Release date: 2016-09-01
The reporter learned from the website of the Shanghai Municipal Human Resources and Social Security Bureau yesterday that eight departments including the Municipal Human Resources and Social Security Bureau and the Civil Affairs Bureau recently issued a notice to carry out pilot work on the medical care plan for the elderly. The pilot needs to meet the requirements of the city's household registration, 70 years of age and above, and assessed to meet certain nursing needs. The medical care provider charges 65 yuan / time, the practicing nurse 80 yuan / time, 90% of the employee basic medical insurance pool fund.
Assessment costs are paid by the individual
The cost of medical care needs assessment for the elderly is tentatively set at 50 yuan/time, which is borne by the individual. In the pilot phase, the assessment cost is temporarily included in the annual departmental budget by the assessment department, and is financed by the same level of finance.
Heavy weekly door-to-door service 7 times
Approved by the administrative department of health and family planning, the primary care and health institutions such as nursing stations, community health service centers, nursing homes, and outpatient departments that have obtained the “Medical License for Medical Institutions†can be administered to the Health and Family Planning Administration under the overall management of the community health service center platform. The department applies for the service method of home medical care service, and provides home medical care services for eligible elderly people in the districts and counties where the practice address is located.
â—Service time and frequency
Each visit service time is 1 hour, through the elderly medical care needs level assessment or the elderly care uniform needs assessment, mild or care level 2 weekly door-to-door service 3 times, moderate or care for the third and fourth-level elderly weekly door-to-door service 5 Second, severe or care for the fifth and sixth grade elderly people to serve 7 times a week.
â—Medical care service content
Includes basic care, common clinical care, and appropriate care instructions. For eligible elderly people, the primary health care institutions determine the specific service content according to the service time and frequency of the nursing needs level and the actual nursing needs of the elderly.
The medical institutions set up by the old-age care institutions can provide home-based medical care services for the elderly who have been assessed to meet the requirements of the medical care plan for the elderly, and encourage the elderly care institutions that do not have medical institutions to be set up, according to the actual situation. Establish a cooperative relationship with the primary health care institutions in the jurisdiction to provide home medical care services for eligible elderly people who have been assessed to meet the requirements.
Medical insurance pooling fund pays 90%
The home medical care service program is set up. The home medical care service (medical caregiver) charges 65 yuan / time, and the home medical care service (practicing nurse) charges 80 yuan / time. The home medical care service extends to the old-age care institution, and the fee items and standards are separately formulated.
The expenses incurred by the home medical care service shall be paid 90% by the employee basic medical insurance pooling fund, and the rest shall be paid by the personal medical account balance fund, and the insufficient part shall be borne by the individual. The expenses paid by the medical insurance fund shall be settled by the medical insurance department in accordance with the relevant provisions of medical insurance and the designated primary medical and health institutions. For individuals who meet the conditions for civil medical assistance, the individual is responsible for the expenses, and the district government where the individual resides is given a 50% subsidy.
The "Opinions on the Pilot Work of the Medical Care Plan for the Elderly in the City" will be implemented from July 1 this year and will be valid until June 30, 2018. Details can be found on the website of the Municipal Human Resources and Social Security Bureau (http://).
Attached to the General Office of the Shanghai Municipal People's Government to forward the opinions of the eight departments of the Municipal Human Resources and Social Security Bureau on the pilot work of the city's medical care plan for the elderly
Shanghai Office [2016] No. 67
The relevant district committees, county people's governments, municipal government committees, offices, and bureaus:
Municipal Human Resources and Social Security Bureau, Municipal Medical Insurance Office, Municipal Development and Reform Commission, Municipal Price Bureau, Municipal Health and Family Planning Commission, Municipal Finance Bureau, Civil Affairs Bureau, Shanghai Insurance Regulatory Bureau, on the pilot work of the city's medical care plan for the elderly The Opinion has been agreed by the municipal government and is now forwarded to you. Please follow the implementation carefully.
Shanghai Municipal People's Government Office
August 14, 2016
Opinions on the pilot work of the city's medical care plan for the elderly
In order to actively respond to the aging of the city's population, we will continue to improve the social security system that is in harmony with economic and social development, ensure that elderly people receive basic elderly medical care services, and promote the development of medical care services for the elderly. According to the requirements of the municipal government, the city is now The following work was carried out on the pilot work of the medical care plan for the elderly:
First, the main tasks of the pilot
In accordance with the principle of “government-led, social participation, home-based, and old-age care institutions supplementedâ€, the existing elderly medical care service resources will be fully utilized and integrated, and the basic medical insurance system will be used to assess the needs of elderly urban elderly in this city. For certain levels of care needs, basic primary care services will be provided by primary health care institutions, and medical insurance will be used to pay for home care.
In the pilot phase, starting from the senior citizens living in the city's basic medical insurance for the employees of the city, the districts can gradually expand the scope of the pilot towns and towns in accordance with the actual conditions, so that eligible eligible elderly people should be guaranteed.
