Guiding Opinions of the Ministry of Human Resources and Social Security and the Ministry of Finance on Further Strengthening Management over the Basic Medical Insurance Fund

人力资源和社会保障部、财政部关于进一步加强基本医疗保险基金管理的指导意见

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

Document Number: Ren She Bu Fa [2009] No. 67

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

文      号: 人社部发[2009]67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) of all provinces, autonomous regions and municipalities directly under the Central Government, the Labor Security Administration and the Financial Administration of the Xinjiang Production and Construction Corps: 

In accordance with the requirements of the Opinions of the Central Committee of the Communist Party of China (hereinafter referred to as the "CPC") and the State Council on Furthering Medical and Health System Reform (Zhong Fa [2009] No. 6) and the Notice of the State Council on Printing and Circulating the Plan for Implementing Key Procedures of Medical and Health System Reforms in Recent Periods (year 2009-2011) (Guo Fa [2009] No. 12), the following opinions are hereby promulgated on relevant issues in order to further strengthen management over the basic medical insurance fund and improve efficient fund utilization:

    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),新疆生产建设兵团劳动保障局、财务局:

    根据《中共中央国务院关于深化医药卫生体制改革的意见》(中发〔2009〕6号)和《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)的要求,为进一步加强基本医疗保险基金管理,提高基金使用效率,现就有关问题提出如下意见:

1. To fully recognize the imperativeness of strengthening management over the basic medical insurance fund

(1) Acceleration of the construction of the basic medical security system, bringing of all urban and rural residents under the coverage of basic medical security system and gradual elevation of the level of basic medical security are important contents of intensifying medical and health system reform. The proper management and use of the basic medical insurance fund in accordance with the principle of "expenditure determined by revenue, balance between revenue and expenditure, with certain surplus" has practical significance towards guaranteeing the rights and interests of insurance participants to basic medical treatment as well as reducing people's burden of medical expenses. All departments concerned at all levels shall enhance their thought process, constantly improve upon policies, innovate management mechanism, strengthen fund management, enhance mutual aid and support abilities of the fund, and improve fund use efficiency.

       一、充分认识加强基本医疗保险基金管理的重要性和紧迫性

    (一)加快推进基本医疗保障制度建设,将全体城乡居民纳入基本医疗保障制度,逐步提高基本医疗保障水平,是深化医药卫生体制改革的重要内容。按照以收定支、收支平衡、略有结余的原则,管好、用好基本医疗保险基金,对保障参保人员的基本医疗权益,减轻人民群众医药费用负担有着十分重要的现实意义。各级各有关部门要提高认识,不断完善政策,创新管理机制,强化基金管理,增强基金的共济和保障能力,提高基金使用效率。

2. To enhance mutual aid and support abilities of the basic medical insurance fund

(2) To strengthen expansion of the coverage of basic medical insurance and fund collection. Aiming at not less than 90 per cent of the rate of insurance participation in the immediately preceding three years, all places shall further strengthen expansion of the coverage of basic medical insurance for urban employees and urban residents. By practically adhering to the requirements of the Notice on Properly Settling the Issues Relevant to the Medical Security for Retired Personnel from Closed-down or Bankrupt State-owned Enterprises (Ren She Bu Fa [2009] No. 52), they shall properly settle the issue of participation of personnel retired from closed-down or bankrupt State-owned enterprises in the basic medical insurance for urban employees through fund-raising by various channels such as liquidity of the property of bankrupt enterprises, income from transferring lands that are not bankruptcy property, financial subsidies, adjustment of the balance of pooling fund of basic medical insurance, etc. At the same time, all places shall provide extensive solutions to medical security issues with respect to the other urban personnel including retired persons from closed-down or bankrupt collective enterprises and employees of financially weak enterprises. They shall further strengthen their collection and audit over the basic medical insurance fund in order to ensure the collection of all receivables of basic medical insurance. 

(3) To gradually improve the security level of basic medical insurance and to mitigate the burden on individual insurance participants. All places shall, on the basis of meticulous calculation, properly raise the reimbursement level for inpatient service costs, gradually raise the maximum limit for expenses paid by pooling funds and regulate management over outpatient serious diseases. All places are encouraged to actively develop the overall planning of outpatient medical expenses of urban residents under basic medical insurance as well as expand the scope of benefit of basic medical insurance for urban residents. Areas under the overall planning and with adequate conditions may explore ways to adjust the use of individual accounts of basic medical insurance for urban employees, carry out pilot overall-planning of outpatient medical expenses of urban employees under basic medical insurance, gradually increase the reimbursement scope and proportion of outpatient medical expenses, and improve efficient utilization of individual account funds.  

