Recently
Issued by the General Office of the State Council
"On Improving the Participation in Basic Medical Insurance
Guiding Opinions on Long-term Mechanisms》
The relevant person in charge of the National Health Insurance Administration said
After the issuance of the Guiding Opinions
The insured can enjoy five major dividends
Information Office of the State Council
It will be held on the afternoon of August 1
Regular briefing on the policies of the State Council
Briefing on the situation and answering questions from reporters
The household registration restriction on participating in insurance at the place of employment has been completely abolished
National Health Security Administration:
Relaxing the restrictions on household registration can make people and children who are employed, worked, living and going to school in other places better insured on the spot, so as to better facilitate medical insurance reimbursement when they seek medical treatment nearby and purchase medicines.
The "Guiding Opinions" fully implement the Third Plenary Session of the 20th Central Committee of the Communist Party of China to improve the social security system for flexible employment personnel, migrant workers, and new forms of employment, and fully cancel the requirement of household registration restrictions on insurance participation in the place of employment.
The personal account of the employee's medical insurance can be shared with close relatives
National Health Security Administration:
Employee medical insurance personal account mutual aid means that the money in the personal account can be used by the family, which we summarize as "family mutual aid can participate in insurance, help the elderly and help the young".
On the one hand, the scope of mutual aid has been extended to close relatives.
The document stipulates that the personal account of the employee's medical insurance can be used for the payment of resident medical insurance by his close relatives. Among them, close relatives refer to spouses, parents, children, siblings, grandparents, grandchildren, and grandchildren as stipulated in the Civil Code. If these close relatives are insured, they can be settled using the mutual aid person's personal account when reimbursing medical expenses.
On the other hand, the mutual aid area has been further expanded.
The plan is to take two steps, the first step is to expand the scope of mutual aid to the use of cross-provincial areas within the province by the end of this year, and the second step is to accelerate the promotion of cross-provincial mutual aid next year. Of course, it should be emphasized that family mutual aid is mainly the money in the personal account of the mutual aid worker, excluding the part of the pooled fund.
Increase the maximum payment limit for critical illness insurance as an incentive for continuous participation and zero reimbursement for the fund
National Health Security Administration:
Incentives for continuous participation
Continuous insurance incentive refers to the continuous participation in resident medical insurance for 4 consecutive years from 2025, and then for every 1 consecutive year of insurance, you can enjoy continuous insurance incentive, and the maximum payment limit of serious illness insurance can be increased by no less than 1,000 yuan per year, and the specific standards are formulated by each province.
If the insurance is interrupted, the number of years accumulated in the previous continuous insurance will be automatically cleared, and the number of years will need to be recalculated when participating in the resident medical insurance. The reward amount accumulated in the previous period will continue to be retained.
Zero reimbursement incentives for funds
The zero reimbursement incentive of the fund means that from 2025 onwards, if the masses who participate in the resident medical insurance have not used the medical insurance fund reimbursement of all medical expenses, including outpatient and hospitalization, in the current year, then the maximum payment limit of serious illness insurance for urban and rural residents can be appropriately increased in the next year, which is also not less than 1,000 yuan per year, and the specific standards are formulated by each province.
If the critical illness insurance reimbursement occurs in the current year and the incentive amount is used, the incentive amount accumulated in the previous period will be cleared, and the zero reimbursement incentive amount will be calculated again in the next year.
The cumulative increase in the continuous insurance incentive and the zero reimbursement incentive of the fund can reach up to 20% of the maximum payment limit of the critical illness insurance in the overall planning area.
For example:
If the maximum payment limit of critical illness insurance for urban and rural residents in a region is 400,000 yuan, then the incentive mechanism can be increased by 80,000 yuan after the "reward", that is, the maximum payment limit of critical illness insurance is 480,000 yuan.
According to the incentives, as long as you continue to participate in the insurance and the fund has zero reimbursement, this amount will continue to increase, and you can enjoy the increased critical illness insurance amount every year until it is increased to 20% of the maximum payment limit of critical illness insurance, which is equivalent to an additional amount of protection every year.
Setting a waiting period is a protection for all those who are enrolled
National Health Security Administration:
Some people usually do not get sick and do not want to pay medical insurance, but once they are sick and want to participate in medical insurance, they hope to be protected, from another point of view, it is also a recognition of the function of the medical insurance to reduce the burden of costs, but selective insurance is not encouraged, because such an operation is unfair to those who continue to participate in insurance and pay premiums, and cannot well protect the rights and interests of this part of the population.
