Opinions of the Ministry of Human Resources and Social Security and the Ministry of Finance on Settlement Services of Basic Medical Insurance for Non-local Medical Treatment

人力资源和社会保障部、财政部关于基本医疗保险异地就医结算服务工作的意见

Promulgating Institution:Ministry of Human Resources and Social Security; Ministry of Finance

Document Number:Ren She Bu Fa [2009] No. 190

Promulgating Date:12/31/2009

Effective Date:12/31/2009

颁布机关:人力资源和社会保障部; 财政部

文      号:人社部发[2009]190号

颁布时间:12/31/2009

实施时间:12/31/2009

To the Ddepartments (bureaus) of human resources and social security (labour social security), and finance departments (bureaus) of all provinces, autonomous regions and municipalities directly under the Central Government, and the Bureau of Labor Social Security and the Finance Bureau of the Xinjiang Production and Construction Corps, 

With a view to implementing the spirits of the Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical and Health Care System (Zhong Fa [2009] No. 6) and the Notice of the State Council on Printing and Distributing Recent Key Implementation Plans of the Reform of the Medical and Health Care System (Year 2009-2011) (Guo Fa [2009] No. 12), and earnestly strengthening and improving settlement services of basic medical insurance for non-local medical treatment whose focus is on relocated retirees (hereinafter referred to as the Non-local Medical Treatment), the following opinions are hereby put forward:

    各省、自治区、直辖市人力资源社会保障(劳动保障)厅(局)、财政厅(局),新疆生产建设兵团劳动保障局、财务局:

    为贯彻落实《中共中央国务院关于深化医药卫生体制改革的意见》(中发[2009]6号)、《国务院关于印发医药卫生体制改革近期重点实施方案(2009-2011年)的通知》(国发[2009]12号)精神,切实加强和改进以异地安置退休人员为重点的基本医疗保险异地就医(以下简称异地就医)结算服务,现提出以下意见:

1. The basic principles and guiding thoughts of strengthening and improving settlement services for Non-local Medical Treatment are people-oriented, highlighting the focus, step by step implementation and taking various measures simultaneously. With relocated retirees as the focus, improve the level and efficiency of settlement services for Non-local Medical Treatment at the place of insurance participation, enhance medical service monitoring at the place of medical treatment, and vigorously promote regional coordination and the establishment of non-local coordination mechanisms to facilitate the settlement of medical expenses for medical insurance participants who have to undergo Non-local Medical Treatment, reduce reimbursable medical expenses paid thereby, and progressively realize the on-the-spot medical treatment and settlement by card of insurance participants. 

       一、加强和改进异地就医结算服务的基本原则和指导思想是,以人为本、突出重点、循序渐进、多措并举,以异地安置退休人员为重点,提高参保地的异地就医结算服务水平和效率,加强就医地的医疗服务监控,大力推进区域统筹和建立异地协作机制,方便必需异地就医参保人员的医疗费用结算,减少个人垫付医疗费,并逐步实现参保人员就地就医、持卡结算。

2. Raise the coordination level in accordance with the requirements on recent key implementation plans of the reform of the medical and health care system of the State Council, implement coordination at the city (prefecture) level in regions where conditions permit, unify policies, standards and administration and settlement methods of basic medical insurance within the same coordination region and implement unified settlement to reduce the settlement of Non-local Medical Treatment.

       二、按国务院医改近期重点实施方案的要求提高统筹层次,有条件的地区实行市(地)级统筹,在同一统筹地区范围内统一基本医疗保险的政策、标准和管理、结算方式,实行统一结算,减少异地就医结算。

3. Medical expenses incurred by an insurance participant due to emergency diagnosis and treatment of diseases suffered in places other than the place of insurance participation during short-term business trip, study and training, or vacation, etc. shall generally be reimbursed by the place of insurance participation in accordance with the provisions thereof. 

       三、参保人员短期出差、学习培训或度假等期间,在异地发生疾病并就地紧急诊治发生的医疗费用,一般由参保地按参保地规定报销。

4. Where an insurance participant needs to transfer treatment to another place due to limited local medical conditions, medical expenses shall be settled in accordance with relevant provisions of the place of insurance participation. The place of insurance participation shall be responsible for the verification and reimbursement of medical expenses. Regions where conditions permit may, through inter-regional consultation, enter into agreements to entrust the place of medical treatment with the verification.

       四、参保人员因当地医疗条件所限需异地转诊的,医疗费用结算按照参保地有关规定执行。参保地负责审核、报销医疗费用。有条件的地区可经地区间协商,订立协议,委托就医地审核。

5. Where retirees who have been residing in places other than the places of insurance participation for a long time undergo medical treatment at the places of residence, or where permanent non-local staff undergo medical treatment at the places of employment, in principle, policies of the places of insurance participation shall be implemented. Handling agencies in the places of insurance participation may improve services and provide convenience for insurance participants by such means as reimbursement by mail, setting up agency outlets in regions with a higher concentration of insurance participants, entrusting handling agencies of basic medical insurance at the places of medical treatment (hereinafter referred to as the Handling Agency) with administration over reimbursement, etc.

