1. What is "outpatient mutual aid"?
The first is to make overall plans for mutual aid, and reimburse the general outpatient expenses incurred by the insured employees in the designated medical institutions within the scope of the medical insurance policy, so that the employee medical insurance patients who seek outpatient medical treatment can enjoy the reimbursement treatment of the overall fund.
After the implementation of "outpatient mutual aid", the personal accounts of insured employees can be used by spouses, children and parents to improve the utilization rate of personal accounts.
2. Who are the suitable people?
All insured persons of Honghe Prefecture Employee Medical Insurance (hereinafter referred to as the insured persons), including in-service employees, retirees and flexible employment personnel, new employment forms of workers and other employees participating in the employee medical insurance.
3. What are the outpatient benefits included in the "Outpatient Mutual Aid"? What are the specific regulations?
Honghe Prefecture Employee Medical Insurance Outpatient Mutual Aid Guarantee, including Employee Medical Insurance General Outpatient Consultation, Outpatient Chronic Diseases, Outpatient Special Diseases, Outpatient Emergency Rescue, National Medical Insurance Negotiation Drug Outpatient Protection, Day Surgery, etc. The cost of medical treatment in designated medical institutions in the province can be reimbursed in a "one-stop" manner.
The standard of general outpatient treatment in a calendar year is detailed in the following figure:
(Note: Each statement will be paid once according to the minimum payment standard)
The treatment standards for chronic diseases, emergency rescue, negotiated drugs under national medical insurance, and day surgery in a natural year are detailed in the figure below:
4. What are the changes in the personal account?
After the reform, the personal accounts of most in-service employees will be reduced in the current period, but after the reform, the outpatient treatment will be better, and the people who are really sick and the elderly will benefit more. Everyone gets old and sick at times, young and healthy, and although there are not many doctors now, the economic risks of illness are long-term. When you are old and sick, relying on personal accounts and personal accumulation is always limited, and you need to have a solid and sustainable medical insurance to achieve social mutual assistance to resolve the risk of disease.
The reform of personal accounts mainly includes outpatient expenses into the medical insurance pooling fund, and a new guarantee mechanism has been created, and the scope of use has been wider after the reform, and personal accounts have become more active.
First, personal accounts can still be used for personal medical treatment in outpatient clinics and drug purchases in pharmacies, which can still be guaranteed after the reform, and the scope of use has also been expanded.
Second, the accounting method is more equitable. The basic medical insurance premiums paid by the medical insurance units for in-service employees (including the part paid by the units for flexible employees) are all included in the overall fund. The basic medical insurance premiums paid by in-service employees (including flexible employees) are all included in their personal accounts, and the inclusion standard is 2% of their insurance payment base. The proportion of retirees' personal accounts will be temporarily maintained in 2022. Later, depending on the actual situation, it will be gradually adjusted to 2% of the average level of the basic pension in Honghe Prefecture in that year.
5. What are the changes in the use and management of personal accounts?
The original personal account of employees' medical insurance was limited to their own use, and the new policy broadens the scope of use of personal accounts. New policy: Personal accounts can be used to pay for:
1. The medical expenses incurred by the insured person and his or her spouse, parents and children in designated medical institutions, as well as the expenses incurred by individuals in the purchase of drugs, medical devices and medical consumables with national medical insurance standard codes in designated retail pharmacies.
2. The spouses, parents and children of the insured persons participate in the basic medical insurance for urban and rural residents.
3. Insured persons and their spouses, parents and children participate in the personal payment of large medical expense subsidies, long-term care insurance and commercial health insurance.
The scope of spouses, parents and children shall be implemented in accordance with the Civil Code of the People's Republic of China and other laws and regulations. In principle, the scope of spouses, parents and children is limited to the insured persons in Yunnan Province.
6. How to bind relatives to personal accounts?
Insured persons can apply through the "Yunnan Medical Insurance" WeChat applet or to the local agency to apply through the "Smart Medical Insurance" information system online platform, and bind the spouses, parents and children who meet the conditions for participating in Yunnan Province to their personal accounts and add them to the list of personal account payers.
Note: "Relatives mutual aid" refers to the sharing and sharing of their personal accounts, if the violation of the provisions of the sharing and sharing of the relevant treatment involving the payment of the pooled fund, it is suspected of violating the relevant laws and regulations of medical security, and its behavior will be punished accordingly.
7. Other issues of concern to everyone.
(1) After the outpatient mutual aid of employee medical insurance is launched, can the spouse, parents and children of the insured employee enjoy the outpatient reimbursement ratio of the insured person after binding the personal account of the insured employee?
No. After the spouse, parents and children of the insured employees are bound to the personal accounts of the insured employees, they can only use the balance on the personal accounts of the insured employees, and cannot enjoy the outpatient reimbursement treatment together with the insured employees.
(2) After the outpatient mutual aid of employee medical insurance is launched, what kind of consumption cannot be made in the personal account of employee medical insurance?
1. The personal account shall not be used for public health expenses, sports and fitness, health care consumption, health examination and other expenses that are not covered by basic medical insurance.
2. Expenses for outpatient prenatal examination during pregnancy for insured female employees.
(3) What is the scope of non-payment of outpatient services for employees' basic medical insurance?
1. Pre-hospital emergency, rescue and other medical expenses that have been included in the hospitalization settlement of basic medical insurance;
2. Outpatient medical expenses incurred during hospitalization;
3. Medical expenses that should be paid from the work-related injury insurance fund;
4. Medical expenses that should be borne by a third party;
5. Medical expenses that should be borne by public health;
6. Medical expenses incurred abroad;
7. Other expenses that do not meet the scope and payment standards of basic medical insurance.
(4) How to reimburse insured employees for outpatient treatment in designated medical institutions outside the province?
Insured employees who seek outpatient treatment in designated medical institutions outside the province should apply for direct settlement and filing of medical treatment in other places in advance, and can apply for instant completion through channels such as the local medical insurance agency, Yunnan public service platform (a mobile phone service, Yunnan medical insurance service official account, Yunnan medical insurance WeChat applet) or the national medical insurance service platform APP. If there is no filing for direct settlement of medical treatment in other places, the insured employee shall provide the original medical bills, prescriptions or expense lists or checklists, ID cards, social security cards or bank cards and other materials to the medical insurance agency in the place of insurance for manual reimbursement.
Editor: Mao Huan