The Opinions of the Ministry of Finance, the Ministry of Health, the Ministry of Labor and Social Security, National Development and Reform Commission, State Food and Drug Administration, and State Administration of Traditional Chinese Medicine on the Medical Service Management of Basic Medical Insurance for Urban Residents

财政部、卫生部、劳动和社会保障部、国家发展和改革委员会、国家食品药品监督管理局、国家中医药管理局关于城镇居民基本医疗保险医疗服务管理的意见

 

Promulgating Institution: Ministry of Finance; Ministry of Health; Ministry of Labour and Social Security; National Development and Reform Commission; State Food and Drug Administration; State Administration of Traditional Chinese Medicine

Document Number: Lao She Bu Fa [2007] No. 40

Promulgating Date: 10/10/2007

Effective Date: 10/10/2007

颁布机关: 财政部; 卫生部; 劳动和社会保障部; 国家发展和改革委员会; 国家食品药品监督管理局; 国家中医药管理局

文      号: 劳社部发[2007]40号

颁布时间: 10/10/2007

实施时间: 10/10/2007

 

To the labor and social security departments (bureaus), development and reform commissions, financial departments (bureaus), departments (bureaus) of health, food and drug administrations, administrations of traditional Chinese medicine of all provinces, autonomous regions and municipalities directly under the Central Government:

In accordance with the fundamental nature of the Guiding Opinions of the State Council on Developing Pilot Programs of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No. 20) and for the purpose of successfully carrying out the work regarding the pilot programs, these Opinions on relevant issues of the medical service management of basic medical insurance for urban residents are hereby promulgated as follows: 

    各省、自治区、直辖市劳动和社会保障厅(局)、发展改革委、财政厅(局)、卫生厅(局)、食品药品监督管理局、中医药管理局:

    根据《国务院关于开展城镇居民基本医疗保险试点的指导意见》(国发〔2007〕20号)精神,为做好城镇居民基本医疗保险试点工作,现就城镇居民基本医疗保险医疗服务管理的有关问题提出如下意见:

1.   Fundamental requirements for the medical service management of basic medical insurance for urban residents 

(1)   To establish a basic medical insurance system for urban residents, which is based on comprehensive arrangement for serious diseases, is an important measure in implementing the human-oriented scientific development view and constructing a socialist harmonious society. To strengthen and improve the medical service management is of great significance in safeguarding the medical rights and interests of residents under insurance coverage, standardizing medical service practice, controlling medical expenditure, increasing the use efficiency of medical insurance fund and ensuring the sound operation of relevant systems. All relevant departments at all levels shall closely cooperate with each other to strengthen the medical service management of basic medical insurance for urban residents in their work of carrying out pilot programs so as to practically satisfy the basic medical requirements of extensive residents under insurance coverage.  

(2)   The service management of basic medical insurance for urban residents shall include the management over medical service scope, the management over appointed medical service institutions and the management over settlement of medical expenses. The basic medical insurance for urban residents shall start from a lower level. The medical service scope and level under the payment of fund of basic medical insurance for urban residents as well as the settlement measures and standards of medical expenses shall be reasonably determined in accordance with the fund-raising and fund security capabilities of basic medical insurance for urban residents, considering the economic affordability of urban residents and based on the principle of emphatically ensuring the medical expenses for hospitalization and out-patient serious diseases and areas of adequate conditions attaching importance to normal out-patient expenses.  

(3)   To improve relevant policies of the medical service management of the basic medical insurance by reference to the regulations regarding the service management of basic medical insurance for urban employees and by considering the characteristics of urban residents. Regulations regarding the medical service management of new rural cooperative medical system may be applicable to a place that practices integration management of basic medical insurance for urban residents and new rural cooperative medical system. All places shall, in accordance with State's relevant regulations and the spirits hereof and according to local conditions, actively explore the specific medical service management measures of basic medical insurance for urban residents.  

       一、城镇居民基本医疗保险医疗服务管理的基本要求

    (一)建立以大病统筹为主的城镇居民基本医疗保险,是落实以人为本的科学发展观和构建社会主义和谐社会的重要举措。加强和完善医疗服务管理,对保障参保居民合理的医疗权益,规范医疗服务行为,控制医疗费用支出,提高医疗保险基金的使用效率,保证制度的平稳运行,具有重要意义。各级各相关部门要密切配合,在城镇居民基本医疗保险试点工作中,强化城镇居民基本医疗保险医疗服务管理,切实保障广大参保居民的基本医疗需求。

    (二)城镇居民基本医疗保险医疗服务管理包括医疗服务的范围管理、医疗服务的定点管理和医药费用的结算管理。城镇居民基本医疗保险坚持从低水平起步。要根据城镇居民基本医疗保险筹资水平和基金保障能力,考虑城镇居民的经济承受能力,按照重点保障住院和门诊大病、有条件的地区兼顾一般门诊医疗费用的原则,合理确定城镇居民基本医疗保险基金支付的医疗服务范围、水平,以及医疗费用的结算办法及标准。