Second, the object and scope of the pilot
In the pilot phase, senior citizens who meet the following conditions can apply for home care services:
(1) Having basic household registration, age 70 and above, and participating in basic medical insurance for employees of this Municipality;
(2) After the evaluation reaches a certain level of nursing needs, the pilot stage is tentatively determined to be an elderly person who has been assessed to have a mild, moderate or severe level of care needs;
(3) Living at home and living in the area of ​​the administrative division of the pilot town. The scope of pilot towns and towns shall be determined by each district according to actual conditions.
Third, the assessment of the needs of elderly medical care
(1) The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) and the Municipal Health and Family Planning Commission shall, in accordance with the principle of “scientific, rational, and operabilityâ€, formulate assessment criteria for medical care needs for the elderly, and comprehensively evaluate the disease and health status of the elderly. , self-care ability, etc.
(2) The municipal, district/county medical insurance department shall be responsible for the handling and registration of the elderly medical care needs assessment. Medical institutions with professional technical ability and corresponding qualifications are organized by the health and family planning department and the human resources and social security department to evaluate the elderly who apply for home medical care services.
(3) Personnel carrying out the assessment of the needs of medical care for the elderly shall have medical or nursing related qualifications and work experience, and after passing the training of the health and family planning department and the human resources and social security department, the assessment shall be qualified. The management methods for assessing the professional qualifications and training assessments shall be separately prescribed by the Municipal Human Resources and Social Security Bureau. The evaluation and training expenses of the evaluators shall be temporarily included in the annual departmental budget by the training and assessment department, and shall be borne by the financial department at the same level.
(4) The cost standard for elderly medical care needs assessment is tentatively set at 50 yuan/time, which is borne by the individual. In the pilot phase, the assessment cost is temporarily included in the annual departmental budget by the assessment department, and is financed by the same level of finance.
(5) Those participating in the pilot towns and towns have not carried out the pilot project for the unified needs assessment of the elderly care in this city. The assessment of the elderly medical care needs is still carried out in accordance with the provisions of this opinion and relevant documents; if the pilot of the unified needs assessment for the elderly care in this city has been carried out, The assessment is carried out in accordance with the relevant documentation requirements of the Uniform Needs Assessment and the corresponding assessment levels are determined.
Fourth, the provision of elderly medical care services
(1) The grassroots medical and health institutions such as nursing stations, community health service centers, nursing homes, and outpatient departments that have obtained the approval of the Health Care and Family Planning Administration are under the overall management of the community health service center platform. The health and family planning administrative department applies for the service mode of home medical care service, and provides home medical care services for eligible elderly people in the districts and counties where the practice address is located. Grassroots medical and health institutions such as social care stations, outpatient departments, and nursing homes shall sign labor contracts with qualified elderly medical care service personnel according to law.
(2) The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) and the Municipal Health and Family Planning Commission shall be based on the employees' basic medical insurance fund (hereinafter referred to as the “medical insurance fundâ€), the actual nursing needs of the elderly, and the service capacity of the elderly medical care institutions. According to the mild, moderate and severe levels of different nursing needs, determine the time and frequency of home medical care services paid by the medical insurance fund.
The service time and frequency of the pilot phase are: 1 hour for each door-to-door service, assessed by the elderly medical care needs level or the unified needs assessment for the elderly care, mild or care level 2 weekly door-to-door service 3 times, moderate or care 3 The fourth-grade elderly person visits the service five times a week, and the elderly or the seniors of the fifth and sixth grades come to the door seven times a week.
(3) The contents of home medical care services, including basic care, common clinical care and corresponding nursing guidance. For eligible elderly people, the primary health care institutions determine the specific service content according to the service time and frequency of the nursing needs level and the actual nursing needs of the elderly.
(4) The elderly medical care service personnel shall have relevant professional (professional) qualifications and work experience in nursing, etc., which shall be separately stipulated by the Municipal Human Resources and Social Security Bureau in conjunction with the Municipal Health and Family Planning Commission. The cost of vocational training for service personnel shall be implemented in accordance with the relevant provisions of the municipal vocational training subsidy.
(5) Grassroots medical and health institutions shall participate in third-party liability insurance to prevent medical accidents and personal or property risks caused by the elderly in the process of medical care for the elderly. In the pilot phase, the insurance premiums will be subsidized by the district and county governments where the grassroots medical and health institutions are registered.
(6) Incorporate primary health care institutions into the management of designated medical institutions for basic medical insurance in this Municipality. The Municipal Medical Insurance Department signed a service agreement with the primary medical and health institutions, stipulating that the rights and obligations and responsibilities of both parties in the process of medical care for the elderly shall be observed by both parties.
