欧洲杯竞猜

《九江市人民政府办公室转发市医保局等部门关于九江市医疗保险基金市级统收统支工作实施方案的通知》的政策解读

发布时间:2019-10-30 16:34 来源:本网字体: [ ]

  • 信息类别:
  • 文件编号:
  • 规范性文件有效性: 有效
  • 公开方式: 主动公开
  • 生成日期: 2019-10-30
  • 公开时限: 常年(nian)公开(kai)
  • 公开范围: 面向全社会
  • 信息索取号: 000014349/
  • 责任部门: 纳子公(gong)司(si)

一、制(zhi)定政(zheng)策的背(bei)景和依据

逐步提高(gao)基(ji)(ji)金统(tong)(tong)(tong)(tong)(tong)(tong)(tong)筹层次是医(yi)保(bao)(bao)事业高(gao)质量(liang)发展(zhan)的必(bi)然要求,为推(tui)进(jin)全省各设区市(shi)做实(shi)(shi)市(shi)级统(tong)(tong)(tong)(tong)(tong)(tong)(tong)筹,为今(jin)后实(shi)(shi)现省级统(tong)(tong)(tong)(tong)(tong)(tong)(tong)筹奠定(ding)基(ji)(ji)础,2020年5月(yue)省政(zheng)府(fu)办公(gong)厅(ting)印发了《江(jiang)西省人民(min)(min)政(zheng)府(fu)办公(gong)厅(ting)转发省医(yi)保(bao)(bao)局等部门(men)关于推(tui)进(jin)医(yi)疗保(bao)(bao)险(xian)基(ji)(ji)金市(shi)级统(tong)(tong)(tong)(tong)(tong)(tong)(tong)收统(tong)(tong)(tong)(tong)(tong)(tong)(tong)支(zhi)工(gong)作意见的通知》(赣(gan)府(fu)厅(ting)字〔2020〕38号)文件,明确要求从2021年1月(yue)1日起,在全省设区市(shi)范围(wei)内(nei)实(shi)(shi)行城(cheng)镇职(zhi)工(gong)医(yi)保(bao)(bao)(包(bao)(bao)括基(ji)(ji)本医(yi)保(bao)(bao)和生育保(bao)(bao)险(xian)、大病保(bao)(bao)险(xian)、机关事业单位人员医(yi)疗补助,不包(bao)(bao)括离休干部医(yi)药(yao)费单独统(tong)(tong)(tong)(tong)(tong)(tong)(tong)筹)和城(cheng)乡居民(min)(min)医(yi)保(bao)(bao)(包(bao)(bao)括基(ji)(ji)本医(yi)保(bao)(bao)、大病保(bao)(bao)险(xian))基(ji)(ji)金市(shi)级统(tong)(tong)(tong)(tong)(tong)(tong)(tong)收统(tong)(tong)(tong)(tong)(tong)(tong)(tong)支(zhi),统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)核算,统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)管理,建立“六统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)”(覆盖范围(wei)统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)、筹资政(zheng)策(ce)统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)、待遇水平统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)、基(ji)(ji)金管理统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)、经办流程统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi)、信息系统(tong)(tong)(tong)(tong)(tong)(tong)(tong)统(tong)(tong)(tong)(tong)(tong)(tong)(tong)一(yi)(yi)(yi)(yi))的医(yi)保(bao)(bao)市(shi)级统(tong)(tong)(tong)(tong)(tong)(tong)(tong)筹制度(du)。

为此,我局(ju)(ju)会同市(shi)财政(zheng)(zheng)局(ju)(ju)、九江(jiang)(jiang)税务局(ju)(ju)、人行九江(jiang)(jiang)中心支行,根据(ju)《江(jiang)(jiang)西省(sheng)人民政(zheng)(zheng)府办公厅转发(fa)省(sheng)医保(bao)局(ju)(ju)等部门关于推进医疗保(bao)险基(ji)金市(shi)级(ji)统(tong)(tong)(tong)收(shou)统(tong)(tong)(tong)支工作意见(jian)的(de)通(tong)知》(赣府厅字(zi)〔2020〕38号)文(wen)件精神,在深(shen)入调研、听取意见(jian)、凝聚共识的(de)基(ji)础(chu)上(shang),结(jie)合九江(jiang)(jiang)实(shi)际,四部门联合起草了《九江(jiang)(jiang)市(shi)医疗保(bao)险基(ji)金市(shi)级(ji)统(tong)(tong)(tong)收(shou)统(tong)(tong)(tong)支工作实(shi)施(shi)方(fang)案》,报市(shi)政(zheng)(zheng)府同意后(hou)下发(fa)。

