中英对照2021国务院办公厅关于健全重特大疾病医疗保险和救助制度的意见.docx

OpinionsoftheGeneralOfficeoftheStateCouncilontheImprovementoftheMedicalInsuranceandReliefSystemforSeriousandCriticalDiseasesDocumentNumber：No.422021of(heGeneralOfficeoftheSlateCouncilAreaofLaw:PovertyAlleviation,DisasterRelief,andRemediesHealthCarereform of the medical security system and improving the social1.evelofAuthority：RegulatoryDocumentsoftheStateCouncilIssuingAuthority：GeneralOfficeoftheStateCouncilDateIssued：10-28-2021EffectiveDate10-28-2021Status：EffectiveOpinionsoftheGeneralOfficeoftheStateCouncilontheImprovementoftheMedicalInsuranceandReliefSystemforSeriousandCriticalDiseases(No.422021oftheGeneralOfficeoftheStateCouncil)Thepeople'sgovernmentsofallprovinces,autonomousregionsandmunicipalitiesdirectlyundertheCentralGovernment;andallministriesandcommissionsoftheStaleCouncil,andallinstitutionsdirectlyundertheStateCouncil:Medicalsecurityforseriousandcriticaldiseasesisameasureofvitalimportancetofurtherreducingtheburdenofmedicalexpensesonpeopleindifficultiesandpatientssufferingfromseriousdiseases,preventingthemfrombeingcausedtofallintoorfallingbackintopovertyduetodiseases,andstrengtheningeffortstoensuretheirbasiclivingconditions.InordertodeeplyimplementthedecisionsandplansoftheCPCCentralCommitteeandtheStaleCouncilondeepeningthe国务院办公厅关于健全重特大疾病医疗保险和救助制度的意见(国办发(2021)42号)各省、自治区、直辖市人民政府，国务院各部委、各直属机构：做好重特大疾病医疗保障，是进一步减轻困难群众和大病患者医疗费用负担、防范因病致贫返贫、筑牢民生保障底线的重要举措。为深入贯彻党中央、国务院关于深化医疗保障制度改革和完善社会救助制度的决策部署，巩固拓展医疗保障脱贫攻坚成果，不断增强人民群众获得感、幸福感、安全感，经国务院同意，现就健全重特大疾病医疗保险和救助制度提出以下意见。reliefsystem,consolidateandexpandtheachievementsmadeinthebattleofmedicalsecurityandpovertyalleviation,andmakeunswervingeffortstohelppeoplefeelsafer,happierandmoresatisfied,withtheconsentoftheStateCouncil,theOpinionsontheimprovementofthemedicalinsuranceandreliefsystemforseriousandcriticaldiseasesareherebyofferedasfollows.I.GeneralrequirementsWithXiJinpingThoughtonSocialismwithChineseCharacteristicsforaNewEraasguidance,effortsshallbemadetocomprehensivelyimplementtheunderlyingprincipleofthe19lhCPCNationalCongressandtheSecond,Third,Fourth,andFifthPlenarySessionsofthe19thCPCCentralCommittee,continuetopursuepeople-centereddevelopmentandmovesteadilytowardcommonprosperity,remaincommittedtoensuringmedicalinsuranceandbasiclivingconditionsforallpeople,andworkpersistentlyandunswervinglytoimprovepeople'slivelihoodinamoresustainedmanner.Focusingonreducingtheburdenofmedicalexpensesonpeopleindifficultiesandpatientssufferingfromseriousandcriticaldiseases,effortsshallalsobemadetoestablishalong-termmechanismforthepreventionandresolutionofsinkingbacktopovertyduetodiseases,enhancetheintegratedsystemofbasicmedicalinsurance,seriousillnessinsuranceandmedicalassistance(hereinafterreferredtoasthe44triplemedicalsecuritysystem"),determinethestandardsofmedicalsecurityforpeopleindifficultiesbasedontheiractualconditions,ensurethatpoorpopulationshaveaccesstobasicmedicalsecurity,andpreventthemfrombeing一、总体要求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，坚持以人民为中心，坚持共同富裕方向，坚持应保尽保、保障基本，尽力而为、量力而行，推动民生改善更可持续。聚焦减轻困难群众重特大疾病医疗费用负担，建立健全防范和化解因病致贫返贫长效机制，强化基本医保、大病保险、医疗救助（以下统称三重制度）综合保障，实事求是确定困难群众医疗保障待遇标准，确保困难群众基本医疗有保障，不因罹患重特大疾病影响基本生活，同时避免过度保障。