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漳州调整和完善基本医疗保险政策有关规定

作者:huludao   文章来源:葫芦岛市人口与计划生育委员会   点击:    更新时间:2018-07-02 19:02:53     

▲市医院窗口,市民使用医保卡结账

 

  漳州市职工医保门诊特殊病种,由原来20种增加至35个病种;取消职工医保个人账户定点零售药店支付购买日限额……这些内容是导报记者昨日从漳州市政府下发的《关于调整和完善我市基本医疗保险政策有关问题的通知》中获悉的。

 

  职工门诊特殊病种从20种增加至35个病种 

 

  调整增加职工门诊特殊病种数量,实现与城乡居民门诊特殊病种相一致。将漳州市职工医保门诊特殊病种,由原来20种调整增加至与城乡居民医保门诊特殊病种26大病类(35个病种)相一致。

  职工医保门诊特殊病种起付线按医院等级设定,具体为:三级医院800元,二级医院600元,一级医院300元。公立一级医疗机构(含延伸医保终端公益性村卫生所)普通门诊统筹报销,单次报销及年度内累计总额含普通门诊诊查费用,基本医疗保险普通门诊统一按70%给予报销。

 

  在厦、泉、龙就医可以持卡即时结报 

 

  职工医保、城乡居民医保参保门诊特殊病种患者根据实际情况,可自行选择两家定点医疗机构(机构等级不限)就诊特殊病种。年度内按所选的最高级别医院计算起付标准。

  根据相关约定,漳州市参保人员赴厦门、泉州、龙岩定点医疗机构就医的,执行免予备案登记管理制度,持卡即时结报。到其他统筹区医保定点医疗机构就诊的,按照有关文件要求,执行登记备案管理等相关规定。

  医保缴满12个月 生育医疗费纳入医保支出

  职工医保的参保人员连续参保缴费时间满12个月及以上的,本人生育医疗费用纳入基本医疗保险支出(首次参加职工医保,连续参保缴费不满12个月的,统筹基金支付比例为50%);本人未参加职工基本医疗保险,但符合生育保险费用报销政策规定的,按原生育保险政策规定执行。

 

  个人账户药店买药取消日限额规定 

 

  鼓励个人账户资金余额超过5000元的参保人员,按照个人自愿原则,在预留5000元后剩余部分可用于参保人员本人和直系亲属购买与基本医疗保险相衔接的、不具有理财投资性质的、经由中国保监会核准的商业补充健康保险。使用医保个人账户资金购买商业补充健康保险要求退保的,所用个人账户资金应当退回个人账户。

  值得一提的是,个人账户在定点零售药店支付购买药品(准字号药品、中药饮片)、医疗器械(食药监械字、药监械字)和消毒用品(卫消字)费用,不设日限额规定。

 

  自杀、酗酒等情形不纳入医保支付范围 

 

  自杀、自残、酗酒、打架斗殴、吸毒、戒毒、违法犯罪行为等人为因素所致疾病的医疗费用,这些情形不纳入城乡居民医疗保险统筹基金支付范围。其他未调整内容,仍按有关文件等规定执行。

  本通知中,门诊特殊病种按医院等级及重性精神病、结核病起付线设定的条款从2019年1月1日起执行,其他条款自2018年9月1日起执行。

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