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In order to accelerate the development of rural health and improve the health level of farmers, the municipal government decided to continue to implement the new rural cooperative medical system in the rural areas of the city on 20 13. In order to ensure the smooth implementation and smooth operation of the new rural cooperative medical system in our city, the following implementation plan is formulated.

I. Working principles

(1) Financing principles.

Implement a financing mechanism that combines individual financing and government funding.

(2) The principle of fund allocation and compensation.

In accordance with the principle of "large amount of hospitalization supplement, outpatient compensation, fixed expenditure based on income, balance of payments, slight balance and moderate security". Give priority to hospitalization compensation, taking into account outpatient co-ordination, medical treatment of major diseases, large outpatient medical expenses compensation for chronic diseases, and fixed subsidies for normal delivery.

(3) Principles of fund management, use and supervision.

Adhere to the principle of "openness, justice, fairness and convenience"; Urban planning, earmarking; Establish special accounts and store them in special accounts; Specialized agencies, managed by specialized personnel; Regularly publish accounts and implement a double-line three-level publicity system; The fund shall operate independently and in a closed manner.

Ii. participants and their rights and obligations

(1) participants.

Farmers with agricultural registered permanent residence in this city (except those who have enjoyed the basic medical insurance for urban workers) will voluntarily participate in the insurance with their families (households) as the unit, issue a unified certificate, have a certificate for each household, and be certified for medical treatment. The participation period is calculated on an annual basis.

(2) rights.

Seek medical treatment and medication in designated medical institutions at all levels, enjoy basic medical services, and enjoy compensation for medical expenses in accordance with the scope and proportion of compensation stipulated in the implementation plan; Supervise the service quality and price of designated medical institutions and ask questions.

(3) obligations.

Pay individual participation funds in full and on time according to regulations, and abide by management measures and systems.

Third, raise funds.

(1) funding criteria.

In 20 13, each participating farmer paid 60 yuan, and the financial subsidy funds at all levels were 280 yuan, and the total amount of funds raised per person in the whole year was 340 yuan.

(2) Financing method.

1. Individual payment: the rural level is the main body of work, and it is uniformly collected by families (households). Five-guarantee households and low-guarantee households receive the part of 18 children under the age of one-child parents' honor certificate, which is fully funded by the municipal finance. The Municipal Civil Affairs Bureau shall, jointly with the township government, determine the personnel of five-guarantee households and low-guarantee households, apply for financial funds, and pay them into the special account of the cooperative medical fund simultaneously with the funds of other participating farmers.

2. After the annual payment of individual farmers is implemented, the municipal financial subsidy funds will be allocated in time, and the provincial and central financial subsidy funds will be applied step by step.

Four. allocation of funds

(1) outpatient fund.

1. The outpatient co-ordination fund is used for reimbursement of participating farmers' general outpatient clinics. According to each participating farmer 40 yuan.

2 special disease outpatient fund for special disease outpatient medical expenses reimbursement. According to each participating farmer 8 yuan or so.

3. General medical expenses include registration fee, medical treatment fee, injection fee (including intravenous infusion fee, excluding medicine fee and disposable consumables fee) and pharmaceutical service fee. For the implementation of outpatient co-ordination and drug zero-difference rate sales of township and village general outpatient compensation. Calculated by each participating rural resident per year 16 yuan.

(2) serious illness pooling fund.

The serious illness pooling fund was established after deducting outpatient fund and risk fund from the total amount raised in that year. The serious illness co-ordination fund is specifically divided into: hospitalization co-ordination fund, normal birth hospital delivery subsidy fund, serious illness hospitalization fund and serious illness insurance fund, which are used for farmers' hospitalization compensation, normal birth hospital delivery subsidy, serious illness treatment compensation and hospitalization large medical expenses subsidy respectively.

(3) Risk fund.

If the scale of the venture fund does not reach 65,438+00% of the total fund in the current year, it will be supplemented from the raised funds.

Verb (abbreviation of verb) compensation method

(1) compensation scope.

Compensation shall be made in accordance with the Catalogue of Drugs Reimbursed by New Rural Cooperative Medical System in Hebei Province (version 20 12) and the Compensation Regulations for Diagnosis and Treatment Projects of New Rural Cooperative Medical System in Hebei Province. Improve the level of protection for major diseases and diseases within the scope of fixed payment for single diseases.

(2) Provisions on farmers' medical treatment and referral.

