Starting from March 1, 222, the threshold for hospitalization of basic medical insurance in tertiary first-class hospitals was adjusted from 1,5 yuan to 1,2 yuan.
(II) Adjusting the referral hospitalization treatment for adult residents
From March 1, 222, if the adult residents who participated in the medical insurance for urban and rural residents were referred by the contracted community health service institutions (township hospitals) and hospitalized in the secondary and above medical institutions in the city, the hospitalization expenses would be above the Qifubiaozhun to 4, yuan (inclusive), and the payment ratio of the medical insurance fund would be adjusted to 7%, with more than 4, yuan to the payment limit (.
(III) Adjusting the medical insurance benefits of the old workers who participated in the revolutionary work before the founding of the People's Republic of China
From March 1, 222, the personal out-of-pocket medical expenses incurred by the old workers who participated in the revolutionary work before the founding of the People's Republic of China in outpatient, inpatient and outpatient special diseases will be halved on the basis of enjoying the basic medical insurance benefits for retired workers, and the half amount will be paid by the overall fund.
(IV) Adjusting the payment policy for screening and diagnosis and treatment-related expenses in COVID-19
In order to effectively prevent and control the epidemic situation, from January 1, 222, the Notice of Ningbo Municipal Health and Health Commission, Ningbo Municipal Finance Bureau, Ningbo Municipal Medical Security Bureau on Doing a Good Job in the Settlement of Screening and Diagnosis and Treatment-related Expenses in COVID-19 (Yong Wei Fa [22] No.88) was published in Items (1) to (5) of Article 1.
II. Adjusting some measures for the management of medical treatment
(I) Adjusting the method for the settlement of expenses during the suspension of medical insurance settlement service
The insured person holds a social security card for medical treatment during the online and offline switching of the provincial smart medical insurance platform, and the outpatient medical expenses within the scope of medical insurance fund are entitled to emergency accounting treatment, of which 2% are borne by employees, 15% by retirees, 5% by urban and rural medical insurance participants, and the rest are paid by the overall fund; 1% of the co-ordinators shall be paid by the fund. After the designated medical institutions keep accounts, they still upload the details of emergency accounting expenses according to the original channels, and the handling agencies will upload the payment information to the provincial smart medical insurance system after the settlement and payment of the original medical insurance system.
after the launch of the provincial smart medical insurance platform, when the medical insurance computer system of the medical insurance agency or designated medical institution needs to suspend the medical insurance settlement service due to failure or maintenance, if the insured person has medical expenses in the designated medical institution, the individual will pay all the expenses. After the system is restored, he will bring the original self-funded bill and his social security card (or medical insurance electronic certificate) to the original designated medical institution, and the medical institution will re-settle the medical expenses paid by the individual through the medical insurance system. Or apply for sporadic reimbursement to the medical insurance agency as required.
(II) Adjustment of settlement method for out-of-hospital examination (treatment)
From March 1, 222, if the insured person needs out-of-hospital examination and treatment according to regulations during hospitalization, the designated medical institution shall handle the out-of-hospital examination (treatment) procedures for the insured person (registration of foreign inspection and purchase), and the related expenses shall be paid by the insured person at his own expense before applying for sporadic reimbursement with valid bills, and enjoy the out-of-hospital examination (treatment) treatment according to regulations.
(III) Temporary adjustment of the method of purchasing drugs with external prescriptions Before the electronic circulation function of external prescriptions on the "Smart Health Insurance" platform is improved, the method of purchasing drugs with external prescriptions will be temporarily adjusted. From March 1, 222, insured persons who want to purchase drugs outside designated retail pharmacies must hold paper external prescriptions issued by designated medical institutions. When the designated medical institutions issue prescriptions for external use, they should strictly distinguish five types of prescriptions: general outpatient prescriptions for medical insurance, prescriptions for special diseases in medical insurance outpatient clinics, prescriptions for special drugs for serious diseases, prescriptions for hepatitis C drugs and prescriptions for external use at their own expense. The external prescription issued shall be stamped with the seal of the medical institution and the special seal of the doctor's name, and the medical insurance settlement grade (category) shall be specified on the prescription.
according to five types of prescriptions, designated retail pharmacies choose the corresponding medical insurance settlement treatment. Among them, when receiving the prescription of medical insurance for general outpatient service, they should choose "tertiary hospitals (general outpatient service)", "other hospitals (other outpatient service)" and "community hospitals (village health clinics)" to upload information according to the settlement grade (category) of medical institutions marked on the prescription, and the insured still enjoy the corresponding treatment of purchasing drugs according to the settlement grade (category) of designated medical institutions that issue prescriptions. (IV) Standardizing the payment scope of individual account funds over the years
From March 1, 222, drugs (including Chinese herbal pieces and self-made preparations) and services and materials outside the catalogue with national codes will be included in the payment scope of individual account funds over the years, and those without national codes will be paid by individuals in cash. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance.
the personal payment part of the family doctor's contract service fee is paid by personal cash, and the payment part of the medical insurance fund is reviewed by the health administrative department where the medical institution is located, and the relevant data of contract signing is provided to the medical insurance agency affiliated to the medical institution for payment.
the provisions of dental implant payment shall be implemented in accordance with the terms of the agreement on focusing on the reform of medical insurance payment to promote the implementation of medical insurance dental implant projects with Fuyu (hereinafter referred to as the agreement), and the payment scope of individual accounts over the years is limited to implants within the brand catalogue of the agreement and the medical insurance payment standards stipulated.
(V) Defining the scope of personal burden of medical expenses
Personal burden of medical expenses includes personal expenses and personal expenses.
Personal expenses refer to medical expenses and other expenses that are not included in the basic medical insurance payment scope and need to be paid by the insured individuals according to regulations.
the individual pays refers to the medical expenses that are included in the basic medical insurance payment scope and need to be paid by the insured person according to the regulations, including the expenses paid by the individual in advance in proportion for Class B medical expenses, the expenses borne by the individual within the Qifubiaozhun, and the expenses borne by the individual in proportion after entering the overall fund for payment.
the expenses exceeding the price limit in the basic medical insurance catalogue are included in the personal out-of-pocket expenses, but not included in the prescribed payment scope of supplementary reimbursement such as civil service subsidy, serious illness insurance and medical assistance.
the annual medical expenses of the basic medical insurance are calculated according to the medical expenses incurred, excluding the self-paid expenses beyond the scope of payment of the basic medical insurance, the personal out-of-pocket expenses of the Class B medical expenses, the emergency bookkeeping expenses of outpatient service, and the out-of-hospital examination (treatment) expenses.
for the above-mentioned policies implemented from March 1, 222, the actual effective time of medical expenses settlement shall be based on the time when our city is included in the provincial "smart medical insurance" system.
Legal basis: Article 55 of the Social Insurance Law of the People's Republic of China
Maternity medical expenses include the following items:
(1) Maternity medical expenses;
(2) medical expenses for family planning;
(3) other project expenses stipulated by laws and regulations.
Article 56 An employee may enjoy maternity allowance in accordance with the provisions of the state under any of the following circumstances:
(1) Female employees enjoy maternity leave when giving birth;
(2) Enjoy family planning operation leave;
(3) other circumstances stipulated by laws and regulations.
The maternity allowance is calculated and paid according to the average monthly salary of the employees in the employing unit of the previous year.