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索  引  号: 011746318/2019-00905 主题分类: 卫生、计划生育、妇女儿童
发布机构: 巴彦淖尔市人民政府办公室 发文日期: 2019-08-19
标       题: 巴彦淖尔市人民政府办公室关于印发《2020年巴彦淖尔市城乡居民基本医疗保险工作方案》的通知
文       号: 巴政办发〔2019〕22号 主  题  词:
巴彦淖尔市人民政府办公室关于印发《2020年巴彦淖尔市城乡居民基本医疗保险工作方案》的通知
巴政办发〔2019〕22号
各旗县区人民政府,巴彦淖尔经济技术开发区管委会,市直各部门,驻市各单位:
  现将《2020年巴彦淖尔市城乡居民基本医疗保险工作方案》印发给你们,请结合实际抓好落实。
 
  巴彦淖尔市人民政府办公室
  2019年8月19日    
  
2020年巴彦淖尔市城乡居民
基本医疗保险工作方案
  为进一步加强城乡居民基本医疗保险基金管理,完善城乡居民医疗保险制度,提高基金使用效率,按照内蒙古自治区人民政府《关于建立统一的城乡居民基本医疗保险制度的实施意见》(内政发〔2016〕122号)、国家医疗保障局《关于做好2019年基本医疗保险参保和征缴工作的通知》(医保函〔2019〕12号)和自治区医保局 财政厅《关于做好2019年城乡居民基本医疗保障工作的通知》(内医保发〔2019〕6号)文件要求,结合我市实际,制定本方案。
  一、目标任务
  以旗县区为单位,城乡居民基本医疗保险参保人数、基金征缴收入与2019年相比不降低,参保率稳定在95%以上。
  二、基本原则
 ?。ㄒ唬┘岢忠允斩ㄖ?、收支平衡、略有结余的原则;
 ?。ǘ┘岢止愀哺?、?;?、多层次、可持续的原则;
 ?。ㄈ┘岢殖镒始氨U纤接肷缁峋梅⒄顾较嗍视Φ脑?;
 ?。ㄋ模┘岢指鋈私煞延胝怪嘟岷系脑?;
 ?。ㄎ澹┘岢质屑锻吵?、分级核算、风险共担的原则。
  三、筹资标准
  2020年我市城乡居民基本医疗保险个人缴费300元/人,在国家要求的财政补助标准基础上,市、旗县区两级财政额外补助城乡居民基本医疗保险基金50元/人,按照市、旗县区2:8的比例进行分担,列入同级财政预算,任何单位和个人不得从其中提取其他保险费。建档立卡贫困人口、低保、特困人口、残疾人等人员个人缴费由当地政府按照相关标准给予补贴。
  四、参保时间
  城乡居民基本医疗保险实行年预缴费制度,2020年参保时间为2019年9月1日—2020年2月28日。各旗县区于2019年12月25日前完成城乡居民集中参保、缴费、登记、信息录入工作,特殊情况未能在规定时间内登记缴费参保的,可延长至2020年2月28日。2020年3月1日,全市城乡居民参保信息录入截止,参保系统关闭,在此期间未缴费登记的居民,视为放弃2020年参保资格。各旗县区财政局在参保结束后15个工作日内将个人缴费部分上划到市财政医?;鹱ɑ?。各旗县区财政补助资金于2019年4月15日前一次性缴入到市财政医保专户。
  五、参保方式
  按照自治区政府关于社会保险费职责划转工作部署的要求,各旗县区政府负责组织落实城乡居民参保筹资整体工作,城乡居民医疗保险费征缴工作由税务机关按职责办理,税务机关应采取“政府统一组织、多方协作配合、集中征收或委托村(社区)学校等集中代收”方式,为缴费人提供更为便利的多元化缴费渠道,并负责参保筹资的宣传、登记、征缴、基金的上划等工作,务必在3月1日系统关闭前,按时完成城乡居民的系统参保、登记工作,以保证2020年城乡居民医保正常报销,因旗县区原因导致无法参保、报销的由各旗县区自行负责。
  六、参保对象
  覆盖城镇职工基本医疗保险范围以外的城乡居民,包括农村牧区居民、城镇非从业居民、各类全日制学校在校学生、学龄前儿童、国家和自治区规定的其他人员,应参加巴彦淖尔市城乡居民基本医疗保险。
  建立巴彦淖尔市内异地就医参保制度,取得巴彦淖尔市居住证的非本市户籍城乡居民,可自愿选择户籍所在地或居住地参保,享受与居住地参保人员相同的医疗保险待遇。参保地财政应比照本地参保人员给予补助。参保人员不得同时参加城乡居民基本医疗保险和职工基本医疗保险,不得重复享受医疗保险待遇。
  七、补偿政策
  全市执行统一的门诊统筹(含门诊慢性病、门诊小手术)+住院统筹(含特殊疾?。?大病商业补充保险的补偿政策。
 ?。ㄒ唬┟耪锊钩フ?/div>
  1.普通门诊补偿。参保人在苏木乡镇卫生院、社区卫生服务中心和嘎查村卫生室门诊就诊的门诊费用按照50%的比例进行报销,起付线为50元,年度封顶线200元/人。门诊使用蒙中医药报销比例提高15个百分点,建档立卡贫困人口报销比例提高10个百分点。
  2.门诊慢性病补偿政策。特殊慢性病患者按照《巴彦淖尔市城乡居民慢性病管理办法》规定予以补偿。签约管理的慢性病贫困人口医药费用城乡居民基本医保政策范围内报销比例达到70%以上。
  3.门诊小手术补偿政策。参保人员门诊小型手术费用,起付线300元,报销比例70%,封顶1200元。
 ?。ǘ┳≡翰钩フ?。
  1.起付线、补偿比例、封顶线。

