中英对照2021国务院办公厅关于建立健全职工基本医疗保险门诊共济保障机制的指导意见.docx
GuidingOpinionsoftheGeneralOfficeoftheStateCouncilonEstablishingandImprovingaGeneralSupportMechanismforCoveringOutpatientMedicalBillsundertheBasicMedicalInsuranceforUrbanEmployeesDocumentNumber：No.142021oftheGeneralOfficeoftheStateCouncilAreaofLaw:SocialWelfareandSocialSecurity1.evelofAuthority：RegulatoryDocumentsoftheStateCouncilIssuingAuthority：GeneralOfficeoftheStateCouncilDateIssued：04-13-2021EffectiveDate04-13-2021Status：EffectiveGuidingOpinionsoftheGeneralOfficeoftheStateCouncilonEstablishingandImprovingaGeneralSupportMechanismforCoveringOutpatientMedicalBillsundertheBasicMedicalInsuranceforUrbanEmployees(No.142021oftheGeneralOfficeoftheStateCouncil)Thepeople'sgovernmentsofallprovinces,autonomousregions,andmunicipalitiesdirectlyundertheCentralGovernment;allministriesandcommissionsoftheStateCouncil;andallinstitutionsdirectlyundertheStateCouncil:Forthepurposesoffurtherimprovingthesystemofbasicmedicalinsuranceforemployeesthatfeaturesmutualassistanceandsharedresponsibility(hereinafterreferredtoasthe“medicalinsuranceforemployees),bettersolvingtheproblemofoutpatientguaranteeforemployeeswhoarecoveredbymedicalinsurance,andeffectivelyreducingtheirmedicalexpensesburdens,accordinglotheaangemenlsof国务院办公厅关于建立健全职工基本医疗保险门诊共济保障机制的指导意见（国办发（2021）14号）各省、自治区、直辖市人民政府，国务院各部委、各直属机构：为进一步健全互助共济、责任共担的职工基本医疗保险（以下简称职工医保）制度，更好解决职工医保参保人员门诊保障问题，切实减轻其医疗费用负担，按照党中央、国务院关于深化医疗保障制度改革任务部署，经国务院同意，现就建立健全职工医保门诊共济保障机制提出如下意见。theCPCCentralCommitteeandtheStateCouncilfor一、总体要求（一）指导思想。以习近平新时代中国特色社会主 义思想为指导，全面贯彻党的十九大和十九届二中、三 中、四中、五中全会精神，既尽力而为、又量力而行，坚 持人人尽责、人人享有，完善制度、引导预期，加快医疗 保障重点领域和关键环节改革，将门诊费用纳入职工医保 统筹基金支付范围，改革职工医保个人账户，建立健全门 诊共济保障机制，提高医保基金使用效率，逐步减轻参保 人员医疗费用负担，实现制度更加公平更可持续。（二）基本原则。坚持保障基本，实行统筹共济, 切实维护参保人员权益。坚持平稳过渡，保持政策连续deepeningthereformofmedicalsecuritysystem,anduponapprovalbytheStateCouncil,thefollowingopinionsonestablishingandimprovingageneralsupportmechanismforcoveringoutpatientmedicalbillsunderthemedicalinsuranceforemployeesareherebyputforward.I.Generalrequirements1. Guidingideology.UndertheguidanceofXiJinpingThoughtonSocialismwithChineseCharacteristicsforaNewEra,theguidingprinciplesofthe19thCPCNationalCongressandthesecond,third,fourth,andfifthplenarysessionsofthe19thCPCCentralCommitteeshallbefullyimplemented.AlllocalgovernmentsanddepartmentsshalldowhateverliesintheirpowerandactaccordingtoIheircapabilitytoensurethateveryoneperformshisdutiesandsharesthebenefits.Systemsshallbeimprovedandexpectationsshallbeguided.Thereformofkeyareasandlinksofmedicalsecurityshallbeacceleratedtoreimburseoutpatientbillsthroughunifiedaccountsformedicalinsuranceforemployees.Individualaccountsformedicalinsuranceforemployeesshallbereformed,andageneralsupportmechanismforcoveringoutpatientmedicalbillsshallbeestablishedandimproved,soastoimprovetheefficiencyofthemedicalinsurancefund.Gradualstepsshallbetakentowardsreducingthemedicalexpensesburdensfortheemployeescoveredbythemedicalinsurancesoastomakethesystemfairerandmoresustainable.2. Basicprinciples.Thebasicmedicalneedsshallbemet,andoverallplanningandmutualassistanceshallbeimplemented,soastoeffectivelyprotecttherightsandinterestsoftheinsured.Asmoothtransitionshallbeensuredtomaintainpolicycontinuity.Thesmoothtransitionofbenefitsbeforeandafterthereformshallbeensured.Crdinationandinteractionshallbeadheredto.Themeasuresforimprovingtheoutpatientbillsguaranteemechanismandimprovingthepersonalaccountsystemshallbepromotedsimultaneouslyandtransformedonastep-by-stepbasis.Measuresshallbetailoredtolocalconditions.Onthebasisoftheoveralldesign,thelocalgovernmentshallbeencouragedtoactivelyexploreeffectivewaystoenhancetheoutpatientguaranteeformedicalinsuranceforemployees.11.Mtyormeasures3. Thegeneralsupportforcoveringoutpatientmedicalbillsshallbeenhanced.Amechanismfortheoverallplanningofcoveringgeneraloutpatientbillsunderthemedicalinsuranceforemployeesshallbeestablishedandimproved.Onthebasisofensuringthemedicalinsuranceforhypertension,diabetes,andotheroutpatientchronicdiseasesandspecialdiseases(hereinaftercollectivelyreferredtoasoutpatientchronicandspecialdiseases)forwhichIhegeneralpublicpatientsbearaheavyburden,gradualstepsshallbetakentowardsreimbursingthegeneraloutpatientbillsforfrequentlyoccurringandcommondiseasesthroughunifiedaccounts.Thepooledaccountforgeneraloutpatientbillsshallcoveralltheinsuredpeoplebythemedicalinsuranceforemployees,andtheproportionofpaymentexpensescoveredbyrelevantpoliciesshallstartfrom50%.Withtheincreasingaffordabilityofthemedicalinsurancefund,thecoverlevelshallbe性，确保改革前后待遇顺畅衔接。坚持协同联动，完善门诊保障机制和改进个人账户制度同步推进、逐步转换。坚持因地制宜，在整体设计基础上，鼓励地方从实际出发，积极探索增强职工医保门诊保障的有效途径。二、主要措施(三)增强门诊共济保障功能,建立完善职工医保普通门诊费用统筹保障机制，在做好高血压、糖尿病等群众负担较重的门诊慢性病、特殊疾病(以下统称门诊慢特病)医疗保障工作的基础上，逐步将多发病、常见病的普通门诊费用纳入统筹基金支付范围。普通门诊统筹覆盖职工医保全体参保人员，政策范围内支付比例从50%起步，随着医保基金承受能力增强逐步提高保障水平，待遇支付可适当向退休人员倾斜。针对门诊医疗服务特点，科学测算起付标准和最高支付限额，并做好与住院费用支付政策的衔接。同步完善城乡居民基本医疗保险门诊统筹，并逐步提高保障水平。graduallyimproved,andthepaymentofbenefitsmaybeappropriatelyweightedtowardsretirees.Accordingtothecharacteristicsofoutpatientmedicalsen,ices,theminimumpaymentstandardandthemaximumpaymentlimitshallbecalculatedinascientificway,andconnectionwiththepolicyofhospitalizationexpensepaymentshallbeensured.Thepooledaccountsforgeneraloutpatientbillsunderthebasicmedicalinsuranceforruralandnon-workingurbanresidentsshallbesimultaneouslyimproved,andthecoverlevelshallbegraduallyincreased.Accordingtothebearingcapacityofthemedicalinsurancefund,thescopeofchronicdiseasespaidforoutpatientsshallbe根据医保基金承受能力，逐步扩大由统筹基金支付的门诊慢特病病种范围，将部分治疗周期长、对健康损害大、费graduallyexpanded.Theoutpatientexpensesofsomediseaseswithlongtreatmentcycles,greatdamagetohealthandheavycostburdenshallbeincludedinthegeneralsupportmechanism.Somespecialtreatmentthatissuitableforoutpatientservices,whicharemoreeconomicalandconvenientthanhospitalization,maybegovernedmutatismutandisbytherelevantregulationonhospitalizationtreatment.Thegeneralsupportmechanismforcoveringoutpatientmedicalbillsshallbecontinuouslyimproved,inthehopeofachievingagradualtransitionininsurancefromdiseasetypesguaranteetoexpensessolvingguarantee.Drugguaranteeservicesprovidedbyeligibledesignatedretaildrugstoresshallbeincludedinthe用负担重的疾病门诊费用纳入共济保障，对部分适合在门诊开展、比住院更经济方便的特殊治疗，可参照住院待遇进行管理。