Participating farmers can choose designated medical institutions at all levels in the city for medical treatment with certificates.

If it is necessary to transfer to a medical institution outside the city for medical treatment, the attending doctor will issue a referral certificate, which can be transferred to a medical institution outside the city after being audited and filed by the municipal joint management center. Unaudited transfer to medical institutions outside the city will not be reimbursed. The recommendation approval form will take effect as soon as it is signed. Critical patients can be referred for treatment first, and the referral procedures should be handled with relevant certificates within 5 days. If you go out on business or get sick during work, you can be admitted to the nearest hospital for treatment, but you must report to the municipal joint management center within 5 days of admission, and you must issue an emergency certificate from the hospital where you live when you compensate for the expenses.

(3) Compensation reimbursement procedures.

1. outpatient compensation. Participating farmers with the "new rural cooperative medical certificate of Hebei Province", in the township and village designated medical institutions for outpatient treatment, follow-up compensation. Township and village-level designated medical institutions shall pay in advance according to the relevant provisions of outpatient co-ordination, register and summarize monthly (reimbursement materials include outpatient co-ordination compensation accounts, prescriptions and bills) and report to the township joint management station for audit, and the township joint management station shall report to the municipal joint management center for unified audit. City joint management center after the audit, approved by the financial department issued payment vouchers, submitted to the agent bank will directly allocate funds to the township joint management station, and by the township joint management station timely return to the township and village-level designated medical institutions.

2 city (county) discharge report on the implementation of hospitalization compensation. Medical expenses are paid in advance by individuals. When discharged from the hospital, the cooperative medical certificate, ID card or household registration book will be used for settlement, and the designated medical institutions will advance the compensation amount to the participating farmers according to the prescribed proportion, and report the compensation situation to the municipal joint management center in the following year 1 month. After the audit of the city joint management center, it shall be submitted to the financial department for examination and approval and issue a payment voucher, and submitted to the agent bank to directly allocate funds to designated medical institutions.

3. If the hospital is hospitalized outside the city (county) with the approval of the city joint management center, the cooperative medical certificate, patient ID card or household registration book, diagnosis certificate, expense details, hospitalization bills, medical records and other materials shall be submitted to the city joint management center for review and reimbursement within 5 days after discharge.

4. Compensation for large outpatient expenses of chronic diseases: Participating farmers suffering from chronic diseases within the compensation scope of our city shall be appraised and approved in accordance with the Measures for the Administration of Compensation for Chronic Diseases of New Rural Cooperative Medical System in Shijiazhuang (Trial). Outpatient medical expenses of designated medical institutions at or above the township level in the city shall be paid in advance by individuals, and monthly by chronic disease identification certificate, cooperative medical certificate, ID card or household registration book, outpatient cases, supplementary inspection documents, legal and valid bills, and "xinji city new rural cooperative medical system outpatient special prescription". Township agencies monthly summary of compensation, reported to the municipal joint management center. After being audited by the city joint management center, they will submit the financial department for approval and issue payment vouchers, which will be directly allocated to the township agencies by the agent bank.

Sixth, the compensation standard

(a) outpatient co-ordination compensation standards.

1. Compensation range. (1) Drug expenses (only drugs reimbursed by the new rural cooperative medical system in Hebei Province (version 20 12)); ② Material cost (disposable infusion set, syringe); (3) Medical technical inspection fees (B-ultrasound, electrocardiogram, X-ray and laboratory tests are limited to township-level designated medical institutions); ④ Treatment expenses (debridement and suture, dressing change, acupuncture, cupping, massage and scraping).

2. Compensation standard. Compensation ratio: 45% of the medical expenses incurred by participating farmers in village-level designated medical institutions and 40% of the medical expenses incurred in township-level designated medical institutions. The annual cumulative capping line of individual compensation is 200 yuan, which cannot be used by family members.

3. Compensation method. (1) The medical expenses and examination expenses incurred in the outpatient service of the participating patients shall be directly compensated by the designated medical institutions according to the compensation standard, and the compensation voucher (expense receipt) shall be printed by the designated medical institutions and signed by the patients. (2) Each designated medical institution shall submit the outpatient prescription, outpatient compensation voucher (expense receipt) and compensation summary table to the township joint management station for review at the specified time every month, and the township handling personnel shall report it to the county handling institution for review at the specified time every month. County-level agencies after the audit, according to the audit amount timely disbursement. The reimbursement of common diseases in outpatient department should be settled in real time, and the participating farmers shall not participate in the reimbursement after accumulation.

