unite Farm Hospital, the reimbursement threshold is 200 yuan, and the reimbursement ratio is 60%.

The remaining policies are implemented in accordance with the original "Gaozhou City 2009 Rural Cooperative Medical Compensation System".

Gaozhou City Rural Cooperative Medical Care Leading Group Office

March 18, 2009

About "Gaozhou City 2009 New Rural Cooperative Medical Care Compensation" Notice on the supplementary provisions of the "System"

All town (street) cooperative medical offices, financial offices, and municipal designated units of rural cooperative medical care:

In order to further strengthen the management of new rural cooperative medical care in our city , to ensure the steady and healthy development of this work. According to the spirit of the "Maoming City New Rural Cooperative Medical Care Management Measures" Maofu [2008] No. 91, combined with the actual situation of our city, the following supplementary provisions are hereby made on the relevant issues of the "Gaozhou City 2009 New Rural Cooperative Medical Care Compensation System":

1. Strictly implement the medication catalog, diagnosis and treatment scope, and medical service charging standards. Each designated medical institution uniformly implements the drug catalog stipulated in the "Guangdong Province Urban Employees Medical Insurance Drug Catalog" (2004 Edition) and the "Guangdong Province Urban Employees Medical Insurance Insurance Interim Measures for the Management of Diagnosis and Treatment Projects" and the scope of diagnosis and treatment to treat participating patients in a unified manner. The service charging standards stipulated in the "Medical Service Prices of Non-Profit Medical Institutions in Maoming" (2007 Edition) will be implemented. Those who do not comply with regulations will not be reviewed and reimbursed.

2. Specify the scope of reimbursement for some examinations and treatments. Examination fees that are not included in the scope of reimbursement include: CT, DR, CR, MRI, etc.; other expenses that are not included in the scope of reimbursement include: consulting service fees, education fees, training fees, copy fees, cost of production, ambulances Fees, companionship fees, temperature measurement fees, equipment depreciation fees, etc.; bed fees shall not exceed 30 yuan per day, color ultrasound examination shall not exceed 70 yuan per part, and treatment of critically ill patients in the ICU ward shall not exceed 500 yuan per day. The scope of hospitalization reimbursement; the rest of the rural cooperative medical care that is not reimbursable is detailed in Attachment 1, Attachment 2, and Attachment 3.

3. Responsibility and accountability. (1) Staff of the Municipal Cooperative Medical Care Office will conduct random inspections of designated medical institutions regularly or irregularly. For designated medical units that are found to have arbitrary charging behaviors such as split charging, repeated charging, expanded charging, or independent project charging during random inspections, the Municipal Cooperative Medical Office will select the patient data with the highest illegal charging from the random inspection results as the calculation standard to calculate the violation The ratio of the fees collected to the total hospitalization expenses is multiplied by the total expenses of cooperative medical patients of the hospital in that month, and the cooperative medical compensation expenses of the hospital for that month are deducted based on this result. And hold the responsible persons and relevant leaders accountable. If violations are found three times within the year, their qualifications as designated medical institutions will be cancelled. (2) Strictly control the increase in medical expenses, reduce the expenditure of cooperative medical funds, and reduce the medical expense burden of participating farmers. In principle, the calculation of cooperative medical hospitalization expenses is based on the per capita hospitalization expenses in the same period last year. If the per capita hospitalization expenses in the current month are within the standard range of the per capita hospitalization expenses in the same period last year, the cooperative medical compensation will be allocated in accordance with regulations; the per capita hospitalization expenses in that month If the standard of per capita hospitalization expenses is higher than that of the same period last year, the cooperative medical compensation will be calculated and allocated based on the per capita hospitalization expenses of the same period last year. It is settled on a quarterly basis. Any excess cooperative medical compensation in the current quarter compared with the same period last year will be paid by the designated medical institutions themselves (note: except for special circumstances). The specific situation will be controlled by the Municipal Cooperative Medical Office.

4. Strictly control the review. (1) All relevant units must strictly control the audit in accordance with regulations, and the non-payable portion that is not set up in the system must be manually deducted in accordance with relevant regulations. (2) Anyone who fails to report as required, fails to verify hospitalization expenses or whose declaration procedures are illegal will not be reimbursed. (Note: 1. Verification of hospitalization expenses: If the hospitalization is outside Gaozhou City and the total hospitalization expenses are more than 5,000 yuan, it must be sent to the Municipal Cooperative Medical Office for verification before reimbursement can be processed. 2. Hospitalization invoice: The legal hospitalization invoice is a national tax Printed uniformly by the department or financial department. Any hospitalization invoices printed privately by XX hospital, XX company, etc. are considered illegal and will not be reimbursed).

(3) For rural patients who participate in both commercial insurance and rural cooperative medical care, the method of calculating cooperative medical compensation is: rural cooperative medical compensation amount = [(total hospitalization expenses - commercial insurance compensated expenses) - starting line] × reimbursement ratio .

5. Adjust the partial reimbursement ratio. Participating farmers from Panzhou, Shanmei, Shiziling and Baoguang subdistricts are hospitalized in Gaozhou Second People's Hospital and Gaozhou Maternal and Child Health Hospital, and the reimbursement rate is adjusted from "60%" to "70%".

The rest shall be implemented according to the original regulations.

6. The above supplementary provisions shall be implemented from June 21, 2009 (referring to the time of discharge).

7. The right to interpret these regulations lies with the Gaozhou Rural Cooperative Medical Care Leading Group.

Gaozhou Rural Cooperative Medical Care Leading Group Office

June 10, 2009