促进三重制度综合保障与慈善救助、商业健康保险等协同发展、有效衔接，构建政府主导、多方参与的多层次医疗保障体系。adverselyaffectedbyseriousandcriticaldiseasesintheirdailylifeorfrombeinggrantedexcessivegovernmentsubsidies.Inthemeanwhile,moreeffortsshallbemadetocoordinatetheintegratedtriplemedicalsecuritysystemwithcharityassistanceandcommercialhealthinsurance,soastobuildamulti-tieredmedicalsecuritysystemthatisledbythegovernmentandinvolvesvariousparticipants.11.Scientificallydeterminingmedicalassistancetargets1. Promptlyandaccuratelydeterminingmedicalassistancetargets.Medicalassistanceshallequallycoverworkersindifficultsituationsandurbanandruralresidentswithaheavyburdenofmedicalexpenses,anddifferenttargetpopulationsshallbeprovidedwithdifferentassistance.Medicalassistanceshall,asrequired,begrantedtopeoplelivingonsubsistenceallowance,theimpoverished,familiesapproachingsubsistenceallowancestandards,theruralpopulationpronetofallingbackintoorbeingcausedtofallintopoverty,aswellaspatientsfallingintopovertyduetodiseaseswhoareincludedinthetargets.Acertainamountofassistanceshallbeprovidedtopatientssufferingfromseriousandcriticaldiseaseswhoarenotpeoplelivingonsubsistenceallowance,theimpoverishedorfamiliesapproachingsubsistenceallowancestandards,butwithextremedifficultiesinbasicfamilylifeduetohighmedicalexpenses(hereinafterreferredtoas“patientsfallingintopovertyduetoseriousdiseases*')accordingtotheiractualconditions.Takingintofullconsiderationofthefinancialsituationsoffamilies,medicalexpensesandpaymentofbasicmedicalinsurance,thecivilaffairsdepartmentsofallprovinces,autonomousregionsandmunicipalitiesdirectly二、科学确定医疗救助对象范围（一）及时精准确定救助对象。医疗救助公平覆盖医疗费用负担较重的困难职工和城乡居民，根据救助对象类别实施分类救助。对低保对象、特困人员、低保边缘家庭成员和纳入监测范围的农村易返贫致贫人口，按规定给予救助。对不符合低保、特困人员救助供养或低保边缘家庭条件，但因高额医疗费用支出导致家庭基本生活出现严重困难的大病患者（以下称因病致贫重病患者），根据实际给予一定救助。综合考虑家庭经济状况、医疗费用支出、医疗保险支付等情况，由省（自治区、直辖市）民政部门会同医疗保障等相关部门合理确定因病致贫重病患者认定条件。县级以上地方人民政府规定的其他特殊困难人员，按上述救助对象类别给予相应救助。undertheCentralGovernmentshallworkwiththemedicalsecuritydepartmentsandotherrelevantdepartmentstoreasonablydeterminetheconditionsforidentifyingpatientsfallingintopovertyduetoseriousdiseases.Otherpeoplewithspecialdifficultiesasdeterminedbylocalpeople'sgovernmentsatthecountylevelshallbeprovidedwithmedicalassistanceaccordingtotheaforesaidcategoriesofassistancetargets.三、强化三重制度综合保障III.Strengtheningtheintegratedtriplemedicalsecuritysystem（二）确保困难群众应保尽保。困难群众依法参加基本医 保，按规定享有三重制度保障权益。全面落实城乡居民基 本医保参保财政补助政策，对个人缴费确有困难的群众给 予分类资助。全额资助特困人员，定额资助低保对象、返 贫致贫人口。定额资助标准由省级人民政府根据实际确 定。适应人口流动和参保需求变化，灵活调整救助对象参 保缴费方式，确保其及时参保、应保尽保。2. Ensuringthatallpoorpopulationshaveaccesstomedicalinsurance.Peopleindifficultiesshallparticipateinbasicmedicalinsuranceinaccordancewith(helaw,andhaveaccesstobasicmedicalinsurance,seriousillnessinsuranceandmedicalassistanceasrequired.Financialsubsidypoliciesthatsupportthebasicmedicalinsuranceofurbanandruralresidentsshallbecomprehensivelyimplemented,andfinancialassistanceshallbeprovidedtopeoplewithdifficultiestopaymedicalinsuranceaccordingtodifferentcategoriesofassistancetargets.Allmedicalexpensesoftheimpoverishedshallbecoveredbymedicalassistance,andafixedamountofmedicalexpensesofpeoplelivingonsubsistenceallowanceandpopulationsbeingcausedtofallintoorfallingbackintopovertyshallbecoveredbymedicalassistance.Thecriteriaofthefixedamountofassistanceshallbedeterminedbythepeople'sgovernmentsattheprovinciallevel.Inordertoadapttotheflowofpopulationsandthechangesofinsuranceneeds,themethodsofinsurancepaymentformedicalassistancetargetsshallbeadjustedinaflexiblemannertoensurethatallrevitalization.peopleparticipateinmedicalinsuranceinatimelymannerandallpoorpopulationshaveaccesstomedicalinsurance.3. Promotingthecoordinationofbasicmedicalinsurance,seriousillnessinsuranceandmedicalassistance.Effortsshallbemadetoleveragetheprimaryfunctionofbasicmedicalinsuranceinmedicalsecurity,andstrictlyfulfillthescopeandcriteriaofpaymentofbasicmedicalinsurance,soastoensurethatallpopulationshaveaccesstomedicalsecurityinafairandappropriatemanner.Thefunctionofseriousillnessinsuranceinreducingtheburdenofmedicalexpensesshallbestrengthened,andpoliciesonthepaymentofseriousillnessinsuranceinfavorofpeoplelivingonsubsistenceallowance,theimpoverishedorpopulationsbeingcausedtofallintoorfallingbackintopovertyshallbeimproved,soastoleveragetheroleofseriousillnessinsuranceinmedicalsecurity.Thefunctionofmedicalassistanceinmeetingthebasicmedicalneedsshallbeconsolidated,andmedicalassistanceshallbeprovidedtotargetpopulationswithaheavyburdenofpersonalmedicalexpensesevenafterthepaymentofbasicmedicalinsuranceandseriousillnessinsuranceundertheprincipleoftinsurancebeforeassistance'*,soastojointlypreventtheriskoffallingbackintoorbeingcausedtofallintopovertyduetodiseases.Inthemeanwhile,effortsshallbemadetoimprovethemeasuresofprovidingmedicalinsurancesupportfortheruralpopulationpronetofallingbackintoorbeingcausedtofallintopoverty,andpromoteeffectivecoordinationbetweenconsolidatingandexpandingtheachievementsmadeinpovertyalleviationthroughmedicalsecurityandrural（三）促进三重制度互补衔接。发挥基本医保主体保障功能，严格执行基本医保支付范围和标准，实施公平适度保障：增强大病保险减负功能，探索完善大病保险对低保对象、特困人员和返贫致贫人口的倾斜支付政策，发挥补充保障作用；夯实医疗救助托底保障功能，按照“先保险后救助”的原则，对基本医保、大病保险等支付后个人医疗费用负担仍然较重的救助对象按规定实施救助，合力防范因病致贫返贫风险。完善农村易返贫致贫人口医保帮扶措施，推动实现巩固拓展医疗保障脱贫攻坚成果同乡村振兴有效衔接。IV.Consolidatingtheroleofmedicalassistanceinaddressingbasicmedicalneeds4. Determiningthecoverageofassistancefees.Effortsshallbemadetoensurebasicmedicalassistanceandproperlysolvetheproblemofaddressingthemedicalneedsofassistancetargetswithintherangeofpolicies.Assistancefeesshallmainlycoverhospitalizationfeesoftargetpopulationsincurredindesignatedmedicalinstitutions,medicationfeesforchronicdiseasesoroutpatienttreatmentcostsforseriousandcriticaldiseases.Inprinciple,medicines,medicalconsumables,andtreatmentitemspaidbymedicalassistancefundsshallbesubjecttotheprovisionsofthestateonthecoverageofbasicmedicalinsurance.Feespaidbyindividualrecipientswithintherangeofpoliciesbelowthedeductibleofbasicmedicalinsuranceandseriousillnessinsuranceshallbeincludedinthecoverageasrequired.Unlessotherwisespecifiedbythegovernment,allareassubjecttooverallplanningmaynotdeterminebythemselvesorexpandthecoverageofmedicalassistancefeeswithoutpermissioninaflexiblemanner.5. Reasonablydeterminingthebasicassistancelevel.Thedeductibleofannualmedicalassistance(hereinafterreferredtoasthe"deductible”)shallbeestablishedaccordingtothedifficultsituationsofdifferenttargetfamilies.Inprinciple,thedeductibleforpeoplelivingonsubsistenceallowanceortheimpoverishedshallberemoved.Inareasthatdonottemporarilymeetcertainconditions,thedeductiblemaynotbehigherthan5%ofpercapitadisposableincomeoflastyearinareassubjecttooverallplanning,andeffortsshallbemadetoremovethedeductiblestepbystep.Thedeductibleoffamilies四、夯实医疗救助托底保障（四）明确救助费用保障范围。