(2) compensation for hospitalization.

Designated medical institution level

plan

Payment line

Salary ratio (%)

Town level

150

80

County level

celebrity

73

Municipal level (according to the management of secondary hospitals)

Eight hundred

63

Municipal level (managed by tertiary hospitals)

1 100

59

Provincial level

1500

55

other

3500

45

1. Medical institutions managed by secondary and tertiary hospitals shall be implemented according to the List of Designated Medical Institutions of New Rural Cooperative Medical System in Shijiazhuang (version 20 13).

2. Drugs listed in the national essential drugs list (equipped and used by primary medical and health institutions) and the non-essential drugs list in Hebei Province, Chinese patent medicines, Chinese herbal pieces, Chinese medicine diagnosis and treatment projects and Chinese medicine preparations (including hospital preparations) listed in the reimbursement list of the new rural cooperative medical system. The proportion of hospitalization compensation increased by 5 percentage points.

3. If the newborn is not within the payment time limit at birth, the compensation expenses incurred shall be calculated according to the treatment of the new rural cooperative medical system enjoyed by one of its parents. Newborns are exempt from the participation fee of the year, and the number of participants in the year is not counted, and the financial departments at all levels do not recover the subsidy funds.

4. If the same rural resident is hospitalized again due to different diseases in the same year, the deductible will be deducted again; Because of the same disease, such as end-stage renal disease, malignant tumor, etc. The deductible is not deducted during the second hospitalization in that year.

5. Insured rural residents who are transferred from higher medical institutions to lower medical institutions for continuous hospitalization due to the same disease shall not be deducted from the hospitalization deductible of lower medical institutions when calculating the hospitalization compensation expenses of lower medical institutions; If the hospitalization from a lower medical institution is transferred to a higher medical institution for further hospitalization, the deductible expenses of the lower medical institution shall be deducted from the deductible of the higher medical institution when calculating the hospitalization compensation expenses.

6 participating rural residents can choose the designated medical institutions of the new rural cooperative medical system independently in the overall planning area. If referral is needed due to illness, the designated medical institutions shall handle the referral procedures in time, and the patients or their families shall go to the county-level new rural cooperative medical system for examination and approval. Due to special reasons such as urgency, danger and severity of illness, patients or their families can't go through the referral filing formalities in time, and should report to the participating institutions of the new rural cooperative medical system in time and go through the relevant formalities within the prescribed time limit.

7. The reimbursement rate of designated medical institutions that did not perform the immediate discharge report was reduced by 5 percentage points.

8. Under any of the following circumstances, the new rural cooperative medical system will compensate according to the compensation scheme actually paid by the participating farmers:

The medical services received are subsidized by the special fund;

(2) The medical services received are reduced or exempted by medical institutions.

9. The participating farmers are hospitalized within the administrative area of Shijiazhuang City, and the designated medical institutions that implement the "one card" management shall be based on the List of Designated Medical Institutions of New Rural Cooperative Medical System in Shijiazhuang City (version 20 13); Designated medical institutions that are hospitalized outside the administrative area of Shijiazhuang City and implement "one card" management shall be subject to the designated medical institutions of the new rural cooperative medical system organized by the government.

(3) Allowance for normal delivery in hospital.

The hospital plans to give birth normally, and each case will be subsidized by 300 yuan.

(four) large outpatient compensation for special diseases.

The diseases compensated by large outpatient expenses for special diseases include: various heart diseases complicated with chronic heart failure, high-risk and high-risk hypertension in phase III, sequelae of cerebrovascular disease (with severe neurological, mental and limb dysfunction), chronic moderate and severe viral hepatitis (decompensated liver function), liver cirrhosis (decompensated liver function), diabetes (complicated with serious complications), malignant tumor radiotherapy and chemotherapy, leukemia, hemophilia, aplastic anemia, rheumatoid arthritis (with severe limb dysfunction)

End-stage renal disease, malignant tumor radiotherapy and chemotherapy, leukemia, hemophilia, psychosis and other special diseases. , should be compensated according to the inpatient compensation method.

There is no deductible line for large outpatient compensation for special diseases, and the reimbursement ratio is 60%. The capping line for the use of anti-rejection immunomodulators in aplastic anemia and organ transplantation is 30 thousand yuan, and the capping line for other special diseases is 2000 yuan.

