中英对照2021国务院办公厅关于建立健全职工基本医疗保险门诊共济保障机制的指导意见.docx

GuidingOpinionsoftheGeneralOfficeoftheStateCouncilonEstablishingandImprovingaGeneralSupportMechanismforCoveringOutpatientMedicalBillsundertheBasicMedicalInsuranceforUrbanEmployeesDocumentNumber：No.142021oftheGeneralOfficeoftheStateCouncilAreaofLaw:SocialWelfareandSocialSecurity1.evelofAuthority：RegulatoryDocumentsoftheStateCouncilIssuingAuthority：GeneralOfficeoftheStateCouncilDateIssued：04-13-2021EffectiveDate04-13-2021Status：EffectiveGuidingOpinionsoftheGeneralOfficeoftheStateCouncilonEstablishingandImprovingaGeneralSupportMechanismforCoveringOutpatientMedicalBillsundertheBasicMedicalInsuranceforUrbanEmployees(No.142021oftheGeneralOfficeoftheStateCouncil)Thepeople'sgovernmentsofallprovinces,autonomousregions,andmunicipalitiesdirectlyundertheCentralGovernment;allministriesandcommissionsoftheStateCouncil;andallinstitutionsdirectlyundertheStateCouncil:Forthepurposesoffurtherimprovingthesystemofbasicmedicalinsuranceforemployeesthatfeaturesmutualassistanceandsharedresponsibility(hereinafterreferredtoasthe“medicalinsuranceforemployees),bettersolvingtheproblemofoutpatientguaranteeforemployeeswhoarecoveredbymedicalinsurance,andeffectivelyreducingtheirmedicalexpensesburdens,accordinglotheaangemenlsof国务院办公厅关于建立健全职工基本医疗保险门诊共济保障机制的指导意见（国办发（2021）14号）各省、自治区、直辖市人民政府，国务院各部委、各直属机构：为进一步健全互助共济、责任共担的职工基本医疗保险（以下简称职工医保）制度，更好解决职工医保参保人员门诊保障问题，切实减轻其医疗费用负担，按照党中央、国务院关于深化医疗保障制度改革任务部署，经国务院同意，现就建立健全职工医保门诊共济保障机制提出如下意见。theCPCCentralCommitteeandtheStateCouncilfor一、总体要求（一）指导思想。以习近平新时代中国特色社会主 义思想为指导，全面贯彻党的十九大和十九届二中、三 中、四中、五中全会精神，既尽力而为、又量力而行，坚 持人人尽责、人人享有，完善制度、引导预期，加快医疗 保障重点领域和关键环节改革，将门诊费用纳入职工医保 统筹基金支付范围，改革职工医保个人账户，建立健全门 诊共济保障机制，提高医保基金使用效率，逐步减轻参保 人员医疗费用负担，实现制度更加公平更可持续。（二）基本原则。坚持保障基本，实行统筹共济, 切实维护参保人员权益。坚持平稳过渡，保持政策连续deepeningthereformofmedicalsecuritysystem,anduponapprovalbytheStateCouncil,thefollowingopinionsonestablishingandimprovingageneralsupportmechanismforcoveringoutpatientmedicalbillsunderthemedicalinsuranceforemployeesareherebyputforward.I.Generalrequirements1. Guidingideology.UndertheguidanceofXiJinpingThoughtonSocialismwithChineseCharacteristicsforaNewEra,theguidingprinciplesofthe19thCPCNationalCongressandthesecond,third,fourth,andfifthplenarysessionsofthe19thCPCCentralCommitteeshallbefullyimplemented.AlllocalgovernmentsanddepartmentsshalldowhateverliesintheirpowerandactaccordingtoIheircapabilitytoensurethateveryoneperformshisdutiesandsharesthebenefits.Systemsshallbeimprovedandexpectationsshallbeguided.Thereformofkeyareasandlinksofmedicalsecurityshallbeacceleratedtoreimburseoutpatientbillsthroughunifiedaccountsformedicalinsuranceforemployees.Individualaccountsformedicalinsuranceforemployeesshallbereformed,andageneralsupportmechanismforcoveringoutpatientmedicalbillsshallbeestablishedandimproved,soastoimprovetheefficiencyofthemedicalinsurancefund.Gradualstepsshallbetakentowardsreducingthemedicalexpensesburdensfortheemployeescoveredbythemedicalinsurancesoastomakethesystemfairerandmoresustainable.2. Basicprinciples.Thebasicmedicalneedsshallbemet,andoverallplanningandmutualassistanceshallbeimplemented,soastoeffectivelyprotecttherightsandinterestsoftheinsured.Asmoothtransitionshallbeensuredtomaintainpolicycontinuity.Thesmoothtransitionofbenefitsbeforeandafterthereformshallbeensured.Crdinationandinteractionshallbeadheredto.Themeasuresforimprovingtheoutpatientbillsguaranteemechanismandimprovingthepersonalaccountsystemshallbepromotedsimultaneouslyandtransformedonastep-by-stepbasis.Measuresshallbetailoredtolocalconditions.Onthebasisoftheoveralldesign,thelocalgovernmentshallbeencouragedtoactivelyexploreeffectivewaystoenhancetheoutpatientguaranteeformedicalinsuranceforemployees.11.Mtyormeasures3. Thegeneralsupportforcoveringoutpatientmedicalbillsshallbeenhanced.Amechanismfortheoverallplanningofcoveringgeneraloutpatientbillsunderthemedicalinsuranceforemployeesshallbeestablishedandimproved.Onthebasisofensuringthemedicalinsuranceforhypertension,diabetes,andotheroutpatientchronicdiseasesandspecialdiseases(hereinaftercollectivelyreferredtoasoutpatientchronicandspecialdiseases)forwhichIhegeneralpublicpatientsbearaheavyburden,gradualstepsshallbetakentowardsreimbursingthegeneraloutpatientbillsforfrequentlyoccurringandcommondiseasesthroughunifiedaccounts.Thepooledaccountforgeneraloutpatientbillsshallcoveralltheinsuredpeoplebythemedicalinsuranceforemployees,andtheproportionofpaymentexpensescoveredbyrelevantpoliciesshallstartfrom50%.Withtheincreasingaffordabilityofthemedicalinsurancefund,thecoverlevelshallbe性，确保改革前后待遇顺畅衔接。坚持协同联动，完善门诊保障机制和改进个人账户制度同步推进、逐步转换。坚持因地制宜，在整体设计基础上，鼓励地方从实际出发，积极探索增强职工医保门诊保障的有效途径。二、主要措施(三)增强门诊共济保障功能,建立完善职工医保普通门诊费用统筹保障机制，在做好高血压、糖尿病等群众负担较重的门诊慢性病、特殊疾病(以下统称门诊慢特病)医疗保障工作的基础上，逐步将多发病、常见病的普通门诊费用纳入统筹基金支付范围。普通门诊统筹覆盖职工医保全体参保人员，政策范围内支付比例从50%起步，随着医保基金承受能力增强逐步提高保障水平，待遇支付可适当向退休人员倾斜。针对门诊医疗服务特点，科学测算起付标准和最高支付限额，并做好与住院费用支付政策的衔接。同步完善城乡居民基本医疗保险门诊统筹，并逐步提高保障水平。graduallyimproved,andthepaymentofbenefitsmaybeappropriatelyweightedtowardsretirees.Accordingtothecharacteristicsofoutpatientmedi