Recently, several rumors about medical insurance have spread on the Internet, such as "pharmacies have stopped co-ordinating quota payments" and "medical insurance outpatient co-ordination will not be reimbursed by the end of December". In this regard, the medical security bureaus in many places issued statements to refute rumors.
Source: Social security card. Photo by Li Jinlei
Inner Mongolia
Recently, in some areas of the Inner Mongolia Autonomous Region, news such as "the outpatient medical insurance quota of 5,000 yuan will be cleared by the end of December" and "there will be no outpatient co-ordination policy next year" have spread on the Internet, causing concern. Is this news true? This reporter verified it.
"'Policy cancellation' is pure rumor, and 'zero-clearing at the end of the year' is a misunderstanding and misreading of the medical insurance policy!" said the Medical Security Bureau of Inner Mongolia Xilin Gol League, Xilin Gol League will implement the outpatient mutual aid security mechanism of basic medical insurance for employees from October 1, 2022, and the system stipulates that the outpatient co-ordination treatment standard is that within a natural year, the general outpatient medical expenses incurred by the insured personnel in the designated medical institutions within the policy scope shall be settled according to the policy. In 2024, the outpatient expenses of insured employees will be re-accumulated, and they will enjoy the outpatient co-ordination treatment according to the regulations after reaching the minimum payment standard. Therefore, there is no such thing as "zero reimbursement amount" and "policy cancellation".
According to reports, the overall planning of employee medical insurance outpatient covers all personnel who participate in the basic medical insurance of employees, that is, in-service employees, retirees and flexible employment personnel can enjoy the overall treatment of Xilin Gol League's employee medical insurance outpatient treatment. The ordinary outpatient expenses incurred by the insured employees in the designated medical institutions that meet the scope of the basic medical insurance policy for drugs, medical consumables and medical service items, if they exceed the minimum payment standard, shall be included in the scope of payment of the overall fund. Payment limits are not carried forward or accumulated to the following year.
Previously, a rumor about "Hohhot City's medical insurance outpatient co-ordination deadline for November 20" also spread on the Internet. The reporter learned from the Hohhot Municipal Medical Security Bureau that according to the relevant provisions of the "Implementation Rules for the Establishment and Improvement of Outpatient Mutual Assistance Security for Employees' Basic Medical Insurance in Hohhot" issued by the Office of the People's Government of Hohhot Municipality on June 30, 2022 and implemented on October 1, 2022, the outpatient co-ordination treatment standard is that within a natural year, the general outpatient medical expenses incurred by the insured persons in the designated medical institutions within the policy scope shall be settled according to the policy.
The relevant person in charge of the Hohhot Medical Security Bureau said that according to the regulations, the period of enjoying the overall treatment of medical insurance outpatient clinics in Hohhot in 2023 is from January 1 to December 31.
Relevant departments remind you to pay attention to the official WeChat public account or official website of the local medical security bureau in a timely manner, know the authoritative information of the dynamic adjustment of the medical insurance policy at the first time, improve your information identification ability, and not be confused by unconfirmed news, so as not to believe rumors, do not spread rumors, and do not spread rumors!
Hunan
"The overall quota for employee outpatient services will be cleared by the end of December. ”
"You have to hurry up and use it, otherwise it will be wasted. ”
Recently, the kind of medical insurance topics that everyone has seen in some WeChat groups and WeChat circle of friends have also raised questions about whether the overall amount of medical insurance will be cleared. On December 19, according to the Hunan Provincial Medical Insurance Bureau, such statements are a misunderstanding of the medical insurance policy.
The relevant person in charge of the Hunan Provincial Medical Insurance Bureau said that the annual reimbursement amount of medical insurance is the maximum payment limit that can be reimbursed by the medical insurance pooling fund according to the regulations of the medical expenses incurred by the insured in a natural year. In the new natural year, the annual reimbursement amount of the general outpatient clinic of the employee medical insurance will be updated according to the new statistical data to ensure that the insured receives continuous and adequate amount protection. In other words, after the end of 2023 and into 2024, the annual reimbursement amount of the insured person's outpatient co-ordination will be updated according to the new statistics in 2024 and calculated in the new natural year. Therefore, there is no such thing as "clearing", "waste", or "money refunded if it is not used up".
To be precise, the outpatient reimbursement limit is only the maximum payment standard that can be reimbursed for outpatient medical treatment by the insured person during the insurance year, not the maximum limit for everyone to report to. This is the same as the hospitalization reimbursement limit of medical insurance, such as the maximum payment limit of 650,000 yuan for basic medical care and serious illness insurance for insured employees, not every insured employee has to report 650,000 yuan for hospitalization every year, but the maximum reimbursement of basic medical insurance and serious illness insurance in a insured year when sick hospitalization is 650,000 yuan. The same is true for outpatient reimbursement maximums.
At the same time, a doctor's prescription is required to enjoy the outpatient co-ordination treatment when using outpatient co-ordination to see a doctor and purchase drugs; the purchased drugs must be included in the medical insurance catalogue before they can be reimbursed by medical insurance; designated medical institutions shall not reduce or exempt patients' own expenses when carrying out outpatient reimbursement; and designated medical institutions shall strictly verify the identity information of the insured. In layman's terms, insured patients can only use the outpatient quota when they go to designated medical institutions for outpatient treatment due to illness, and individuals need to pay a certain percentage of themselves. The medical insurance department will implement all-round supervision over the use of outpatient pooling funds to prevent the medical insurance fund from "running and leaking".