不断健全门诊共济保障机制，逐步由病种保障向费用保障过渡。将符合条件的定点零售药店提供的用药保障服务纳入门诊保障范围，支持外配处方在定点零售药店结算和配药，充分发挥定点零售药店便民、可及的作用。探索将符合条件的“互联网+”医疗服务纳入保障范scopeofoutpatientcare,andthesettlementanddispensingof围。prescriptionsshallbesupportedindesignatedretaildrugstores,soastomaximizetheconvenienceandaccessibilityofdesignatedretaildrugstores.Waysofincludingeligible'internetPlus“medicalservicesinthecovershallbeexplored.4. Themethodofpersonalaccountaccountingshallbe（四）改进个人账户计入办法。科学合理确定个人improved.Thepersonalaccountaccountingmethodsandaccountinglevelshallbedeterminedinascientificandreasonablemanner.Thebasicmedicalinsurancecontributionspaidbyindividualsshallbeaccountedinpersonalaccountsofin-serviceemployees,andinprinciple,theaccountingstandardsshallbewithin2%ofthecontributionbase.Thebasicmedicalinsurancecontributionspaidbytheemployershallbeaccountedinthepooledaccountsasawhole.Thefundsinpersonalaccountsforretirees,inprinciple,shallbetransferredatfixedamountsfrompooledaccounts,andtheamounttransferredshallbegraduallychangedioabout2%oftheaveragelevelofbasicpensionfortheregionssubjecttotheoverallplanningofmedicalinsurancefundsintheyearwhenthereformwaslaunchedinaccordancewiththeseOpinions.Thespecifictransferproportionorstandardsfortheindividualaccountshallbedeterminedbytheregionsubjecttotheoverallplanningofmedicalinsurancefundsaccordingtoitsactualconditionsasguidedundertheafbre-mentionedprinciplesbytheprovincialmedicalinsurancedepartmentinconjunctionwiththefinancedepartment.Aftertheratioofpooledaccountstopersonalaccountsisadjusted,theincreasedportionofthepooledaccountsshallbemainlyusedforthegeneralsupportforcoveringoutpatientmedicalbills,thusincreasingtheoutpatienttreatmentfortheinsured.5. Thescopeofuseofpersonalaccountsshallberegulated.Theindividualaccountshallbemainlyusedtopaytheout-of-pocketexpensesincurredbytheinsuredatdesignatedmedicalinstitutionsorretaildrugstoreswithinthescopeoftherelevantpolicy.Itmayalsobeusedtopaymedicalexpensesincurredbytheinsuredpersonandhisorherspouse,parents,and账户计入办法和计入水平，在职职工个人账户由个人缴纳的基本医疗保险费计入，计入标准原则上控制在本人参保缴费基数的跳，单位缴纳的基本医疗保险费全部计入统筹基金；退休人员个人账户原则上由统筹基金按定额划入，划入额度逐步调整到统筹地区根据本意见实施改革当年基本养老金平均水平的2%左右。个人账户的具体划入比例或标准，由省级医保部门会同财政部门按照以上原则，指导统筹地区结合本地实际研究确定。调整统筹基金和个人账户结构后，增加的统筹基金主要用于门诊共济保障，提高参保人员门诊待遇。（五）规范个人账户使用范围。个人账户主要用于支付参保人员在定点医疗机构或定点零售药店发生的政策范围内自付费用。可以用于支付参保人员本人及其配偶、父母、子女在定点医疗机构就医发生的由个人负担的医疗费用，以及在定点零售药店购买药品、医疗器械、医用耗childreninthedesignatedmedicalinstitutions,aswellastheexpensesincurredbytheindividualinthepurchaseofdrugs,medicaldevices,andmedicalconsumablesinthedesignatedretaildrugstores.Theuseofpersonalaccountsforspouses,parents,andchildren'sindividualcontributionstothebasicmedicalinsuranceforruralandnon-workingurbanresidentsshallbeexplored.Personalaccountsshallnotbeusedforpublichealthexpenses,physicalfitnessorhealthcareconsumptionandotherexpendituresthatarenotwithinthescopeofthebasicmedicalinsurance.Theadministrativemeasuresfortheuseofpersonalaccountsshallbeimproved,andthecollectionofinformationonincomeandexpendituresshallbeeffectivelycarriedout.6. Supervisionandadministrationshallbestrengthened.Managementandservicemeasuresshallbeimproved,andtheoperationalmechanismofthesystemshallbeinnovatedon.Therationaluseofmedicalresourcesshallbeguidedtoensurethestableoperationofmedicalinsurancefundsandmaximizetheirguaranteefunction.Thebudgetmanagementsystemformedicalinsurancefundsshallbestrictlyimplemented,andthebuildingofthefund'sauditsystemandinternalcontrolsystemshallbestrengthened.Amechanismofthewhole-processdynamicmanagementofpersonalaccountsshallbeestablished,andtheauditoftheuseandsettlementofpersonalaccountsshallbestrengthened.Supervisionofmedicalpracticesandexpensesshallbestrengthened.Illegalactivitiessuchascounterfeithospitalizationandinducedhospitalizationshallbeinvestigatedandpunished.Asecuritypreventionandcontrolmechanismforthemedicalinsurancefundshallbeestablished.Fraudulentinsuranceactivitiesshallbecracked材发生的由个人负担的费用。探索个人账户用于配偶、父母、子女参加城乡居民基本医疗保险等的个人缴费。个人账户不得用于公共卫生费用、体育健身或养生保健消费等不属于基本医疗保险保障范围的支出。健全完善个人账户使用管理办法，做好收支信息统计。（六）加强监督管理。完善管理服务措施，创新制度运行机制，引导医疗资源合理利用，确保医保基金稳定运行，充分发挥保障功能。严格执行医保基金预算管理制度，加强基金稽核制度和内控制度建设。建立对个人账户全流程动态管理机制，加强对个人账户使用、结算等环节的审核。强化对医疗行为和医疗费用的监管，严肃查处“挂床”住院、诱导住院等违法违规行为。建立医保基金安全防控机制，严厉打击欺诈骗保行为，确保基金安全高效、合理使用。创新门诊就医服务管理办法，健全医疗服务监控、分析和考核体系，引导定点医疗机构规范提供诊疗服务。加快全国统一的医疗保障信息平台建设，推进门诊费用异地就医直接结算。通过协同推动基层医疗服务体系建设、完善家庭医生签约服务、规范长期处方管理等，引导参保人员在基层就医首诊。结合完善门诊慢特病管理措施，规范基层定点医疗机构诊疗及转诊等行为。downontoensurethesafe,efficient,andrationaluseofthefund.Themeasuresfortheadministrationofoutpatientmedicalservicesshallbeinnovatedon.Thesystemformonitoring,analyzing,andevaluatingmedicalsen,icesshallbeimproved,anddesignatedmedicalinstitutionsshallbeencouragedtoprovidestandardizeddiagnosisandtreatmentservices.Thedevelopmentofaunifiednationalmedicalsecurityinformationplatformshallbeacceleratedtopromotetheon-the-spotsettlementofoutpatientbillsforcross-provincemedicaltreatment.Theinsuredpeopleshallbeencouragedtoreceivetheirfirstmedicaltreatmentincommunity-levelhospitalsbydevelopingacommunity-levelmedicalservicesysteminacoordinatedway,improvingcontractservicesforfamilydoctors,andregulatingthemanagementoflong-termprescriptions.Thepracticesofdiagnosis,treatmentinandreferralbydesignatedgrassrootsmedicalinstitutionsshallberegulatedbasedonthemeasuresforthemanagementofoutpatientchronicdiseases.（七）完善与门诊共济保障相适应的付费机制。对 基层医疗服务可按人头付费，积极探索将按人头付费与慢 性病管理相结合；对日间手术及符合条件的门诊特殊病 种，推行按病种或按疾病诊断相关分组付费；对不宜打包 付费的门诊费用，可按项目付费。科学合理确定医保药品 支付标准，引导医疗机构和患者主动使用疗效确切、价格 合理的药品。