(2) the scope of participation. Participants should be registered as agricultural household registration residents. Whether the place where the household registration system reform is implemented is a rural resident can be defined according to the family planning policy, the veterans resettlement policy and the urban minimum living security policy enjoyed by their families. Primary and secondary school students and preschool children with rural household registration should participate in the new rural cooperative medical system with their parents; In the year when the newborn was born, the mother automatically obtained the eligibility and enjoyed the treatment of the new rural cooperative medical system, and paid the participation fee according to the regulations from the second year.
Second, unify the capping line and deductible line.
(1) top line. The top line of the participating farmers' new rural cooperative medical system is still 6.5438+0.5 million yuan.
(2) the deductible line. The hospitalization deductible lines of township, county, municipal, provincial and provincial designated medical institutions are 200 yuan, 500 yuan, 1 10,000 yuan, 1 10,000 yuan and 1.200 yuan respectively. Deductible expenses are not compensated. Severe mental illness, tuberculosis, radiotherapy and chemotherapy for malignant tumor, end-stage renal disease, hemophilia and severe aplastic anemia with the same disease in a medical year can only be calculated as the one-time deductible line of the highest level hospital.
Fourth, the compensation standard
Outpatient compensation
Refer to 20 12 Opinions on Adjusting the Compensation Scheme of New Rural Cooperative Medical System (Taifufa [2065438+065438+0] No.50) for the relevant provisions of outpatient compensation.
(2) Hospitalization compensation
1, general hospitalization compensation
Township designated medical institutions (community health service centers) implement the basic drug system, and some basic drugs above the deductible for hospitalization-related compensation are compensated by 90%, while others are compensated by 85%; For the part above the deductible of hospitalization expenses that has not implemented the basic drug system, 65% will be compensated.
Hospitalization in designated medical institutions at the county level involves the above deductible, and compensation shall be made at a rate of not less than 70%. The specific compensation standard shall be determined by counties (cities, districts).
Municipal designated medical institutions can compensate 55% for hospitalization-related expenses above deductible.
In Tai 'an designated medical institutions outside the city, the part above the deductible related to hospitalization expenses shall be compensated according to the proportion of 50%, and the specific provisions shall be determined by counties and urban areas.
2, major illness hospitalization compensation
The hospitalization of major diseases still implements the fixed-point quota examination and approval system for major diseases. The qualified designated medical institutions of the new rural cooperative medical system shall apply to the designated health administrative department for examination and approval, and promise to limit the fees. After passing the review, it is recognized as a designated medical institution for major diseases at the provincial and municipal levels.
Major diseases are tentatively defined as: childhood leukemia, congenital heart disease in children, severe psychosis, breast cancer, cervical cancer, end-stage renal disease, hemophilia, opportunistic infection of AIDS, multidrug-resistant tuberculosis, severe aplastic anemia, myelodysplastic syndrome, severe hand-foot-mouth disease, viral meningitis, type II diabetic nephropathy, subarachnoid hemorrhage, retinal detachment and infectious septicemia. Aortic dissection, necrotizing myocarditis, cleft lip and palate, chronic myeloid leukemia, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, type I diabetes, hyperthyroidism, acute myocardial infarction and cerebral infarction.
The medical expenses incurred within the above-mentioned 3 1 major diseases shall be compensated by the new rural cooperative medical system according to the proportion of 70%, and the actual compensation ratio of the new rural cooperative medical system shall not be less than 60%. Medical expenses exceeding the limit shall be borne by designated medical institutions. Non-major diseases hospitalized in designated medical institutions, still according to the original compensation policy. The civil affairs department will provide medical assistance to children with leukemia and congenital heart disease by increasing the compensation ratio of the new rural cooperative medical system by 20 percentage points. It can be used for treating severe mental illness, breast cancer, cervical cancer, end-stage renal disease, hemophilia, AIDS opportunistic infection, multidrug-resistant pulmonary tuberculosis, severe aplastic anemia, myelodysplastic syndrome, severe hand-foot-mouth disease, viral encephalomyelitis, type II diabetic nephropathy, subarachnoid hemorrhage, retinal detachment, infectious septicemia, acute pulmonary embolism, aortic dissection, necrotizing myocarditis, cleft lip and palate, chronic myeloid leukemia, etc. Medical assistance for 29 kinds of serious diseases, such as gastric cancer, colon cancer, rectal cancer, type I diabetes, hyperthyroidism, acute myocardial infarction and cerebral infarction, was gradually expanded from low-income families to low-income families, and medical assistance was given appropriately on the basis of the compensation ratio of the new rural cooperative medical system.
After the medical expenses of 20 major diseases determined by the state are reimbursed by the new rural cooperative medical system, the serious illness insurance shall be implemented with reference to the relevant policies of the state and the province.
3. Participate in maternity compensation. Insured pregnant women who give birth in different places outside Tai 'an enjoy the corresponding fixed subsidy from the designated medical institutions in the city.
This compensation standard is the lowest guiding standard in the city. Counties (cities, districts) should reasonably determine the local actual compensation standards according to the use of funds in the previous year, the overall situation of funds in this year and the level of medical consumption in the region, so as to ensure that the benefit level of participating farmers in 20 13 years is effectively improved.
Five, the new rural cooperative payment reform and related policies
1 and 20 13, the city unified the new rural cooperative medical system hospitalization total quota payment. The specific plan shall be reasonably formulated by counties and cities according to the actual compensation of designated medical institutions at all levels in previous years. When signing a service agreement with a designated medical institution, the main indicators such as the number of inpatients, the average cost, the actual compensation ratio, the satisfaction of participating patients, and the reporting situation are included in the agreement, which restricts the possible phenomenon of shirking patients and declining service quality in the total fixed payment system. The plans of counties and urban areas should be reported to the bureau-based gynecology department for the record at the end of 20 13 and 1.
In 2.20 13 years, the city continued to implement the total prepayment system for the general outpatient service of the new rural cooperative medical system, and the calculation of the total prepayment should be specific to each village clinic. The specific plans of counties and urban areas should be reported to the bureau-based gynecology department for the record at the end of 20 13 and 1.
3, 20 13, the city continued to unify the single-disease quota subsidy policy for appendicitis, etc. 10 hospitalization surgery (see annex for the specific quota and subsidy standard after adjustment), and other relevant regulations refer to 20 12 Opinions on Adjusting the Compensation Scheme of the New Rural Cooperative Medical System (Taiwan Health Plan Recurrence [201kl]
The new rural cooperative medical system stipulates that fights, traffic accidents, medical disputes, plastic surgery, work-related injuries and responsible persons will not be reimbursed!