Guiding Opinions of the Ministry of Human Resources and Social Security, the Ministry of Finance and the Ministry of Health on Developing Overall Outpatient Planning under Basic Medical Insurance for Urban Residents

人力资源和社会保障部、财政部、卫生部关于开展城镇居民基本医疗保险门诊统筹的指导意见

Promulgating Institution: Ministry of Human Resources and Social Security; Ministry of Finance;Ministry of Health

Document Number: Ren She Bu Fa [2009] No. 66

Promulgating Date: 07/24/2009

Effective Date: 07/24/2009

颁布机关:人力资源和社会保障部; 财政部; 卫生部

文      号: 人社部发[2009]66号

颁布时间: 07/24/2009

实施时间: 07/24/2009

To the departments (bureaus) of human resources and social security (labor security), the departments (bureaus) of finance, the departments (bureaus) of health of all provinces, autonomous regions and municipalities directly under the Central Government, the Labor Security Administration, the Financial Administration and the Administration of Health of the Xinjiang Production and Construction Corps:

In accordance with the spirit of the Notice of the State Council on Printing and Distributing the Plan of Implementing Key Procedures of Medical and Health System Reforms in Recent Periods (year 2009-2011) (Guo Fa [2009] No. 12) and the Guiding Opinions of the State Council on Developing Pilot Programs of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No. 20), the following opinions are hereby promulgated on relevant issues for the purposes of expanding the benefit coverage of basic medical insurance system for urban residents as well as practically reducing the burden of insurance participants in outpatient medical expenses, areas with adequate conditions may gradually improve the overall outpatient planning work with respect to basic medical insurance for urban residents:

    各省、自治区、直辖市人力资源社会保障(劳动保障)厅(局)、财政厅(局)、卫生厅(局),新疆生产建设兵团劳动保障局、财务局、卫生局:

    根据《国务院关于印发医药卫生体制改革近期重点实施方案(2009-2011年)的通知》(国发〔2009〕12号)和《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)的精神,为扩大城镇居民基本医疗保险制度受益面,切实减轻参保居民门诊医疗费用负担,有条件的地区可逐步开展城镇居民基本医疗保险门诊统筹工作,现就有关问题提出如下意见:

1. To develop overall outpatient planning under basic medical insurance for urban residents, on the basis of adhering to the policies and regulations of basic medical insurance, we shall comprehensively consider the characteristics of outpatient medical service and the imperative needs of urban residents with respect to fundamental outpatient medical guarantee, thereby improving the coverage scope of basic medical insurance, and relevant policies such as fund raising and payment, management measures such as seeking medical services, expense settlement and business handling. The outpatient medical expenses of insurance participants shall be reasonably shared through overall planning and joint efforts.

       一、开展城镇居民基本医疗保险门诊统筹,要在坚持基本医疗保险政策规定的基础上,充分考虑门诊医疗服务特点和城镇居民对门诊医疗基本保障的迫切需要,进一步完善基本医疗保险的保障范围、筹资、支付等政策和就医、费用结算、业务经办等管理措施,通过统筹共济的方式合理分担参保居民门诊医疗费用。

2. To develop overall outpatient planning, the following principles shall be adhered to: basic guarantee, starting from a lower level and gradually moving upwards in mitigating people's burden of outpatient medical expenses; take advantage of social strength, adjusting fund operation through overall fund planning and enhancing fund security; mainly relying on grass-root medical and health organizations such as community health service centers (stations) to provide convenience for people seeking medical service thereby reducing their medical costs.

       二、开展门诊统筹应坚持以下原则:立足基本保障,从低水平起步,逐步减轻群众门诊医疗费用负担;实行社会共济,通过基金统筹调剂使用,提高基金保障能力;主要依托社区卫生服务中心(站)等基层医疗卫生机构,方便群众就医,降低医疗成本。

3. According to the paying ability of the basic medical insurance fund for urban residents and on the basis of giving priority to guaranteeing the medical expenses of insurance participants during hospitalization and/or affliction with serious ailments, we shall gradually move towards the inclusion of medical expenses for minor ailments within the payment scope of the fund. The basic medical insurance fund for urban residents shall comply with the principle of balance between income and expenditure; the fund necessary for overall outpatient planning shall be allocated from the basic medical insurance fund for urban residents and an independent account book shall be maintained.

       三、根据城镇居民基本医疗保险基金支付能力,在重点保障参保居民住院和门诊大病医疗支出的基础上,逐步将门诊小病医疗费用纳入基金支付范围。城镇居民基本医疗保险基金要坚持收支平衡的原则,门诊统筹所需费用在城镇居民基本医疗保险基金中列支,单独列账。

4. The overall outpatient planning may initially be directed either towards aged people who are prone to chronic diseases, or towards the common ailments and chronic diseases that are endemic amongst people of a lower economic and financial stratum. With respect to overall outpatient planning, the threshold standard, payment proportion and maximum payment limit may be independently set up and specific standards may be reasonably determined by all areas under the overall planning in accordance with actual prevalent situations. The payment level for overall outpatient planning shall correspond with the level of local economic development and medical consumption level as well as to the fund-raising level of the basic medical insurance for local residents.