7. Thepaymentmechanismcorrespondingtothegeneralsupportforcoveringoutpatientmedicalbillsshallbeimproved.Community-levelmedicalservicesmaybechargedpercapita.Waysofintegratingpaymentspercapitawithchronicdiseasemanagementshallbeexplored.Daysurgeryandeligibleoutpatientspecialdiseasesshallbechargedbydiseasetypeordiseasediagnosis.Outpatientexpenditurethatisnotsuitableforpackagepaymentmaybepaidonanitem-byitembasis.Thepaymentstandardsfordrugscoveredbymedicalinsuranceshallbedeterminedinascientificandreasonableway.Medicalinstitutionsandpatientsshallbeguidedintakingtheinitiativetousedrugswithdefiniteefficacyandreasonableprices.11.OrganizationandImplementation8. Organizationalleadershipshallbestrengthened.Establishingandimprovingageneralsupportmechanismforcoveringoutpatientmedicalbillsunderthemedicalinsuranceforemployeesisanimportantpartofdeepening(hereformofthemedicalsecuritysystem.Itinvolvesthevitalinterestsoftheinsuredpersonnelandmanypolicyandtechnicalconsiderations.People'sgovernmentsattheprovinciallevelshallattachgreatimportancetoit,earnestlystrengthenleadership,establishcoordinationmechanisms,andensureeffectiveimplementation.TheNationalHealthcareSecurityAdministrationandtheMinistryofFinanceshall,inconjunctionwithrelevantdepartments,strengthenworkguidanceforlocalauthorities,interactionbetweendepartmentsatupperandlowerlevels,tocreatesynergy.9. Therelevanttasksshallbeactivelyyetprudentlyadvanced.Thepeople'sgovernmentsattheprovinciallevelshall,asrequiredbytheseOpinions,makeoverallarrangementsandscientificdecisions,andissuetheimplementationmeasuresbeforetheendofDecember2021toguidetheimplementationbytheregionssubjecttotheoverallplanningofthemedicalinsurancefund.Theymaysetatransitionperiodofthreeyearsorsotograduallyachievethereformgoals.Allregionssubjecttotheoverallplanningofthemedicalinsurancefundshallfurtherclarifyandrefinepoliciesandregulationsinlightoftheirlocalconditions,andproperlyhandlepolicyalignmentbeforeandafterthereform,soastoensureasmoothtransition三、组织实施（八）加强组织领导。建立健全职工医保门诊共济保障机制是深化医疗保障制度改革的重要内容，涉及广大参保人员切身利益，政策性和技术性强。各省级人民政府要高度重视，切实加强领导，建立协调机制，抓好工作落实。国家医保局、财政部要会同相关部门加强对各地的工作指导，上下联动，形成合力。（九）积极稳妥推进。各省级人民政府要按照本意见要求，统筹安排，科学决策，在2021年12月底前出台实施办法，指导各统筹地区推进落实，可设置3年左右的过渡期，逐步实现改革目标。各统筹地区要结合本地实际，进一步明确和细化政策规定，妥善处理好改革前后的政策衔接，确保参保人员待遇平稳过渡，已经开展相关工作的要进一步规范政策标准，尚未开展相关工作的要积极稳妥启动实施。（十）注重宣传引导。要创新宣传方式，丰富宣传 手段，广泛开展宣传，准确解读政策。充分宣传建立健全 职工医保门诊共济保障机制对减轻参保人员医疗费用负 担、促进制度更加公平更可持续的重要作用，大力宣传医 疗保险共建共享、互助共济的重要意义。要建立舆情监测 和处置机制，积极主动回应社会关切，营造良好舆论氛 围。国务院办公厅inthetreatmentoftheinsuredpeople.Thosethathavecarriedouttherelevantworkshallfurtherregulatepolicystandards,whereasthosethathavenotyetcarriedoutrelevantworkshallactivelyandprudentlystartimplementingthem.1().Attentionshallbepaidtopublicityandguidance.Stepsshallbetakentoinnovateonpublicitymethods,enrichpublicitymeans,extensivelycarryoutpublicity,andaccuratelyinterpretpolicies.Theimportantroleofestablishingandimprovingageneralsupportmechanismforcoveringoutpatientmedicalbillsunderthemedicalinsuranceforemployeesinreducingthemedicalexpensesburdensfortheinsuredandmakingthesystemfairerandmoresustainableshallbepublicized.Thesignificanceofco-construction,sharing,andmutualaidofmedicalinsuranceshallbevigorouslypublicized.Amechanismformonitoringandhandlingpublicopinionsshallbeestablished.Publicconcernsshallbeactivelyrespondedto,soastocreateafavorablepublicopinionatmosphere.GeneralOfficeoftheSta
