About the integration of urban and rural residents of the state council

The opinions of the basic medical insurance system

The 2016-01-12 national health and population and family planning commission of the People's Republic of China

The country is sent [2016] no. 3

The provinces, autonomous regions and municipalities directly under the central government, ministries under the state council, directly affiliated institutions:

Integration of the basic medical insurance for urban residents (hereinafter referred to as the urban residents health insurance) and the new rural cooperative medical care system (hereinafter referred to as the \"new farming close) two system, establish a unified urban and rural residents basic medical insurance system of medical insurance) (hereinafter referred to as the urban and rural residents, promote the reform of medical and health system, realize the urban and rural residents basic medical insurance rights and interests enjoyed fair, promote social fairness and justice, to improve the well-being of the people important measures, to promote urban and rural economic and social coordinated development, build a well-off society in an all-round way is of great significance. Summarizing the urban residents medical insurance and new farming operation and local exploration, on the basis of practical experience, regarding the integration build system of urban and rural residents health following opinions are put forward.

A, general requirements and basic principles

(a) general requirements.

To deng xiaoping theory and \"three represents\" important thought, the concept of scientific development as guidance, earnestly implement the party's eighteen big, the 18th session of 2, 3, 4, fifth plenary session, and xi jinping, general secretary of the series of important speech spirit, the implementation of the party central committee and state council on deepening the reform of medical health system, according to the whole, the basic, multi-level and sustainable policy, strengthen overall coordination with the top-level design, follow the principle of easy to difficult, step by step after the first, perfect the policy of promoting urban residents health care and new farming and system integration, and gradually establish a unified urban and rural residents across the country health care system, and promote more formal security more fair, management services, medical resources more effectively, promote the sustained and healthy development of universal health care system.

(2) the basic principles.

1. Overall planning and coordinated development. To urban and rural residents health care integration into the development of universal health care system and deepen the reform, overall arrangement, reasonable planning, highlight the three medical health care, medical treatment, medicine, linkage and strengthening the basic medical insurance, serious illness insurance, medical treatment, disease, emergency rescue, commercial health insurance, such as cohesion, strengthen the system of systematic, holistic, collaborative.

2. Based on the basic, safeguard fair. To give an accurate positioning, scientific design, based on the level of economic and social development, urban and rural residents burden and fund bear ability, mature and gradually narrow the gap between urban and rural, regional differences, safeguard fair enjoy treatment of primary health care, urban and rural residents of urban and rural residents health care system to realize the sustainable development.

3. Adjust measures to local conditions, orderly. Want to combine practical, comprehensive analysis, careful formulation implementation plan, strengthen the integration and cohesion, ensure that the work is smooth succeeded, an orderly transition, ensure that the treatment of primary health care is not affected, ensure security and medical insurance fund system running smoothly.

4. The innovation mechanism, and improve efficiency. To adhere to the pipe run separately, to carry out the government responsibility, perfect the management mechanism, further promote the reform of payment, improve the health service efficiency of funds and management agency service efficiency. Fully give play to the role of market mechanism, to mobilize social forces to participate in basic medical insurance agency services.

Second, the integration of basic system policy

(a) uniform coverage.

Urban and rural residents health care coverage, including the existing urban residents medical insurance and new farming all should join (us), which should cover in addition to the worker is basic medical treatment insurance ginseng protect personnel other than those of all urban and rural residents. Migrant workers and personnel of flexible obtain employment to worker is basic medical treatment insurance in accordance with the law, have difficulty can be according to the regulations of the local health care in urban and rural residents. The ginseng protect mode should be improved and the facilitating should defend and defend avoid duplication of ginseng.

(2) unified financing policy.

Adhere to the multi-channel financing, continue to integrate individual capture to expend and government subsidies of financing way, to encourage collective, unit or other social economic organizations to support or fund. Around to overall consideration of urban and rural residents medical insurance and serious illness insurance demand, according to the principle of fund balance, reasonable determination of the financing of urban and rural unified standards. Existing urban residents medical insurance and new farming and individual pay cost standard gap larger area, can adopt the difference to expend means, use 2 to 3 years to gradually transition. Consolidated real per capita financing and individual pay cost shall not be lower than current levels.

Perfecting the financing dynamic adjustment mechanism. On the basis of actuarial balance, gradually establish and the level of economic and social development, the parties bear ability to accommodate the stable financing mechanism. Gradually establish individual pay cost standard and urban and rural residents per capita disposable income of corresponding mechanism. Reasonable division of government and personal funding responsibility, at the same time of increasing government allowances, appropriately increase the proportion of individual pay cost.

(3) the unity to ensure treatment.

Follow the principle of moderation, balance of payments, balance the urban and rural areas to ensure treatment, gradually unified security scope and payment standards, ginseng protect personnel to provide equal basic health care. To properly handle the special security policy before integration, completes the transition and cohesion.

Urban and rural residents medical insurance fund is mainly used to pay the inpatient and outpatient medical expenses ginseng protect personnel to occur. Hospital security level, stable policy within the scope of hospitalization expense proportion pay remain at around 75%. We will further improve the outpatient service as a whole, and gradually raise the level of outpatient service guarantee. Gradually narrowing policy within the scope of the gap between the proportion and the actual payment proportion.

(4) unified medical insurance directory.

Unified urban and rural residents health care medicine and medical service project directory, drugs and medical service to pay limits. Provinces (autonomous regions and municipalities) should be in accordance with the national basic medical insurance drug management and the relevant provisions of the basic drug system, follow the clinic needed, safe and effective, the price is reasonable, appropriate technology, funds can withstand the principle of the existing urban residents medical insurance and new farming directory, on the basis of proper consideration ginseng protect personnel to adjust the demand change, have increase, reduce, charged with expanding, do kinds basic is complete, the overall structure is reasonable. Perfect the measures for the management of medical insurance directory, execute classification management, dynamic adjustment.

(5) designated management.

Unified urban and rural residents health orgnaization management measures, strengthening the management of fixed-point service agreement and establish a sound evaluation mechanism and dynamic access exit mechanism. For the public medical institutions and public medical institution has the same designated management policy. In principle, by as a whole the area management agencies responsible for orgnaization of access, exit, and supervision, the provincial management agencies responsible for formulating principles and measures for the management of orgnaization of access to, and the key to strengthen as a whole the area outside the medical establishment that decide a dot on the provincial and municipal level of guidance and supervision.

(6) fund management.

Urban and rural residents health care the implementation of national unity fund financial system, accounting system and budget management system. Urban and rural residents medical insurance fund into the fiscal revenue, implement \"income and expenses two line management. Fund independent accounting, only door management, no unit or individual may occupy their misuse.

Combination of fund budget management comprehensively advancing pay total amount control. Fund use follow the surely with closing, the principle of balance of payments, somewhat balance, ensure the timely and full specified amount payment should be pay reasonable control fund balance when the balance rate and cumulative rate. Establish and improve the fund operation risk early warning mechanism, prevent fund risks and increase efficiency.

Strengthen their internal audit and external supervision, adhere to the fund income and expenditure operation information disclosure and ginseng protect personnel to go to a doctor and settlement information publicity system, strengthen the social supervision, democratic supervision, and supervision by public opinion.

Three, the straightening out management system

(a) orgnaization of agency of integration.

Encourage conditional area of health care management system, unified basic medical insurance administrative functions. Make full use of existing urban residents health care, new farming and orgnaization of resources, integration of urban and rural residents health insurance agency orgnaization, personnel and information system, regulating the handling process, to provide integrated service charge. Perfect the orgnaization of agency of internal and external supervision and restriction mechanism, strengthen the training and performance evaluation.

(2) the orgnaization of innovation management.

Perfect the management mechanism, improve the service means and management methods, optimize the handling process, improve the efficiency of management and service level. Encourage conditional orgnaization of regional innovation service pattern, promoting tube separated, introducing competition mechanism, on the premise of ensuring the safe and effective supervision of the funds, the way the government purchasing service with qualifications entrusted by the commercial insurance agency orgnaization of social forces to participate in the basic health care services such as, orgnaization of excitation energy.