二(er)、制定(ding)文(wen)件的目标任务

围绕“一个目标”:从2021年1月(yue)1日起,全(quan)市实行城(cheng)镇职工医保(bao)(bao)(包(bao)(bao)括(kuo)基本医保(bao)(bao)和生育保(bao)(bao)险、大病保(bao)(bao)险、机关事业单位(wei)人员医疗补助,不包(bao)(bao)括(kuo)离休干部医药费(fei)单独统筹)、城(cheng)乡居民医保(bao)(bao)(包(bao)(bao)括(kuo)基本医保(bao)(bao)、大病保(bao)(bao)险)基金市级统收(shou)统支,统一核算,统一管理。

开展“四项(xiang)工(gong)作”:1. 基金(jin)(jin)结余(yu)划转。 由(you)审(shen)计部门牵(qian)头负(fu)责,对各(ge)县(xian)(市(shi)(shi)、区)的(de)职工(gong)医(yi)(yi)(yi)保(bao)基金(jin)(jin)、城(cheng)(cheng)(cheng)乡居民(min)(min)医(yi)(yi)(yi)保(bao)基金(jin)(jin)的(de)历年(nian)(nian)结余(yu)进行审(shen)计,经审(shen)计确认后在年(nian)(nian)底(di)前全部转入市(shi)(shi)级(ji)财政(zheng)(zheng)专户。2. 基金(jin)(jin)统收。从2021年(nian)(nian)1月(yue)1日(ri)起实(shi)施职工(gong)医(yi)(yi)(yi)保(bao)基金(jin)(jin)、城(cheng)(cheng)(cheng)乡居民(min)(min)医(yi)(yi)(yi)保(bao)基金(jin)(jin)统一征收。3. 基金(jin)(jin)统支。从2021年(nian)(nian)1月(yue)1日(ri)起实(shi)施职工(gong)医(yi)(yi)(yi)保(bao)基金(jin)(jin)、城(cheng)(cheng)(cheng)乡居民(min)(min)医(yi)(yi)(yi)保(bao)基金(jin)(jin)统一支付。4. 合(he)理(li)分担(dan)基金(jin)(jin)缺口。各(ge)级(ji)医(yi)(yi)(yi)保(bao)、财政(zheng)(zheng)部门要严格执行基金(jin)(jin)年(nian)(nian)度预算,对产生的(de)基金(jin)(jin)缺口建立市(shi)(shi)县(xian)分担(dan)机制。

三、关(guan)键词诠释

医疗(liao)(liao)保险基金(jin)(jin):医疗(liao)(liao)保险基金(jin)(jin)是指(zhi)国家(jia)为保障(zhang)职(zhi)(zhi)工和(he)城(cheng)乡(xiang)居(ju)民(min)的基本医疗(liao)(liao),由相关(guan)部(bu)门按国家(jia)有关(guan)规定通过财(cai)政补助(zhu)和(he)向(xiang)用(yong)人单位(wei)及其(qi)职(zhi)(zhi)工、城(cheng)乡(xiang)居(ju)民(min)个人筹集资金(jin)(jin),用(yong)于支付(fu)其(qi)医疗(liao)(liao)保险待遇的专(zhuan)项基金(jin)(jin)。

医疗保(bao)险市(shi)(shi)(shi)级(ji)(ji)统(tong)(tong)筹(chou):是指为(wei)解决设区(qu)市(shi)(shi)(shi)范(fan)围(wei)内基(ji)本(ben)医疗保(bao)险政策统(tong)(tong)一、待遇水平(ping)一致、管(guan)理(li)(li)规范(fan)以(yi)及(ji)提高(gao)基(ji)金(jin)抗风险能力(li)等问题,各设区(qu)市(shi)(shi)(shi)建立“六统(tong)(tong)一”即覆盖(gai)范(fan)围(wei)统(tong)(tong)一、筹(chou)资(zi)政策统(tong)(tong)一、待遇水平(ping)统(tong)(tong)一、基(ji)金(jin)管(guan)理(li)(li)统(tong)(tong)一、经(jing)办流程(cheng)统(tong)(tong)一、信息系统(tong)(tong)统(tong)(tong)一的医疗保(bao)险市(shi)(shi)(shi)级(ji)(ji)统(tong)(tong)筹(chou)制度。市(shi)(shi)(shi)级(ji)(ji)统(tong)(tong)筹(chou)可(ke)以(yi)选择(ze)实(shi)行基(ji)金(jin)统(tong)(tong)收统(tong)(tong)支或基(ji)金(jin)风险调剂(ji)金(jin)两种模式。