       五、异地长期居住的退休人员在居住地就医,常驻异地工作的人员在工作地就医,原则上执行参保地政策。参保地经办机构可采用邮寄报销、在参保人员较集中的地区设立代办点、委托就医地基本医疗保险经办机构(以下简称经办机构)代管报销等方式,改进服务,方便参保人员。

6. Accelerate the construction of the basic medical insurance information system, and encourage regions where conditions permit to share information and materials between cities or regions and to carry out internet-linked settlement. All regions may actively explore the use of a variety of resources for social services to participate in settlement services for Non-local Medical Treatment.

       六、加快基本医疗保险信息系统建设,鼓励有条件的地区实行城市间或区域间的信息、资源共享和联网结算。各地可积极探索利用各种社会服务资源参与异地就医结算服务。

7. With regard to insured retirees who have supported the construction of border areas and other places by the organization and mobilization of the State and who have handled retirement formalities in accordance with relevant State provisions and are relocated pursuant to administrative regulations of household registration, measures that are connected with the local medical insurance system shall be explored. Specific measures shall be determined through consultation by and between the place of insurance participation and the place of relocation, and be steadily implemented.

       七、对经国家组织动员支援边疆等地建设,按国家有关规定办理退休手续后,已按户籍管理规定异地安置的参保退休人员,要探索与当地医疗保障体系相衔接的办法。具体办法由参保地与安置地协商确定、稳妥实施。

8. Handling Agencies in coordinating regions shall conscientiously fulfil the responsibilities of the administration over medical treatment of local insurance participants and the verification and settlement of medical expenses, while at the same time provide appropriate services for non-local insurance participants who undergo local medical treatment and other Handling Agencies, and monitor medical services. Handling Agencies at the city (prefecture) level in coordinating regions shall strengthen the guidance toward Handling Agencies at the county (district) level, and manage well the connection between and among the construction of medical insurance policies and information system, handling management, medical service administration and technical criteria to ensure the smooth implementation of settlement services for Non-local Medical Treatment. 

       八、统筹地区经办机构认真履行本地参保人员就医管理和医疗费用审核结算的职责,同时要为在本地就医的异地参保人员和其参保地经办机构提供相应服务,对医疗服务进行监控。市(地)级统筹地区经办机构要加强对县(区)级经办机构的指导,做好医疗保险政策、信息系统建设、经办管理、医疗服务管理和技术标准等方面的衔接,保证异地就医结算服务工作顺利开展。

9. Departments of human resources and social security and Handling Agencies at the provincial level shall, under the guidance of State policies, be responsible for the uniform organization, coordination, and implementation of settlement services for Non-local Medical Treatment of insurance participants within their respective province, and standardize the business process of settlement, funds transfer, and basic management for Non-local Medical Treatment, etc. Increase investment in the Jin Bao (Golden Insurance) project, strengthen the construction of the medical insurance information system, implement "one-card solution" of social security, and gradually expand the scope of networking to achieve settlement by card. Provinces with real needs and whose conditions permit (autonomous regions and municipalities directly under the Central Government) may establish settlement platforms for Non-local Medical Treatment. Departments of human resources and social security at the provincial level shall, pursuant to the requirements of these Opinions and in conjunction with finance departments, formulate implementation measures, and report the same to the Ministry of Human Resources and Social Security.

       九、省级人力资源社会保障等部门及经办机构在国家政策指导下,负责统一组织协调并实施省内参保人员异地就医结算服务工作,规范异地就医结算的业务流程、基金划转及基础管理等工作。加大金保工程建设投入,加强医疗保险信息系统建设,推行社会保障“一卡通”,逐步扩大联网范围,实现持卡结算。确有需要且有条件的省(自治区、直辖市)可建立异地就医结算平台。省级人力资源社会保障部门要根据本意见的要求,会同财政部门制定实施办法,并报人力资源社会保障部。

10. For regions that have established the coordination mechanism for Non-local Medical Treatment, relevant standards on collaborative service charges shall be determined by both parties in collaboration through consultation, and the required expenses shall be included in the fiscal budget at the same level. Collaborative programs and networking programs for settlement of Non-local Medical Treatment cross provinces (autonomous regions and municipalities directly under the Central Government) shall be reported to the Ministry of Human Resources and Social Security for record-filing purposes.

Ministry of Human Resources and Social Security 

Ministry of Finance 

December 31, 2009

       十、建立异地就医协作机制的地区，相关协作服务费标准由协作双方协商确定，所需经费列入同级财政预算。跨省（自治区、直辖市）异地就医结算协作方案及联网结算方案，报人力资源社会保障部备案。

    人力资源和社会保障部

    财政部

    二〇〇九年十二月三十一日