(4) To enhance the overall-planning level of basic medical insurance. All places shall accelerate and advance the work related to raising the overall-planning level of basic medical insurance according to the actual situations of local places, generally realizing the overall planning at the municipality (regional) level until the year 2011. Places with actual difficulties in realizing unified revenue and expenditure of funds may establish a fund risk adjustment system at municipality (regional) level in the first place, and then gradually realize the transition. Places with adequate conditions may practice overall planning at a provincial level.

       二、增强基本医疗保险基金共济和保障能力

    (二)加大基本医疗保险扩面和基金征缴力度。各地要按照3年内基本医疗保险参保率达到90%以上的目标,进一步加大城镇职工基本医疗保险和城镇居民基本医疗保险的扩面力度。要切实按照人力资源社会保障部、财政部等部门《关于妥善解决关闭破产国有企业退休人员等医疗保障有关问题的通知》(人社部发〔2009〕52号)的要求,通过破产企业财产变现、未列入破产财产的土地出让所得、财政补助、医疗保险统筹基金结余调剂等多渠道筹资,妥善解决关闭破产国有企业退休人员参加城镇职工基本医疗保险问题。同时,各地要统筹解决包括关闭破产集体企业退休人员和困难企业职工等在内的其他各类城镇人员的医疗保障问题。进一步加大基本医疗保险基金的征缴和稽核力度,确保基本医疗保险基金应收尽收。

    (三)逐步提高基本医疗保险保障水平,减轻参保人员的个人负担。各地要在精心测算的基础上,适当提高政策内住院医疗费用的报销水平,逐步提高统筹基金最高支付限额,规范门诊大病管理。鼓励各地积极开展城镇居民基本医疗保险门诊医疗费用统筹,扩大城镇居民基本医疗保险受益范围。有条件的统筹地区可以探索调整城镇职工基本医疗保险个人账户使用办法,试行城镇职工基本医疗保险门诊医疗费用统筹,逐步扩大和提高门诊费用的报销范围和比例,提高个人账户基金的使用效率。

    (四)提高基本医疗保险统筹层次。各地要根据本地实际情况,加快推进提高基本医疗保险统筹层次工作,到2011年基本实现市(地)级统筹。实现市(地)级基金统收统支确有困难的地区,可以先建立市(地)级基金风险调剂制度,再逐步过渡。具备条件的地区,可以探索实行省级统筹。

3. To strengthen management over the basic medical insurance fund 

(5) To further strengthen management over the revenue and expenditure budget of basic medical insurance fund. Places practicing overall planning shall seriously implement the financial system for social insurance funds and formulate the budget for revenue and expenditure of basic medical insurance fund each year. When formulating a budget for fund revenue, factors such as local economic development level, level of employee wage income, coverage of medical insurance and fund-raising proportion of medical insurance shall be comprehensively considered. While formulating a budget for fund expenditure, factors such as the age structure of local insurance participants, the possible disease afflictions, increase of medical expenses, scope of benefit of medical insurance, security level of medical insurance and fund balance shall be comprehensively considered. 

(6) To successfully carry out accounting and statistical analysis of the basic medical insurance fund. All places shall seriously implement the accounting system for social insurance fund as well as strengthen the accounting work of the basic medical insurance fund. Medical insurance administrative organizations shall independently maintain statistical tabular accounts for one-off advance payments of basic medical insurance premiums, and strengthen statistical analysis and management over the one-off advance payments of basic medical insurance premiums.  

(7) To establish analytical systems for the operational situations of the fund of basic medical insurance and preemptive risk warning system. All places shall make use of the medical insurance information system to construct the analytical system for the operational situation of basic medical insurance fund and the preemptive risk warning system. The accumulative balance of the pooling fund shall be taken as the key index for the risk monitoring of the basic medical insurance fund and analysis of its fund operation situation shall be strengthened. Other than the one-off advance payments of basic medical insurance premiums, the accumulative balance of the basic medical insurance pooling fund for urban employees at places under overall planning shall be controlled, in principle, at about the average paying level of six to nine months. Where the accumulative balance of the basic medical insurance pooling fund for urban employees is beyond the average paying level of 15 months, the situation is regarded as surplus excess; where the accumulative balance is lower than the average paying level of three months, the situation is regarded as surplus deficiency. With regard to the indices for preemptive risk warning of the basic medical insurance fund for urban residents, all places may make determinations based on their actual situations.