所在地

就诊医疗机构

起付线(元)

报销比例(%

封顶线

(万元)

市内苏木镇

一级医院

200

90

20

市内

二级医院

600

75

三级医院

1500

65

市外

市外医疗机构

2500

55

  2.新生儿、学龄前儿童、未成年人、在校学生住院起付线在上表的基础上降低50%,报销比例、封顶线同上表。
  3.贯彻落实内蒙古自治区人民政府《关于扶持和促进蒙医药中医药事业发展的决定》精神,参保人在市域内定点公立蒙医中医医疗机构就诊,较其他同级医疗机构报销起付线降低40%,各类医疗机构使用目录内中医药报销比例提高10%,使用蒙医药报销比例提高15%,以上各项累加补偿比例不得高于90%。
  4.参保特困供养人员、孤儿、残疾人(指伤残等级鉴定为一、二级)凭民政、残联等部门颁发证件,实行零起付线住院补偿。
  5.新生儿父母任意一方参加巴彦淖尔市内基本医疗保险并按规定缴费的,新生儿出生前在父母任意一方参保地办理参保登记手续,即视同新生儿参加城乡居民基本医疗保险,免缴当年参保费用,发生的医疗费用可通过登记地城乡居民基本医疗保险基金予以报销,次年以新生儿本人身份缴费参保。
  6.参保城乡居民生育医疗费用纳入城乡居民基本医疗保险支付范围,参保孕产妇正常分娩、难产、剖宫产产生的医疗费用按照正常住院比例报销,报销最高限额正常分娩2500元,难产3000元,剖宫产4300元。
  7.对符合居民大病商业补充保险理赔的患者在市内报销实行“一站式结算”,对符合医疗救助的参?;颊?,在县域内实现“一站式服务、一窗口办理、一单制结算”,经基本医保、大病保险、医疗救助等报销后,补偿金额不得超过医疗总费用。
  8.参保人同一年度内在市、旗县区的定点医疗机构第二次及二次以上住院的,住院起付线降低100元;医联体(医共体)内,上级医院将患者转向下级医院,下级医院取消住院起付线;年起付线累计达到5000元,不设起付线。
  9.目录内进口、合资医用材料纳入可报费用的报销比例为50%,国产报销比例为70%,实行限价管理,目录外的不予报销。
 ?。ㄈ┐蟛∩桃挡钩浔O照甙凑栈怪澳芨母锏髡墒幸搅票U暇指涸鹱橹凳?。
  八、下列医疗费用不纳入城乡居民基本医疗保险支付范围
 ?。ㄒ唬┯Φ庇晒参郎图粕裣钅扛旱?,因非病理原因终止妊娠的、保胎、不孕不育、试管婴儿以及不符合国家计划生育政策的医疗费用;
 ?。ǘ┯Φ贝庸ど吮O栈鹬兄Ц兜?;
 ?。ㄈ┯Φ庇傻谌烁旱5?;
 ?。ㄋ模└髦址枪δ苄陨砣毕葜瘟迫缰仨?、屈光不正等、非治疗性美容、整容、矫形手术、各种健康体检、养生项目、镶牙、种植牙、洁牙、牙列不整矫治、黄黑牙、牙缺损、色斑牙、烤瓷牙等诊疗项目所发生的;
 ?。ㄎ澹┮蚍缸?、酗酒(含酒驾)、吸毒、自杀、自残、斗殴、医疗事故等造成的;
 ?。┚惩饩鸵降?;
 ?。ㄆ撸┮搅谱裳?、医疗鉴定、非疾病理疗住院、不遵医嘱拒不出院以及挂床住院等发生的费用;
 ?。ò耍┕液妥灾吻喙胤煞ü?、规章及政策性文件规定不予报销的其他情形。
  本方案从2020年1月1日起执行。
 
  巴彦淖尔市人民政府办公室文电科     2019年8月19日印发 
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