(5) Compensation for major diseases.

20 13 increased compensation standards for six diseases such as childhood leukemia and congenital heart disease and four major diseases such as lung cancer13 shall be implemented according to relevant documents.

(six) large medical expenses for hospitalization.

1. compensation object: the cumulative compensation for hospitalization of participating farmers reached 60,000 yuan.

2. Deductible: 60,000 yuan.

3. The design compensation ratio is 30%.

4. The compensation for the accumulated large medical expenses for hospitalization in the whole year was capped at 654.38+10,000 yuan.

5. Compensation method:

Compensation for large hospitalization expenses = (hospitalization expenses belong to the project expenses in the catalogue-60,000 yuan) ×30%.

6. Compensation procedures:

Participating farmers in the designated medical institutions hospitalization compensation costs reached the top line, apply to the city joint management center, the city joint management center to fill in the "new rural cooperative medical system hospitalization large medical expenses compensation approval form", within 30 days after acceptance, report to the Municipal Health Bureau for approval. After being audited by the Municipal Health Bureau, it shall be reported to the county-level financial department for examination and approval, and a payment voucher shall be issued, which shall be paid to the participating farmers by cheque.

(7) the capping line.

The top line is 90,000 yuan per farmer per year, regardless of the level of medical institutions. Annual cumulative calculation (including hospitalization compensation, hospitalization subsidy for normal delivery, large outpatient compensation for special diseases and secondary compensation for hospitalization), hospitalization expenses for major diseases and compensation for serious illness insurance are calculated separately.

(8) Secondary compensation.

In order to make full and effective use of the cooperative medical fund and ensure the maximum benefit of farmers, the balance of the overall fund (including risk funds, the same below) in that year exceeded 15% or the accumulated balance of the overall fund over the years exceeded 25%, and the second compensation was made according to the balance.

Seven. Management and supervision

(1) Responsibilities of the management organization.

The management center of the new rural cooperative medical system is responsible for: formulating various systems and norms, managing the cooperative medical fund according to regulations, reviewing medical records and bills, approving referral procedures, writing off medical expenses, doing financial statistics well, and being responsible for daily affairs such as statistics, analysis and reporting of all kinds of information.

Township agencies are responsible for the preliminary examination and transmission of medical expenses for outpatient and inpatient services of farmers within their jurisdiction, and do a good job in statistics, analysis, reporting and business management of all kinds of information.

(2) fund management.

1. Determination of correspondent bank. City New Rural Cooperative Medical Management Committee (hereinafter referred to as CMC) chooses the state-owned commercial banks with wide coverage, good reputation, high service quality and favorable support conditions as the fund agent banks. The Municipal Finance Bureau, the joint management center and the agent bank signed a contract to ensure the standardized operation of the fund.

2. Payment of funds. The Municipal Finance Bureau shall set up a special account for the new rural cooperative medical fund in the state-owned commercial bank designated by the CMC, establish and improve various rules and regulations for the management of the cooperative medical fund, and timely examine and pay the rural cooperative medical fund. The bank will transfer the funds directly to the designated medical institutions with the audit certificate issued by the Municipal Finance Bureau and the municipal joint management center, and the funds will be used separately and closed for operation.

3. Supervision over the use of funds. The new rural cooperative medical supervision committee shall formulate specific supervision contents and management measures according to the requirements of higher authorities, regularly supervise and inspect the raising, use and management of the new rural cooperative medical fund, supervise and inspect the disclosure of the cooperative medical account, and audit the revenue and expenditure management of the cooperative medical fund every year.

(3) Management of designated medical institutions.

City Health Bureau of the city, township and village medical institutions, in accordance with the "xinji city new rural cooperative medical institutions identified audit approach" for audit, to determine the designated medical institutions of cooperative medical care. City joint management center should sign a service agreement with designated medical institutions, clarify the rights and obligations of both parties, and ensure the efficiency and fairness of fund use. Designated medical institutions provide medical services for participating farmers, strengthen the management of diagnosis and treatment scope, medication scope, bill distribution, referral, information statistics and other links according to the scope of duties, strive to reduce the price of drugs and medical care, and control medical expenses. In order to ensure the rational and effective use of the outpatient co-ordination fund and ensure the safe operation of the fund, the total budget of outpatient co-ordination compensation expenses and the average outpatient expenses in villages and towns are implemented.