(8) To properly settle the issues of excessive surplus of the pooling fund and shortfall in income over expenditure during the current period. Where, due to factors such as an increase in the employee wage level in places under overall insurance planning, the increase in pooling fund income is obviously higher than that in the pooling fund expenditure, and the situation of excessive surplus continues for two years in a place, such place may lower the basic medical insurance fund-raising proportion in a phased manner or appropriately raise the medical insurance treatment level for insurance participants. Places under overall insurance planning that involve shortfalls in income over expenditure in the current period shall find out reasons for overspending and control increases in expenditure through ways such as improving settlement methods and strengthening management over expenditure. Places under overall insurance planning that have a deficient accumulative pooling fund balance and have difficulty in guaranteeing the payment of the current period shall confirm the payment for the current period by resorting to temporary borrowing. In addition, they shall promptly study the making of adjustments to fund-raising or treatment policies. All places under overall insurance planning shall formulate corresponding reserve plans for fund alarm and shall submit reserve plan to the department of human resources and social security (labor security) and the financial department at provincial level for record-filing. Where intending to make policy changes such as to initiate pre-plan response or to adjust rates, a place under overall insurance planning shall submit the situation to the provincial people's government for approval. In the event of adjustment to major policies, the provincial people's government shall submit such adjustments to the Ministry of Human Resources and Social Security and the Ministry of Finance for record-filing. 

(9) To strengthen supervision over the basic medical insurance fund. We shall improve the internal control system for the management over the basic medical insurance fund by forming an internal mechanism that can realize mutual restriction and supervision between departments, posts and businesses. We shall strengthen administrative control by establishing prevention system against defrauding the fund of basic medical insurance to eliminate defrauding acts such as cheating for insurance indemnification. We shall establish and improve the internal auditing system for the basic medical insurance fund and timely rectify problems discovered during an audit. The revenue and expenditure situations of the basic medical insurance fund as well as the situations of insurance participants being entitled to medical insurance treatment shall be regularly publicized to the society to accept the supervision of all aspects of the society.

       三、强化基本医疗保险基金管理

    (五)进一步加强基本医疗保险基金收支预算管理。统筹地区要认真执行社会保险基金财务制度,按年度编制基本医疗保险基金收支预算。编制基金收入预算应综合考虑当地经济发展水平、职工工资收入水平、医疗保险覆盖面、医疗保险筹资比例等因素;编制基金支出预算应综合考虑当地参保人员年龄结构、疾病谱、医疗费用增长、医疗保险受益面、保障水平和基金结余情况等因素。

    (六)做好基本医疗保险基金会计核算和统计分析工作。各地要认真落实社会保险基金会计制度,加强基本医疗保险基金会计核算工作。医疗保险经办机构要单独建立一次性预缴基本医疗保险费统计台账,加强对一次性预缴基本医疗保险费的统计分析和管理。

    (七)建立基本医疗保险基金运行情况分析和风险预警制度。各地要利用医疗保险信息系统,构建基本医疗保险基金运行分析和风险预警系统,将统筹基金累计结余作为基本医疗保险基金风险预警监测的关键性指标,加强对基本医疗保险基金运行情况的分析。除一次性预缴基本医疗保险费外,统筹地区城镇职工基本医疗保险统筹基金累计结余原则上应控制在6-9个月平均支付水平。城镇职工基本医疗保险统筹基金累计结余超过15个月平均支付水平的,为结余过多状态,累计结余低于3个月平均支付水平的,为结余不足状态。城镇居民基本医疗保险的基金风险预警指标,各地可根据当地实际具体确定。