In terms of restrictive measures, the Guiding Opinions set up "two waiting periods", namely a fixed waiting period and a change waiting period.
The "Guiding Opinions" make it clear that from 2025, except for special groups such as newborns, for those who have not participated in the centralized insurance period of resident medical insurance or have not been continuously insured, a fixed waiting period of 3 months will be set after enrollment, of which those who have not been continuously insured will be given a change waiting period of 1 month on the basis of the fixed waiting period of 3 months for every additional year of insurance.
At the same time, taking into account the actual situation of the insured, the insured is allowed to repair the change waiting period through payment, and the payment refers to the individual payment standard of the insured place in the current year, and the change waiting period can be reduced by 1 month for each additional year of payment.
It should be noted that if the payment has been interrupted for 4 consecutive years or more, the waiting period for changes after repair shall not be less than 3 months, and the original fixed waiting period of 3 months will still need to wait for at least 6 months. During the waiting period, medical insurance reimbursement is not available.
This measure is also to protect the rights and interests of all the insured, if they are all sick and then pay for insurance, then the medical insurance system will not be able to continue to operate.
Continue to promote the joint organization of "one thing at birth" for newborns
National Health Security Administration:
Newborns and other key groups of people have always been the object of social concern, according to the convention, medical insurance needs to check the name, ID number, household registration, permanent residence and other basic information of the insured, but newborns often take the name, obtain the ID number, household registration and other time, some places pay special attention to the child's name, can not be taken out for half a year, in the original system is particularly difficult to participate in the insurance. In recent years, the National Health Insurance Administration has continued to promote the joint handling of "one thing at birth" for newborns, continuously optimized the process of newborn insurance, and guided all localities to implement the integrated handling of "one thing at birth" such as birth medical certificates, household registration processing, and medical insurance participation, and minimized the service time and cost of newborn parents through offline "one hall joint office" and online "one network service".
Is it necessary for young people to enroll in basic health insurance?
National Health Security Administration:
Basic medical insurance is a kind of social insurance, which first has the nature of insurance and is used to prevent risks, and the occurrence of diseases often has great uncertainty. "Books are hated when they are used, and people are not insured when they get sick", every group may face the risk of disease, and this risk is actually not small.
According to the data of the national medical insurance platform, the hospitalization rates of the four age groups of 20-29 years old, 30-39 years old, 40-49 years old, and 50-59 years old are 7%, 8%, 10%, and 14% respectively. If you add that some people may be hospitalized twice, in terms of the number of people, these four age groups are 9%, 11%, 15% and 23% respectively, which is quite high. The average cost of hospitalization for these four age groups was 7,253 yuan, 8,195 yuan, 9,264 yuan, and 9,554 yuan respectively, and the minimum was more than 7,000 yuan. The highest expenses for these four age groups are 2.05 million yuan, 4.41 million yuan, 3.8 million yuan, and 3.57 million yuan respectively, and the risk of disease is very high. "It is better to be insured than useless, and not to be insured when it is not available".
Add another 30 yuan, and the financial subsidy standard for medical insurance for urban and rural residents will reach 670 yuan per person per year in 2024
Treasury:
Since the establishment of the medical insurance system for urban and rural residents, financial subsidies have always accounted for more than 60% of the income of the medical insurance fund for urban and rural residents, and are the main source of medical insurance financing for urban and rural residents.
The standard of financial subsidies has also continued to increase, from 20 yuan at the beginning of the establishment of the system in 2003 to 640 yuan in 2023, an increase of more than 30 times. We have also calculated that from 2019 to 2023, all levels of finance have allocated about 3 trillion yuan in medical insurance subsidies for urban and rural residents, of which 1.8 trillion yuan has been allocated by the central government. In 2024, the financial subsidy standard for medical insurance for urban and rural residents will be increased by another 30 yuan to 670 yuan per person per year, and the total scale of financial investment will also increase accordingly.
Every year, the financial departments at all levels also arrange subsidy funds for urban and rural medical assistance to subsidize the needy people to participate in the medical insurance for urban and rural residents, and provide further assistance to their personal out-of-pocket expenses after being reimbursed by the medical insurance. From 2019 to 2023, the central government issued a total of 150.7 billion yuan in subsidies for urban and rural medical assistance.