       四、建立门诊统筹可以从慢性病发生较多的老年人起步,也可以从群众反映负担较大的多发病、慢性病做起。门诊统筹可以单独设立起付标准、支付比例和最高支付限额,具体可由各统筹地区根据实际合理确定。门诊统筹支付水平要与当地经济发展和医疗消费水平相适应,与当地城镇居民基本医疗保险筹资水平相适应。

5. To develop overall outpatient planning, we shall make full use of grass-root medical and health organizations such as community health service centers (stations) as well as traditional Chinese medicine services. We shall include the grass-root medical and health organizations with adequate conditions under the coverage of appointed medical organizations of basic medical insurance. During the preliminary phase, the overall outpatient planning is in principle used for the outpatient medical expenses incurred at the designated grass-root medical and health organizations. With the establishment and improvement of grades for diagnosis and treatment as well as the two-way referral system, we shall gradually expand the payment scope to the referral expenses. We shall simultaneously provide expeditious and convenient services by formulating preferential reimbursement policies as well as encourage and guide insurance participants to make full use of grass-root medical and health services. Health administrative departments at all levels shall reasonably set up grass-root medical and health organizations, promote specialization and cooperation between such organizations and referral medical organizations, explore ways to establish grades for diagnosis and treatment system as well as study management measures and standards relevant to referral. Departments of human resources and social security at places under the overall planning shall, in conjunction with the health administrative department, jointly explore management measures for insurance participants who seek treatment for the first time, or pursuant to referral, in order to promote the establishment of the two-way referral system.

       五、开展门诊统筹应充分利用社区卫生服务中心(站)等基层医疗卫生机构和中医药服务。将符合条件的基层医疗卫生机构纳入基本医疗保险定点范围。起步阶段,门诊统筹原则上用于在定点基层医疗卫生机构发生的门诊医疗费用,随着分级诊疗和双向转诊制度的建立完善,逐步将支付范围扩大到符合规定的转诊费用。同时,要通过制定优惠的偿付政策,提供方便快捷的服务,鼓励和引导参保居民充分利用基层医疗卫生服务。各级卫生行政部门要合理设置基层医疗卫生机构,促进基层医疗卫生机构与转诊医疗机构的分工合作,探索建立分级诊疗制度及转诊相关管理办法和标准。统筹地区人力资源社会保障部门要会同卫生行政部门共同探索首诊和转诊的参保人员就医管理办法,促进建立双向转诊制度。

6. We shall explore appropriate means for the control mechanism and settlement management with respect to the expenses of overall outpatient planning. According to the characteristics of outpatient medical treatment and medical expenditure, we shall actively explore measures to settle relevant expenses such as making advance payment of the total expenses as well as individual payments. We shall fully make use of the advantages of purchase by medical insurance groups, adopt various means such as fixed service organizations, service items, evaluation indices, settlement standards and payment measures to explore comprehensive management measures for the integration of overall outpatient planning in seeking medical service, payment and settlement in order to effectively control outpatient medical expenses.

       六、探索适合门诊统筹费用控制机制和结算管理的方式。根据门诊就医和医疗费用支出特点,积极探索总额预付或按人头付费等费用结算办法。充分发挥医疗保险集团购买的优势,采取定服务机构、定服务项目、定考核指标、定结算标准、定支付办法等方式,探索就医、支付、结算一体化的门诊统筹综合管理办法,有效控制门诊医疗费用。

7. To strengthen organization and leadership. All places shall attach great importance to relevant affairs, make scientific decisions and carefully organize the implementation thereof. The construction of the ability to handle business shall be practically enhanced, the information system for medical insurance shall be improved, innovative means of handling relevant business that adapt to the needs of management over overall outpatient planning, and enhance the level of management and service shall be explored and investigated into. They shall strengthen coordination between community labor security platforms and community health service organizations, and promote management over health of insurance participants. They shall also comprehensively study contemporary situations and problems appearing in their field, actively figure out appropriate solutions and promptly report any important situations encountered.

Ministry of Human Resources and Social Security

Ministry of Finance

Ministry of Health

July 24, 2009

       七、加强组织领导。各地要高度重视，科学决策，精心组织实施。切实加强经办能力建设，完善医疗保险信息系统，探索适应门诊统筹管理需要的经办方式，提高管理服务水平。要加强社区劳动保障平台与社区卫生服务机构的协作，促进参保人员健康管理。要认真研究工作中出现的新情况、新问题，积极探索解决办法，遇有重要情况要及时报告。

    人力资源和社会保障部

    财政部

    卫生部

    二○○九年七月二十四日