I. Rights and obligations of participants

(1) participants

1. All rural residents with rural hukou in this city (including migrant workers, business farmers and landless farmers in cities and towns) can participate in the new rural cooperative medical system on a household basis.

2 farmers who have lived in our city for a long time but have not gone through the formalities of household registration transfer and foreign rural household registration personnel who have no stable labor relations can participate in the new rural cooperative medical system at their place of residence (workplace).

3. Encourage parents to pay in advance for newborns who are expected to be born in the year, and babies enjoy the same compensation policy for participating in the annual general insured. Newborns who missed the payment deadline (2065438+February 29th, 2002) can be included in the compensation scope of the new rural cooperative medical system with their mothers, but the amount of compensation for medical expenses incurred by their infants in hospital must be calculated with their mothers until they reach the local maximum cap line.

4, funding rural five-guarantee households, low-income households, entitled groups and severely disabled people and other rural people with difficulties, to ensure that rural people with difficulties are included in the scope of the new rural cooperative medical care.

For the three medical security systems (basic medical insurance for urban workers, basic medical insurance for urban residents and new rural cooperative medical care) with financial subsidies, you can only choose one of them independently, and you can't enjoy the compensation of more than two medical security systems (excluding the medical insurance of commercial insurance companies) at the same time.

(2) Payment standard

The fund raising standard of the new rural cooperative medical system is 300 yuan per person per year, which mainly consists of three parts: central financial transfer payment, local financial subsidies and farmers' voluntary contributions: central and local financial subsidies for 240 yuan (including central financial subsidies 132 yuan, provincial financial subsidies of 73.8 yuan and county financial subsidies of 34.2 yuan), and the payment standard of individual farmers' insurance participation is still 20% of the raising standard, that is, 60 yuan/year/person.

(3) Time of payment

In order to facilitate the retired soldiers and migrant farmers to participate in the insurance in time, the deadline for sporadic payment of insurance was extended to February 29.

(4) Rights and obligations

Farmers who participate in the new rural cooperative medical system have the right to provide services and medical expenses compensation according to regulations and supervise the new rural cooperative medical system, and have the obligation to pay the new rural cooperative medical system fund on schedule and abide by the rules and regulations of the new rural cooperative medical system.

Second, the main compensation policy

Outpatient compensation

1, general outpatient compensation

Compensation takes the form of "proportion, daily limit and annual limit". That is, the participating farmers can compensate the outpatient medical expenses (by electronic prescription) in the designated medical institutions of the new rural cooperative medical system in their villages or townships. The daily outpatient medical expenses compensation limit is 10 yuan, and the annual compensation capping line for each person is 200 yuan (including general medical expenses compensation).

2, general medical expenses compensation

Participating farmers are treated in outpatient clinics of township hospitals (with electronic prescriptions), and the general standard of medical expenses is each outpatient clinic 10 yuan (the same patient is only treated once in three days in a course of treatment). Among them, individuals paid their own expenses in 3 yuan, and the New Rural Cooperative Fund compensated 7 yuan (from 2011August 15);

The general standard of medical expenses for each outpatient service of participating farmers in township and village clinics (with electronic prescriptions) (one course of treatment and only one patient within three days) in 5 yuan. The individual pays 1 yuan, and the new rural cooperative fund compensates 4 yuan (from 20 1 1,1,3 1).

3, outpatient serious chronic disease compensation

According to the requirements of dynamic management, the objects that meet the management of serious and chronic diseases in outpatient department (20 12 included 22 diseases, an increase of 14 diseases over the previous year) were examined and approved twice a year (June and 165438+ 10), and immediate compensation was implemented.

(2) Hospitalization compensation

1, general hospitalization compensation

For the expenses within the scope of the policy, the deductible line and compensation ratio are set according to different hospital levels and different average hospitalization expenses levels, and the compensation is implemented in a "segmented and proportional" way, with the annual capping line of100000 yuan (the specific compensation ratio policy of medical institutions at all levels is implemented according to the unified guidance of the whole province).

For 3A hospitals, the proportion of hospitalization compensation is increased by 5 percentage points on the basis of subsection compensation standard, while for A hospitals, the proportion of hospitalization compensation is reduced by 5 percentage points on the basis of subsection compensation standard.

2, hospitalization single disease compensation

Some hospitalized diseases (20 12 included 34 diseases, an increase of 15 diseases compared with the previous year) were included in a single disease for fixed payment compensation. That is, when the participating patients are hospitalized in the designated medical institutions that pay for a single disease, they only need to pay the self-paid part stipulated by the single disease first, and go through the compensation procedures at the joint management department of the designated medical institutions at the time of discharge according to the unified subsidy standard of the whole city. The part exceeding the price limit standard shall be borne by medical institutions, and the cooperative medical fund and inpatients shall not be paid.

3, major diseases to improve the level of medical insurance compensation.

In order to further reduce the proportion of personal payment for patients with major diseases, the following 15 diseases are compensated by improving the level of medical security.