The co-ordination of outpatient medical insurance for employees is a good policy, but the insured does not have to blindly use it with the idea of "no need for nothing". The reimbursement must comply with the outpatient co-ordination policy, and the individual needs to pay a certain percentage of the out-of-pocket expenses, and reimbursement is not allowed in the absence of a diagnosed disease. The insured should use it rationally according to the actual situation!
The Hunan Provincial Medical Insurance Bureau reminds that the medical insurance fund is the "medical money" and "life-saving money" used by all the insured!
Jiangxi
Recently, there have been rumors on the Douyin account that "Jiangxi pharmacies have stopped coordinating quota payments". After verification, the rumor is a false rumor on the Internet. According to the preliminary investigation, some designated retail pharmacies have recently been driven by profits, misinterpreted the medical insurance outpatient co-ordination policy, wrongly advertised that "outpatient co-ordination is not used, and the quota will be cleared at the end of the year", and even issued prescriptions online through Internet hospitals to obtain outpatient co-ordination funds, causing major safety hazards to the implementation of outpatient co-ordination policies and the safety of medical insurance funds. At present, the local medical security department has conducted inspections of relevant Internet hospitals and designated retail pharmacies, and found that some Internet hospitals have exceeded the scope of practice to prescribe traditional Chinese medicine decoction pieces, directly prescribe prescriptions without consultation, and issue prescriptions to the same patient multiple times a day, and other prescription management and diagnosis and treatment process are being seriously dealt with in accordance with procedures and laws and regulations. Relevant Internet hospitals and designated retail pharmacies are also being rectified as required.
According to the Guiding Opinions of the General Office of the State Council on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Basic Medical Insurance for Employees (Guo Ban Fa [2021] No. 14), from January 1, 2023, Jiangxi Province will start to implement the outpatient mutual aid guarantee mechanism for basic medical insurance for employees, and clarify the standard for the overall treatment of outpatient services for employees, that is, within a natural year, the general outpatient medical expenses incurred by insured employees in designated medical institutions within the policy scope shall be included in the overall fund for reimbursement according to the policy. In July this year, Jiangxi Province optimized and adjusted the policy: within a natural year, the starting line for the overall planning of general outpatient services for employees was reduced from 600 yuan to 300 yuan, and the proportion of payment for general outpatient care for employees was increased by 5 percentage points, that is, the proportion of in-service personnel in first-level and below, second-level and third-level medical institutions was 65%, 60% and 55% respectively, and the proportion of retirees was 70%, 65% and 60% respectively; The annual payment limit for incumbents has been increased from 1,800 yuan to 2,000 yuan, and for retirees from 2,000 yuan to 3,000 yuan. Insured persons can purchase drugs in designated medical institutions or designated retail pharmacies with the prescriptions issued by designated medical institutions for medical insurance in Jiangxi Province and enjoy the overall reimbursement treatment for outpatient services; for those who need to prescribe through Internet hospitals and purchase drugs at designated retail pharmacies, Internet hospitals shall conduct reasonable diagnosis and treatment of patients in accordance with the provisions of the prescription management measures, and prescribe after diagnosis and treatment; pharmacists in pharmacies shall review the prescriptions in accordance with the regulations, and only sell drugs after the examination is correct, and it is strictly forbidden to sell drugs first and then supplement prescriptions to obtain outpatient pooling funds. At present, the policy is still being implemented and has not been adjusted.
The medical insurance fund is the "medical money" and "life-saving money" of the people. In this special statement, Jiangxi Provincial Medical Insurance designated medical institutions and designated retail pharmacies must strictly abide by national laws and regulations, it is strictly forbidden to collect and stay the medical security vouchers of the insured, it is strictly forbidden to guide and induce the insured to purchase drugs by swiping the card, it is strictly forbidden to include the medical expenses that do not belong to the scope of payment of the medical security fund into the settlement of the medical security fund, and it is strictly forbidden to induce or assist others to impersonate or falsely seek medical treatment and purchase drugs. Where through data analysis, mass reporting, on-site inspections, etc., it is found that the medical insurance settlement data is unreasonable, and there are suspected of illegal centralized card swiping designated medical institutions and designated retail pharmacies, the medical insurance department will first suspend its medical insurance services, suspend the settlement of medical insurance expenses, and immediately carry out joint inspections with public security, health and other departments, once verified, it will be dealt with seriously, and the circumstances will be transferred to the judicial organs for processing.
Outpatient co-ordination reimbursement should be in line with the outpatient co-ordination policy, and individuals need to pay a certain percentage out of pocket. In particular, the majority of insured persons are reminded not to believe rumors or spread rumors, to rationally seek medical treatment and purchase drugs according to the actual situation, and not to use medical security certificates to purchase daily necessities and health care products, not to exchange non-medical insurance and non-special drugs for medical insurance and special drugs, and not to hand over their medical security certificates to others to use or use other people's medical security certificates, and not to take advantage of the opportunity to enjoy medical security treatment to resell drugs. Accepting the return of cash in kind or obtaining other illegal benefits, etc., once the above acts are verified, the illegal gains will be recovered, and the circumstances are serious, and the circumstances will be transferred to the judicial organs for handling.