    (八)妥善解决统筹基金结余过多和当期收不抵支问题。统筹地区因职工工资水平增长等因素,统筹基金收入增幅明显高于支出增幅,连续2年处于结余过多状态的,可阶段性降低基本医疗保险筹资比例或适当提高参保人员医疗保险待遇水平。统筹基金出现当期收不抵支的统筹地区,要认真查找超支原因,通过改进结算方式、加强支出管理等途径,控制费用支出增长。统筹基金累计结余不足、难以保证当期支付的统筹地区,可通过临时借款保证当期支付,并及时研究调整筹资或待遇政策。各统筹地区应根据上述原则制订相应的基金告警预案,并报省级人力资源社会保障(劳动保障)、财政部门备案。统筹地区启动预案响应和费率调整等政策变化,应报省级人民政府批准。重大政策调整省级人民政府应报人力资源社会保障部、财政部备案。

    (九)强化基本医疗保险基金监管。完善基本医疗保险基金管理内控制度,形成部门之间、岗位之间和业务之间相互制衡、相互监督的内控机制。加强行政监管,建立基本医疗保险基金欺诈防范机制,杜绝骗保等欺诈行为的发生。建立和完善基本医疗保险基金内部审计制度,及时整改审计发现的问题。定期向社会公布基本医疗保险基金收支情况和参保人员医疗保险待遇的享受情况,接受社会各界的监督。

4. To strengthen management over the payment of basic medical insurance 

(10) To increase the strength of medical insurance in monitoring medical services and acts. All places shall include the standards for hospital admission and discharge, the standards for clinical diagnosis and treatment, clinical medication guidance as well as prescription administration measures formulated by relevant departments into the scope of management by agreement. They shall establish and improve the examination and evaluation system for service quality of appointed medical organizations. They shall constantly improve the information system of medical insurance, gradually realize the real-time monitoring of medical service acts throughout the whole process, strengthen the monitoring of key medical service projects and the use of important drugs, minimize the occurrence of unreasonable medical expenses and prevent defrauding medical acts. 

(11) To improve expense settlement methods. We shall conduct active exploration in reasonably determining the payment methods and standards for medical services through negotiation between medical insurance administrative organizations, medical organizations and drug suppliers in order to make use of the medical security function in restricting medical services and drug expenses. We encourage the exploration of practicing various settlement methods such as payment according to the disease, advance payment of the total amount and payment per head, which will entirely mobilize the initiative and enthusiasm of medical organizations and doctors to control medical service costs.  

(12) To optimize the process to settle medical expenses. Medical insurance administrative organizations shall further optimize the process to settle medical expenses, gradually realize the direct settlement with appointed medical organizations, and reduce the time taken for settling medical expenses. Medical expenses up to relevant standards shall be timely paid in full amount according to the agreement. Before settling medical expenses, a medical insurance administrative organization may allocate working funds amounting to a certain percentage to medical organizations in advance according to the agreement. The reimbursement and settlement procedures for individual medical expenses shall be simplified; humanized services shall be offered to provide convenience for insurance participants.

Ministry of Human Resources and Social Security

Ministry of Finance

July 24, 2009

       四、加强基本医疗保险支付管理

    （十）加大医疗保险对医疗服务行为的监控力度。各地要把相关部门制定的出入院标准、临床诊疗规范、临床用药指南和处方管理办法等纳入协议管理的范围，建立和完善对定点医疗机构服务质量的考核评价体系。要不断完善医疗保险信息系统，逐步实现对医疗服务行为的全程实时监控，加强对重点医疗服务项目和重点药品使用情况的监测，减少不合理医疗费用的发生，防范医疗欺诈行为。

    （十一）改进费用结算方式。积极探索医疗保险经办机构与医疗机构、药品供应商通过协商谈判，合理确定医药服务的付费方式及标准，发挥医疗保障对医疗服务和药品费用的制约作用。鼓励探索实行按病种付费、总额预付、按人头付费等结算方式，充分调动医疗机构和医生控制医疗服务成本的主动性和积极性。

    （十二）优化医疗费用结算流程。医疗保险经办机构要进一步优化医疗费用结算程序，逐步实现与定点医疗机构直接结算，缩短医疗费用结算时间，符合规定的医疗费用，要按照协议及时足额支付。医疗费用结算前，医疗保险经办机构可按照协议向医疗机构预拨一定比例的周转金。简化个人医疗费用报销结算程序，提供人性化服务，方便广大参保人员。

    人力资源和社会保障部

    财政部

    二○○九年七月二十四日