(1) compensation for children's "two diseases" (six diseases);

For children aged 0~ 14 (including 14) who meet the requirements of improving the level of medical security and are hospitalized in designated medical institutions, the compensation method of "lump sum for expenses and fixed settlement" shall be implemented.

A. The unified quota settlement standard for children with congenital heart disease is: 20,000 yuan for congenital atrial septal defect over 3 years old and 30,000 yuan for children under 3 years old; Congenital ventricular septal defect (VSD) is 20,000 yuan over 3 years old and 32,000 yuan under 3 years old; Congenital patent ductus arteriosus is more than 3 years old10.3 million yuan, and less than 3 years old is 20 thousand yuan; Congenital pulmonary valve stenosis is 20 thousand yuan over 3 years old and 30 thousand yuan under 3 years old. The specific compensation is 70% of the total fixed settlement fee and 20% of the civil assistance paid by the new rural cooperative medical fund, and only 10% of the total fee is paid by the participating children's families. Give 75% compensation and 25% civil assistance to the children of low-income households, families with special care for poor families or rural orphans. Families of children participating in the new rural cooperative medical system will not bear the expenses, and the excess expenses will be borne by designated medical institutions according to the above settlement standards (the adjusted standards will be implemented from 2002 1 month/day).

B, children leukemia unified quota settlement standard is:

The average total cost of children with acute lymphoblastic leukemia in standard risk group is 80 thousand yuan. Among them, the cost standard for the first year of induction, remission, consolidation and strengthening phase is 60,000 yuan, and the cost standard for the second year and the third year of maintenance treatment phase is 6,543.8+0,000 yuan respectively; The average total cost of patients in the middle-risk group is 6.5438+200,000 yuan. Among them, the cost standard for the first year of the induced remission consolidation and strengthening stage is 80,000 yuan, and the cost standard for the second year and the third year of the maintenance treatment stage is 20,000 yuan each (in principle, patients in high-risk groups will be compensated by the post-payment system according to the subsidy policy standard not lower than that of patients in middle-risk groups, and the specific measures will be formulated separately by the municipal joint management office).

The average total cost of acute promyelocytic leukemia in children is 80 thousand yuan. Among them, the cost standard for the first year of induction, remission, consolidation and strengthening period is 60,000 yuan, and the cost standard for the second year and the third year of maintenance treatment period is 6,543.8+0,000 yuan respectively.

The specific compensation shall be borne by the New Rural Cooperative Medical Scheme Fund, accounting for 70% of the total settlement fee, 20% by the Civil Relief Fund and 10% by the participating children's families. For low-income households, children from families with special care and rural orphans, the new rural cooperative fund will bear 80% of the total fixed settlement expenses, the civil assistance fund will bear 20% of the total expenses, and the participating children's families will not bear the expenses (implemented from 20 10 to 65438+February 9).

In this program, the first year, the second year and the third year are counted from the day when the children participate in the first induction chemotherapy. The participating children are treated in designated hospitals, and the related drugs and diagnosis and treatment items used according to the clinical pathway and diagnosis and treatment operation specifications are not restricted by the hospitalization capping line and the new rural cooperative medical system drugs and diagnosis and treatment catalogue, and the hospitalization deductible line is cancelled.

(2) Compensation for severe mental illness (schizophrenia, bipolar disorder, paranoid mental disorder, schizoaffective mental disorder, mental disorder caused by epilepsy and severe mental retardation):

The annual hospitalization expenses are controlled at 6000 yuan/person, and the hospitalization medical expenses are compensated according to the proportion of 70%. When patients with severe mental illness are compensated for hospitalization, the deductible line is cancelled and is not restricted by the new rural cooperative medical system drug list. However, the cumulative compensation for hospitalization expenses of patients with severe mental illness is included in the capping line of annual hospitalization expenses compensation for local individuals (20 1 1 to August 3 1).

(3) Compensation for cervical cancer and breast cancer (two diseases):

The hospitalization medical expenses of patients with cervical cancer and breast cancer are within the highest standard (that is, the third-level hospital for cervical cancer surgery 1 1000 yuan, and the second-level hospital is 9000 yuan; Surgical treatment of breast cancer, tertiary hospital 1 10,000 yuan, secondary hospital 8000 yuan). The medical expenses incurred by the new rural cooperative medical system in designated medical institutions at the city (state) level are compensated by 70%, and the medical expenses incurred by the new rural cooperative medical system in designated medical institutions at the county level are compensated by 80%. Medical expenses exceeding the maximum limit shall be borne by designated medical institutions (from 2065,438+065,438+0,65438).

The participating patients suffering from cervical cancer and breast cancer are hospitalized in designated medical institutions, and the medical expenses incurred enjoy the compensation treatment of the new rural cooperative medical system, and the restrictions on the deductible line and drug list of the new rural cooperative medical system are cancelled, but the accumulated compensation generated by the above-mentioned proportion compensation is included in the local individual annual hospitalization expense compensation capping line.

(4) Compensation for MDR-TB:

The specific compensation policy shall be implemented according to the unified regulations of the whole province.