    (三)参照城镇职工基本医疗保险医疗服务管理的有关规定,结合城镇居民的特点,完善基本医疗保险医疗服务管理的相关政策。城镇居民基本医疗保险与新型农村合作医疗实行一体化管理的,也可以参照新型农村合作医疗有关医疗服务管理的规定执行。各地应按照国家有关规定和本意见精神,因地制宜,积极探索加强城镇居民基本医疗保险医疗服务管理的具体措施。

2.   To reasonably determine the medical service scope

(4)   The medical service scope of basic medical insurance for urban residents shall cover the scope of medication, diagnosis and treatment items and medical service facilities. Relevant departments shall, on the basis of the service management scope of basic medical insurance for urban employees, make appropriate changes to the service management scope of basic medical insurance for urban residents in accordance with relevant procedures and jurisdiction. Labor security departments shall, in conjunction with relevant departments, determine the specific issues in accordance with relevant regulations and on the basis of seriously organizing experts to make evaluations and examinations as well as fully soliciting opinions from parties concerned. 

(5)   To make appropriate changes and reasonable determination on the medication scope of basic medical insurance for urban residents on the basis of State and Provincial (regional, municipal) Drug Catalogue of Basic Medical Insurance and Occupational Injury Insurance. All OTC drugs under the Drug Catalogue of Basic Medical Insurance and Occupational Injury Insurance of the State shall be included under the payment coverage of fund of basic medical insurance for urban residents. The State shall, based on the characteristics of medication for children and adhering to the principle of "necessary clinical medication, safety and efficiency, reasonable price, convenient to take and attaching equal importance to both Chinese and western medicines", adequately increase the varieties and dosage forms of pediatric drugs. 

(6)   With regard to the scope of diagnosis and treatment items and medical service facilities of basic medical insurance for urban residents, the equal scope of basic medical insurance for urban employees shall be applicable in principle. All places may also add necessary diagnosis and treatment items and medical service facilities for pregnant and maternal women as well as for infants and children in a proper manner. They may, according to their actual conditions, increase the number of traditional Chinese medicine diagnosis and treatment items and medical service facilities. All provinces (regions, cities) shall be responsible for formulating the measures for newly added diagnosis and treatment items and medical service facilities. 

(7)   All places shall improve their management over the medication, diagnosis and treatment items, and medical service facilities for basic medical insurance, strengthen their examinations over high-value drugs, newly added diagnosis and treatment items and large medical equipment, as well as access and application of high-value medical disposable materials. All places shall also control their medical expenditure, improve the efficiency of the usage of funds of basic medical insurance for urban residents and relieve the expense burden of fund and personnel under basic medical insurance for urban residents.  

       二、合理确定医疗服务范围

    (四)城镇居民基本医疗保险医疗服务范围包括用药、诊疗项目和医疗服务设施范围。城镇居民基本医疗保险医疗服务范围,由相关部门按照有关程序和权限,在城镇职工基本医疗保险医疗服务范围的基础上进行适当调整。具体范围由劳动保障部门会同有关部门按照相关规定,在认真组织专家评审、充分听取有关方面意见的基础上研究确定。

    (五)城镇居民基本医疗保险用药范围在国家和省(区、市)《基本医疗保险和工伤保险药品目录》的基础上,进行适当调整、合理确定。要把国家《基本医疗保险和工伤保险药品目录》甲类目录药品全部纳入城镇居民基本医疗保险基金的支付范围。国家根据儿童用药的特点,按照"临床必需、安全有效、价格合理、使用方便、兼顾中西药"的原则,适当增加儿童用药的品种及剂型。

    (六)城镇居民基本医疗保险诊疗项目范围、医疗服务设施范围,原则上执行当地城镇职工基本医疗保险的诊疗项目、医疗服务设施范围。各地也可根据本地实际适当增加孕产妇、婴幼儿必需的诊疗项目和医疗服务设施及中医药诊疗项目和医疗服务设施。新增诊疗项目和医疗服务设施暂由各省(区、市)负责制定。

    (七)各地要完善基本医疗保险用药、诊疗项目和医疗服务设施管理,加强对高价药品、新增诊疗项目、大型医用设备检查及高值医用耗材的准入和使用管理,控制医疗费用支出,提高城镇居民基本医疗保险基金的使用效率,减轻城镇居民基本医疗保险基金和参保人员的费用负担。

3.   To strengthen management over appointed medical service institutions

(8)   Management over appointed medical institutions and retail pharmacies should be implemented under basic medical insurance system for urban residents. With regard to specific management measures, relevant regulations on the management over appointed medical institutions and retail pharmacies under basic medical insurance for urban employees shall be applicable. Management over appointed medical service agreement shall be further specified and improved based on the characteristics and needs of urban residents in seeking medical service to fully exert the function of basic medical insurance in regulating medical service. Methods and measures for the appointed management over the medical service for populations under all medical security systems shall be determined on an overall-planning basis in accordance with the needs of coordinate development of all medical security systems. 