Fourth, improve the service efficiency

(a) improve the overall level.

Urban and rural residents health care system in principle, (to) class as a whole, all around a unified treatment of policy, fund management, information systems and settlement and so on key, steadily push forward the city level (ground) as a whole. Do a good job in health care relationship transferring and long-distance medical billing services. According to the region as a whole the economic development of various counties (city, area) and medical service level, strengthen fund classification management, give full play to the government at the county level, management of orgnaization of agency of fund management motivation and initiative. Encourage conditional region implement provincial plan as a whole.

(2) perfect the information system.

Integration of existing information system, the support system of urban and rural residents health operation and function expansion. To promote urban and rural residents medical insurance information system and the designated agency information system, medical treatment information system of business collaboration and information sharing, do a good job in urban and rural residents medical insurance information system information system and participate in orgnaization of service of commercial insurance institutions necessary information exchange and data sharing. Strengthen the information security and privacy of patient information.

(3) improve the payment.

Advancing capitation payment system, according to macro-reforms, according to a bed, pay, total advance payment method combines a variety of composite payment reform, establishing and perfecting the orgnaization of agency of insurance and medical institutions and drug supplier negotiations consultation mechanism and risk sharing mechanism, promote to form a reasonable medical insurance payment standard, guide the medical establishment that decide a dot standard service behavior, control the medical expense unreasonable growth.

By supporting ginseng protect residents and grassroots medical institutions and general practitioners to carry out the contract services, differentiated payment policy measures, such as promoting the construction of the grading system, gradually formed first option at the grass-roots level, two-way referral, acute slow partition, the upper and lower linkage of new medical order.

(4) strengthen the supervision of medical services.

Improve the urban and rural residents health care service regulation, fully using the protocol management, strengthen the monitoring function of the medical service. Health agencies at all levels to take advantage of information technology means, to promote health intelligent audit and real-time monitoring, promote the reasonable treatment and rational drug use. The family planning administrative department of public health to strengthen the supervision of medical services and regulate the behavior of medical service.

Five, carefully organize the implementation, to ensure the conformity work smoothly

(a) to strengthen organization and leadership.

Integration of urban and rural residents health care system is deepening health reform a priority task, relationship between urban and rural residents' vital interests, wide range, strong policy. Across all departments concerned should, in accordance with the deepening reform of strategic layout, fully understand the significance of the work, strengthen the leadership, elaborate organization, to ensure smooth integration work. Provincial health reform leading group to strengthen overall coordination, timely study to solve the problems in the process of integration.

(2) clear work progress and division of responsibility.

The provinces (autonomous regions and municipalities) in 2016 by the end of June to the integration of urban and rural residents health care work plan and deployment, clear timetable and roadmap, perfect work to promote and evaluation mechanism, strictly implement the responsibility system, to ensure that various policy measures put in place. The region as a whole to a concrete implementation plan prior to the end of December 2016. Comprehensive reform pilot provinces to integration of urban and rural residents health care reform as the key content, strengthen overall coordination with other work reform, accelerate.

Around the human resources department of social security, health, family planning should perfect relevant policies and measures to strengthen the linkage between the before and after the integration of urban and rural residents health care system; Financial department to improve the system of fund accounting, in conjunction with relevant departments to do a good job of fund supervision; Insurance regulators should strengthen the participation of orgnaization of service of commercial insurance agency qualification review, service quality and regulation of market behavior; Development and reform department of urban and rural residents to health care system integrated into the national economic and social development plan; Prepare the management departments to work in orgnaization of resource integration and management system of play a role; Reform office wants to coordinate relevant departments to do a good job of tracking evaluation, experience summary and promotion.

(3) to do a good job of publicity.

Must strengthen the positive propaganda and public opinion guidance, timely and accurate interpretation of the policy, propaganda experience around the window, appropriate response to public concern, a reasonable guide social expectations, efforts to create a good atmosphere of integration of urban and rural residents health care system.

The state council

On January 3, 2016