4. Supplementary compensation for serious diseases

Within one year, the self-paid amount of participating patients exceeds the self-paid part of the compensation scope of rural per capita net income in our city last year. At the end of the year, supplementary compensation will be made at a rate of not less than 50%, and the top line of supplementary compensation will be set. The standard for setting the capping line is 654.38+10,000 yuan.

(3) Fixed compensation for hospital delivery

For pregnant women who give birth in hospital within the policy, in addition to special financial subsidies, the new rural cooperative medical system will implement a fixed subsidy according to the 200 yuan standard for each woman. In the designated medical institutions within the jurisdiction of this Municipality, the delivery shall be compensated immediately by the designated medical institutions at the time of discharge. In other medical institutions outside the city hospital delivery, with relevant information to prove to the city joint management office to apply for compensation.

Three. Other relevant regulations.

1, Provisions on Compensation for Accidental Injury of Inpatients

Any accidental injury patient who is transferred to a designated medical institution outside the city will not be included in the scope of immediate compensation reported by the hospital, and will be returned to Yidu Co-management Office to determine whether to compensate according to the policy. For the hospitalization expenses that can be included in the compensation of the new rural cooperative medical system, the compensation ratio is reduced by 20 percentage points, and the capping line is 1 10,000 yuan. At the same time, it is necessary to have the original of the application form for the identification of the nature of trauma and other relevant investigation materials, and implement the method of first publicity (publicity period is one month) and then compensation.

2, hospitalization compensation settlement regulations

Anyone who is hospitalized in a designated medical institution within the jurisdiction of Yidu City or hospitalized in a designated medical institution of the new rural cooperative medical system outside the territory can receive immediate compensation directly at the time of hospitalization settlement.

Compensation for hospitalization in other medical institutions shall be paid after discharge.

1 out-of-hospital referral approval form,

2 household registration book,

3 cooperative medical card,

Patient ID card (if you don't have an ID card, you need to go to the local police station to issue a household registration certificate).

5 cost summary table (hospital seal),

6 discharge records,

7 diagnosis certificate (hospital seal),

Eight procedures, such as the original fee receipt, apply for compensation to the municipal joint management office in a timely manner.

3. Items without compensation payment provisions

(1) Expenses beyond the three catalogues of medical services, medical devices and essential drugs stipulated by the new rural cooperative medical system.

(2) the organ source or tissue source cost of imported drugs and instruments, various organs or tissues transplantation; Expenses of various plasma products (except severe cases and rescue); Self-purchased drugs, examination, treatment and drug expenses unrelated to the disease (exclusive diagnosis and inspection expenses are not included); All kinds of self-use health care, massage, examination and treatment equipment; Glasses, dentures, artificial eyes, artificial limbs, hearing AIDS and other rehabilitation appliances.

(3) Qigong therapy, music therapy, nutrition therapy, magnetic therapy and other auxiliary treatment projects.

(4) Treatment expenses incurred by the other party due to work-related injuries, other injuries, traffic accidents, occupational diseases, etc. Or due to alcoholism, self-mutilation, suicide, etc.

(5) Non-therapeutic medical expenses such as cosmetic surgery, bodybuilding projects, prosthetic dentures, artificial eyes, weight loss, enhancement projects, hearing AIDS, vision (myopia, hyperopia, strabismus, etc.). ).

(6) Medical expenses for family planning operation, infertility (pregnancy), sexually transmitted diseases and sexual dysfunction.

(7) medical expenses for schistosomiasis, tuberculosis and AIDS within the scope of special state financial subsidies.

(8) Medical malpractice or medical expenses that have been identified as medical malpractice disputes but not yet identified.

(9) Out-of-hospital consultation fee, medical record fee, printing fee, etc. ; Check the special medical service fees, such as expedited treatment fees, extra fees for name-based surgery, and self-invited special care; Transportation expenses for referral and first aid; Compensation for food, air conditioning, television, telephone, food heating and public property damage; Family bed hospitalization expenses, escort expenses, nursing expenses, nursing expenses, outpatient decocting expenses and other life service items and service facilities.

(10) Expenses of various scientific research and clinical verification diagnosis and treatment projects.

4, part of the compensation payment provisions

(1) All single large-scale examination and treatment items below 400 yuan are included in the compensation scope, and the part exceeding 400 yuan is included in the compensation scope by half; The cost of a single large-scale material is all included in the scope of compensation within 5,000 yuan, and the part exceeding 5,000 yuan but less than 30,000 yuan is included in the scope of compensation according to the proportion of 30%, and no compensation will be given if it exceeds 30,000 yuan.

(2) The provincial medical institutions shall calculate the bed fee according to the daily 40 yuan, and the excess shall be borne by the patients themselves; City (state) level medical institutions shall be included in the scope of compensation according to the daily 30 yuan, and the excess shall be borne by the patients themselves; County (city) level medical institutions are included in the scope of compensation according to daily 12 yuan, and the excess is borne by the patients themselves; Township-level medical institutions (including other first-level hospitals) shall be included in the scope of compensation according to the daily 8 yuan, and the excess shall be borne by the patients themselves.