基(ji)(ji)金(jin)市级统(tong)(tong)收统(tong)(tong)支:是指医(yi)(yi)疗(liao)保(bao)(bao)(bao)险基(ji)(ji)金(jin)市级统(tong)(tong)筹管理的一种模式,医(yi)(yi)疗(liao)保(bao)(bao)(bao)险基(ji)(ji)金(jin)收入全部纳入设区(qu)(qu)市社保(bao)(bao)(bao)基(ji)(ji)金(jin)财政专(zhuan)户(hu),医(yi)(yi)疗(liao)保(bao)(bao)(bao)险基(ji)(ji)金(jin)支出全部由设区(qu)(qu)市统(tong)(tong)一拨(bo)付并进(jin)行相关财务收支核算。设区(qu)(qu)市不再提取风险调(diao)剂金(jin)。

四、市级统(tong)收统(tong)支制度(du)的(de)特点

市级(ji)医保基金统(tong)收统(tong)支(zhi)制(zhi)度由医疗保障、财政、税务、人民银行等相关部(bu)门各司其职(zhi),密切配合,统(tong)筹推进(jin),实施后将有以下五(wu)个(ge)方面变化:

(一(yi))市(shi)级统收(shou)统支实施后,县(市(shi)、区)不再设立医(yi)保基(ji)金财政(zheng)(zheng)专户,全市(shi)医(yi)保基(ji)金全部纳入市(shi)级财政(zheng)(zheng)专户统一(yi)管理(li),全市(shi)统筹使用。

(二)市级统(tong)收统(tong)支(zhi)实施后,全市各(ge)县(市、区)参保(bao)(bao)人员的(de)(de)参保(bao)(bao)缴费和(he)医保(bao)(bao)报销的(de)(de)执行(xing)政(zheng)策标准不再具有(you)差(cha)异性(xing),全市完全统(tong)一一致。

(三)市级统(tong)(tong)收统(tong)(tong)支实(shi)施(shi)后,全市定点医药机构的准(zhun)入评(ping)估各(ge)县(市、区)不再单独实(shi)施(shi),由(you)市级统(tong)(tong)一(yi)(yi)组(zu)织实(shi)施(shi),全市统(tong)(tong)一(yi)(yi)互认,全市统(tong)(tong)一(yi)(yi)监管,并统(tong)(tong)一(yi)(yi)实(shi)施(shi)违规处(chu)理(li)。

(四)市(shi)级统(tong)收统(tong)支实施后,医(yi)保(bao)基(ji)金(jin)支付不再以县(市(shi)、区(qu))为(wei)单(dan)(dan)位(wei)实行总(zong)额(e)控(kong)制(zhi)管理,提(ti)升至以市(shi)为(wei)单(dan)(dan)位(wei)总(zong)额(e)控(kong)制(zhi)管理。全市(shi)统(tong)一(yi)(yi)基(ji)金(jin)预算管理,统(tong)一(yi)(yi)推(tui)进按病种(DIP)分值付费(fei),统(tong)一(yi)(yi)与各级定点(dian)医(yi)药机构(gou)的结算办法。

(五)市(shi)级(ji)统收统支实施后,参保(bao)人员办(ban)理(li)医疗费用报销、异地(di)就(jiu)医备案(an)等,各县(市(shi)、区)医保(bao)经办(ban)机(ji)构的(de)办(ban)理(li)规程、流(liu)程和所需材料(liao)等全市(shi)统一一致。

综(zong)上(shang),推进落实医保基(ji)金(jin)统(tong)收统(tong)支工作,提(ti)(ti)升统(tong)筹层次,有利于提(ti)(ti)高使用效(xiao)率,提(ti)(ti)高抗(kang)风险(xian)能(neng)力,促进医保事业公平可持续发展。


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