(9)   To reasonably determine the scope and quantity of appointed medical institutions and retail pharmacies and the specific measures shall be jointly determined by labor security departments, industrial and commercial departments, public health departments, traditional Chinese medicine administrative departments, food and drug administration departments at all places. Expenses of residents under insurance coverage on medical service or drug purchase at appointed medical institutions or retail pharmacies shall be paid by their medical insurance fund in accordance with regulations. All places shall, in accordance with the medical demands of residents under insurance coverage, include qualified obstetric hospitals, MCH (mother and child health) hospitals (centers), children's hospitals and community health service institutions in the scope of appointed medical service institutions.  

(10)   All places shall explore management mechanism that can promote residents under insurance coverage to reasonably make use of medical service resources, guide residents under insurance coverage to take full advantage of the medical service and traditional Chinese medicine service provided by community health service institutions and basic-level medical institutions, and make exploration in establishing a dual referral mechanism. With regard to out-patient serious diseases under fund payment and normal out-patient medical service items under the overall planning of medical expenses, management measures and medical expense settlement measures that enable effective use of community and basic-level medical service shall be formulated. Where residents under insurance coverage seek medical service at appointed community health service institutions and basic level medical institutions, the percentage of their medical expenses paid by fund may be properly raised. 

  

       三、加强定点管理

    (八)城镇居民基本医疗保险实行定点医疗机构和定点零售药店管理。具体管理办法按照城镇职工基本医疗保险定点医疗机构和定点零售药店管理的有关规定执行。要根据城镇居民的就医特点和需要,进一步细化和完善定点医疗服务协议管理,充分发挥基本医疗保险对医疗服务的约束作用。要根据各项医疗保障制度协调发展的需要,统筹确定各类医疗保障人群医疗服务定点管理的办法和措施。

    (九)合理确定定点医疗机构和零售药店的范围和数量,具体由各地劳动保障部门商卫生、中医药行政部门和食品药品监管部门确定。参保居民在定点医疗机构和零售药店就医购药所发生的费用,由医疗保险基金按规定予以支付。各地要根据参保居民的医疗需求,将符合条件的妇产医院、妇幼保健院、儿童医院和社区卫生服务机构等纳入定点范围。

    (十)要探索促进参保居民合理利用医疗服务资源的管理机制,引导参保居民充分利用社区卫生服务机构、基层医疗机构提供的医疗服务及中医药服务,探索建立双向转诊机制。对纳入基金支付的门诊大病和实行医疗费用统筹的普通门诊医疗服务项目,要制定有效利用社区和基层医疗服务的就医管理办法和医疗费用结算办法。对参保居民在定点社区卫生服务机构和基层医疗机构就医的费用,可适当提高基金的支付比例。

4.   To improve the management over expense settlement

(11)   In accordance with medical service scope and fund-raising capabilities, expense settlement manners of basic medical insurance shall be established and improved, settlement standards for medical expense shall be reasonably determined and included in agreement management as well. Medical expenses satisfying the requirements of relevant regulations shall be settled in a timely manner according to the agreement and paid in full amount; medical expenses not satisfying the requirements of relevant regulations shall not be paid.  

(12)   To actively explore the payment methods and standards of the medical service determined by medical insurance administrative institutions and appointed medical institutions upon consultation. To make active efforts in exploring the settlement methods of payment by types of diseases and advance payment by total amount so as to arouse the enthusiasm of appointed medical institutions in participating in the management out of their own initiative and reducing medical service cost.  

       四、完善费用结算管理

    (十一)要根据医疗服务范围和筹资水平,建立和完善基本医疗保险费用结算方式,合理确定医疗费用结算标准,并纳入协议管理。对符合规定的医疗费用,要按协议及时结算并足额支付,不符合规定的医疗费用不予支付。

    (十二)积极探索由医疗保险经办机构与定点医疗机构协商确定医疗服务的付费方式及标准。积极探索按病种付费、按总额预付等结算方式,调动定点医疗机构主动参与管理、降低医疗服务成本的积极性。

All relevant departments at all levels shall, under the unified leadership of local governments, actively cooperate with each other to jointly and successfully carry out the work regarding medical service management of basic medical insurance for urban residents. They shall constantly sum up their management experience through practice and exploration. They shall also timely report major problems, if any, to departments at higher level.   

    各级各相关部门要在当地政府的统一领导下,积极配合,共同做好城镇居民基本医疗保险的医疗服务管理工作。要通过实践探索,不断总结管理经验,遇有重大问题及时上报。

Ministry of Labor and Social Security 

Development and Reform Commission 

Ministry of Finance 

Ministry of Health 

Food and Drug Administration 

Administration of Traditional Chinese Medicine 

October 10, 2007

劳动和社会保障部 

发展改革委 

财政部 

卫生部 

食品药品监管局 

中医药局 

二OO七年十月十日