(7) The community health service center shall include the nursing information of the elderly who enjoy the home medical care service in the area into the health file for management. The community health service center arranges the family doctors to which they belong, or the primary health care institutions such as nursing homes and outpatient departments arrange their own practicing doctors to conduct on-the-spot visits and issue medical care related to home medical care services according to the needs of the elderly. . The expenses related to on-site visits are included in the medical insurance settlement with reference to the relevant provisions of the family bed.
(8) The medical institutions set up by the old-age care institutions can provide home-based medical care services for the elderly who have been assessed to meet the requirements of the medical care plan for the elderly, and encourage the elderly care institutions that do not have medical institutions. According to the actual situation, establish a cooperative relationship with the primary health care institutions in the jurisdiction to provide home medical care services for the elderly who have been assessed to meet the requirements. Relevant matters are stipulated separately.
V. Payment and settlement of home medical care expenses
(1) Set up a home medical care service project. The home medical care service (medical caregiver) charges 65 yuan / time, and the home medical care service (practicing nurse) charges 80 yuan / time. The home medical care service extends to the old-age care institution, and the fee items and standards are separately formulated. In accordance with relevant state regulations, the home medical care service project will be included in the scope of basic medical insurance payment. The price department will work with health and family planning, medical insurance and other departments to comprehensively consider factors such as social and economic development, labor costs and price changes, and make regular adjustments to the cost standards.
(2) The expenses incurred by the home medical care service shall be paid 90% by the employee basic medical insurance pooling fund, and the rest shall be paid by the personal medical account balance fund, and the insufficient part shall be borne by the individual. The expenses paid by the medical insurance fund shall be settled by the medical insurance department in accordance with the relevant provisions of medical insurance and the designated primary medical and health institutions. For individuals who meet the conditions for civil medical assistance, the individual's own expenses shall be subsidized by 50% of the district/county government where the individual resides.
6. Supervision and management of medical care for the elderly
If the primary medical and health institutions conduct unauthorised medical care at home or if there is any violation of the "Regulations on the Administration of Medical Institutions" in the provision of services, the administrative department of health and family planning shall, in accordance with relevant regulations, deal with them according to law.
The grassroots medical and health institutions and individuals violate the provisions of this pilot and related supporting documents, or violate the relevant provisions of the service agreement, resulting in the loss of the medical insurance fund or the infringement of the rights and interests of the insured persons. The Municipal Human Resources and Social Security Bureau (the Municipal Medical Insurance Office) is in accordance with medical insurance. Prescribed processing.
Seven, the pilot work requirements
All relevant departments should, under the unified leadership of the municipal party committee and the municipal government, do a good job in pilot work according to their respective responsibilities, strengthen policy linkages, speed up research and development of relevant measures, and rationally allocate various types of medical care services for the elderly to enable the elderly to obtain the body. A care service with appropriate conditions to reduce the burden of care for the elderly.
(1) The Human Resources and Social Security (Medical Insurance) Department is responsible for the pilot management of the medical care plan for the elderly in this city. It is necessary to formulate relevant support for the elderly medical care needs assessment, service, fee payment and settlement, etc. Documents, improve the management of related services, and strengthen the supervision of the use of medical insurance funds.
(2) The health and family planning department should strengthen the management of the elderly medical care service, and actively cooperate with the human resources and social security (medical insurance) department to actively study the connection between the elderly medical care service and the community health service function, the family doctor system, and the family bed service. The construction of the personnel of the evaluation agencies and service organizations, and the vocational training of relevant personnel. It is necessary to strengthen the construction of community health services and the elderly medical care service system, formulate service resource allocation plans and related service standards and standards for grassroots medical and health institutions, beds, establish standards for admission and admission of geriatric nursing homes, and support social forces to organize various types of aged care services. .
(3) The development and reform (price) departments should strengthen the coordination and implementation of the pilot and the related medical service price management, and comprehensively promote the construction of the elderly medical care service system.
(4) The financial department shall, in accordance with the financial subsidy policy, provide corresponding funding guarantees for the pilot work, and give policy implications for the investment in elderly medical care services. The municipal, district and county finances shall support the management and operation funds required for the pilot medical care plan for the elderly, and arrange special funds for the relevant competent departments.
(5) The civil affairs department should work with the human resources and social security (medical insurance) departments to actively study the policy linkage between the community home care service and the elderly home care service, and further improve the home care service.
(6) The insurance supervision department shall strengthen the supervision and management of the provision of third-party liability insurance services by insurance institutions.
(7) The pilot district and county governments shall give active support to the pilot work in terms of organization and implementation, funding and staffing.
This opinion has been implemented since July 1, 2016 and is valid until June 30, 2018.
Shanghai Human Resources and Social Security Bureau
Shanghai Medical Insurance Office
Shanghai Development and Reform Commission
Shanghai Municipal Price Bureau
Shanghai Health and Family Planning Commission
Shanghai Finance Bureau
Shanghai Civil Affairs Bureau
China Insurance Regulatory Commission Shanghai Regulatory Authority
July 20, 2016
Source: Xinmin Evening News Shanghai People's Bureau
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