City joint management center to conduct random sampling audit of designated medical institutions, check prescriptions, medical records and reimbursement procedures, and analyze and evaluate the city's cooperative medical fund. City joint management center should manage the designated medical institutions according to the requirements of higher authorities, conduct regular and irregular inspections on the service quality, service attitude and medical charge price of the designated medical institutions, and report the inspection to the Municipal Health Bureau. The Municipal Health Bureau will punish the problem in accordance with the regulations until the qualification of designated medical institutions is cancelled.

(4) Information management.

Improve the information network and statistical reporting system at the city and township levels. The township governments are responsible for inputting, summarizing and checking the information of the insured, and the township agencies are responsible for business guidance, and transmit the input information to the city joint management center for statistical summary, establish a database, and form a unified information platform in the city. City joint management center implements 24-hour dynamic management of designated medical institutions, and realizes computerized network management of farmers' medical treatment, medical expenses audit, review, verification and settlement. Attention should be paid to collecting the opinions of the masses, strengthening the collection, collation, statistics and analysis of information, and timely announcing the reimbursement and compensation of participating farmers to the public.

Eight. safeguard measure

(1) Raise awareness and strengthen leadership.

In order to ensure the smooth implementation of the new rural cooperative medical system, the Municipal New Rural Cooperative Medical Management Committee provides macro guidance, organization and coordination for the new rural cooperative medical system in the city. The main leaders of towns and parks take overall responsibility for the new rural cooperative medical system in their respective jurisdictions, define the division of labor, assign responsibilities to people, organize the implementation work, and ensure that it is completed on time.

(two) a clear responsibility, grasp the * * * tube.

All relevant departments should carry out their duties and cooperate closely to do a good job in the new rural cooperative medical system.

The Municipal New Rural Cooperative Medical Management Committee organizes and coordinates the work of relevant departments, and supervises, inspects and guides the progress of the new rural cooperative medical care work of relevant departments of towns and municipalities directly under the Central Government.

The Municipal Finance Bureau is responsible for arranging the implementation of the municipal financial subsidy funds, handling personnel funds and work budget for farmers participating in the new rural cooperative medical system, and opening a special fund account; Study and formulate relevant systems to strengthen fund management and supervision.

The Municipal Public Security Bureau is responsible for cooperating with the township government to do a good job in checking the accounts and ID cards of farmers participating in the new rural cooperative medical system.

Municipal Supervision Bureau is responsible for the supervision of the income and expenditure and management of the cooperative medical fund, and investigate and deal with violations.

The Municipal Human Resources and Social Security Bureau is responsible for the investigation of rural health talents and policy formulation, and promotes the related work of personnel system reform in rural health institutions.

The Municipal Health Bureau is the competent department of the new rural cooperative medical system, responsible for formulating the management measures and implementation plans of the new rural cooperative medical system, training township cadres and medical personnel, approving designated medical institutions, and managing and supervising the designated medical institutions.

The Civil Affairs Bureau is responsible for determining the personnel of rural five-guarantee households and low-guarantee households and providing data in time. Establish and improve the rural medical assistance system.

The Municipal Audit Bureau is responsible for auditing the income and expenditure and management of the cooperative medical fund of the rural cooperative medical service agency.

The US Food and Drug Administration is responsible for the circulation, supply and quality supervision of new rural cooperative medical drugs to ensure the safety and effectiveness of farmers' drug use.

City radio and television station is responsible for the publicity and reporting of the new rural cooperative medical system, publicizing the progress of fund-raising work in towns and villages, publicizing health knowledge, popularizing rural health education and improving the self-care ability of rural residents.

The Municipal Education Bureau is responsible for publicizing the new cooperative medical care policy.

The Municipal Price Bureau is responsible for improving the rural medical price supervision policy and strengthening supervision and management.

(3) Strengthen supervision and strictly reward and punish.

The management committee of the new rural cooperative medical system implements the reporting and dispatching system of the new rural cooperative medical system, and conducts supervision and inspection on the work of relevant departments of towns and cities from time to time. Give notice of praise to the towns and departments that leaders attach importance to, take effective measures and achieve remarkable results; Give informed criticism to towns and departments with slow work and slow progress.

IX. Warranty Period

Medical expenses incurred in June+10/October 1 2065438+February 3 1 2065438.

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