How to ensure that the needy groups have "medical treatment"?
National Health Security Administration:
In terms of strengthening policy and financial support:
● Finances at all levels continue to increase the financial subsidies for residents' participation in medical insurance, and medical assistance will provide classified subsidies to the individual contributions of the needy people according to the degree of difficulty, of which the full subsidy will be provided to the extremely poor, and the subsistence allowance will be subsidized in a fixed amount and the eligible people will be monitored to prevent them from returning to poverty.
●Taking the subsistence allowance recipients as an example, in 2023, the individual payment will be 380 yuan, the average subsidy for medical assistance will be more than 200 yuan, and the individual payment will be less than 180 yuan.
In terms of improving the level of management services:
●Guide all localities to establish a subsidy account for the needy to participate in the insurance by taking the overall planning area as a unit, relying on the inter-departmental information sharing mechanism, increasing the verification and comparison of insurance information, and ensuring that all insurance should be guaranteed.
● Improve the collection method, exempt the needy people who are fully subsidized and participate in the insurance, and implement the difference levy for the fixed amount of subsidy, so as to reduce the burden of the masses.
In terms of strengthening the coordination of departmental work:
Improve the coordination mechanism for the participation of the medical insurance, civil affairs, finance, agriculture and rural affairs, taxation and other departments in the work of the needy people, coordinate to increase the mobilization of insurance participation, smooth the channels for insurance payment, and ensure that policy publicity is in place and funding is accurate to the person. In 2023, a total of 80.2 million needy people will be subsidized for medical assistance, and the participation rate of low-income rural people monitored will remain stable at more than 99%.
What is the overall protection of medical insurance benefits for mainland residents?
National Health Security Administration:
To sum it up briefly, it is the "four guarantees".
Hospitalization: The reimbursement ratio within the policy scope reaches about 70%.
At present, the residents' medical insurance is coordinated at the municipal and prefecture levels, and the specific security policies of various regions vary due to the level of economic development and the affordability of the fund.
Overall, the proportion of inpatient medical expenses paid by the fund within the national policy scope has reached about 70%, and the maximum annual payment limit of the fund can reach about 6 times the annual per capita disposable income of local residents.
Outpatient coverage: General outpatient clinics, outpatient chronic diseases, special diseases, and outpatient medications for hypertension and diabetes can be covered.
On the basis of doing a good job in hospitalization security, all localities generally include outpatient expenses for chronic diseases and special diseases with long treatment cycles, great damage to health, and heavy cost burdens into the scope of fund payment, and outpatient radiotherapy and chemotherapy for malignant tumors, uremia dialysis, and anti-rejection therapy after organ transplantation can also refer to inpatient management and payment.
At the same time, the general outpatient co-ordination is generally carried out, and the outpatient medical expenses are guaranteed according to the cost rather than the type of disease, and the ordinary outpatient expenses incurred by the insured in the designated medical institutions are included in the reimbursement scope by relying on the primary medical and health institutions, and the reimbursement ratio within the policy starts from 50%.
Since 2019, the antihypertensive and hypoglycemic drugs that occur in primary medical institutions for patients with hypertension and diabetes have also been included in the scope of insurance, with no starting payment line, and the reimbursement ratio has reached more than 50%. So far, the "two diseases" outpatient drug guarantee mechanism has benefited 180 million patients with "two diseases" and reduced the drug burden by 86 billion yuan.
Serious illness insurance: You can enjoy the treatment of serious illness insurance for urban and rural residents without additional payment.
The high medical expenses incurred after the insured person is sick and hospitalized can be reimbursed through the basic medical insurance, and the personal out-of-pocket expenses can also be further covered through the serious illness insurance.
Taking 2023 as an example, the reimbursement level for seriously ill patients will be increased by at least 15 percentage points on the basis of basic medical insurance reimbursement, and the cost burden of insured patients will be greatly reduced.
Maternity protection: The protection of maternity medical expenses continues to be strengthened.
Resident medical insurance not only covers the insured's outpatient and inpatient medical expenses, but also covers childbirth and other maternity medical expenses, and the insured can be reimbursed in accordance with the relevant procedures after childbirth.
Source / Chinese Government Network Editor / Wei Jiajia