坚持保基本，妥善解决救助对象政策范围内基本医疗需求。救助费用主要覆盖救助对象在定点医药机构发生的住院费用、因慢性病需长期服药或患重特大疾病需长期门诊治疗的费用。由医疗救助基金支付的药品、医用耗材、诊疗项目原则上应符合国家有关基本医保支付范围的规定。基本医保、大病保险起付线以下的政策范围内个人自付费用，按规定纳入救助保障。除国家另有明确规定外，各统筹地区不得自行制定或用变通的方法擅自扩大医疗救助费用保障范围。（五）合理确定基本救助水平。按救助对象家庭困难情况，分类设定年度救助起付标准（以下简称起付标准）。对低保对象、特困人员原则上取消起付标准，暂不具备条件的地区，其起付标准不得高于所在统筹地区上年居民人均可支配收入的5%,并逐步探索取消起付标准。低保边缘家庭成员起付标准按所在统筹地区上年居民人均可支配收入的10%左右确定，因病致贫重病患者按25%左右确定。对低保对象、特困人员符合规定的医疗费用可按不低于70%的比例救助，其他救助对象救助比例原则上略低于低保对象。具体救助比例的确定要适宜适度，防止泛福利化倾 向。各统筹地区要根据经济社会发展水平、人民健康需 求、医疗救助基金支撑能力，合理设定医疗救助年度救助 限额。农村易返贫致贫人口救助水平，按巩固拓展医疗保 障脱贫攻坚成果有效衔接乡村振兴战略有关政策规定执 行。（六）统筹完善托底保障措施。加强门诊慢性病、特殊疾 病救助保障，门诊和住院救助共用年度救助限额，统筹资 金使用，着力减轻救助对象门诊慢性病、特殊疾病医疗费 用负担。对规范转诊且在省域内就医的救助对象，经三重 制度综合保障后政策范围内个人负担仍然较重的，给予倾 斜救助，具体救助标准由统筹地区人民政府根据医疗救助 基金筹资情况科学确定，避免过度保障。通过明确诊疗方approachingsubsistenceallowancestandardsshallbedeterminedby10%ofpercapitadisposableincomeoflastyearinareassubjecttooverallplanning,andthedeductibleofpatientsfallingintopovertyduetoseriousdiseasesshallbe25%,Medicalassistanceshallbeprovidedtopeoplelivingonsubsistenceallowanceandtheimpoverishedaccordingto70%oftheirmedicalexpensesthatmeetrequiredconditions,andthepercentageofmedicalexpensesofotherassistancetargetsshallbeinprincipleslightlylowerthanthatofpeoplelivingonsubsistenceallowance.Thespecificpercentageofmedicalexpensesshallbedeterminedinanappropriatemannersoastopreventexcessivefinancialgovernmentsubsidiesinmedicalinsurance.Allareassubjecttooverallplanningshallreasonablydeterminethelimitofannualmedicalassistanceaccordingtoeconomicandsocialdevelopment,people'shealthcaredemandsandthecapacityofmedicalassistancefunds.Medicalassistanceshallbeprovidedtotheruralpopulationpronetofallingbackintoorbeingcausedtofallintopovertyinaccordancewithrelevantpoliciesontheinitiativeofcoordinationbetweenconsolidatingandexpandingtheachievementsmadeinpovertyalleviationthroughmedicalsecurityandruralrevitalization.6. Comprehensivelyimprovingthemeasuresofaddressingbasicmedicalneeds.Thecoverageofmedicalassistanceshallbeexpandedforoutpatientchronicdiseasesandspecialdiseases.Outpatientsandinpatientsshallsharethesamelimitofannualmedicalassistance,andtheuseoffundsshallbecoordinatedsoastoreducetheburdenofmedicalexpensesonassistancetargetssufferingfromchronicdiseasesaswellasseriousandcriticaldiseases.Moreassistanceshallbeprovided案、规范诊疗等措施降低医疗成本，合理控制困难群众政策范围内自付费用比例。totargetpopulationsreceivingproperreferralsandhospitaltreatmentwithinthedomainofaprovincewithaheavyburdenofmedicalexpenseswithintherangeofpoliciesevenaftertheintegratedtriplemedicalsecuritysystemisimplemented.Specificassistancestandardsshallbedeterminedbylocalpeople'sgovernmentsinascientificmanneraccordingtotheamountofmoneyraisedformedicalassistancefundssoastopreventexcessivegovernmentsubsidies.Medicalcostsshallbereducedthroughspecifictreatmentprograms,effectivemedicaltreatmentandothermeans,soastoreasonablycontrolthepercentageoffeespaidbypeopleindifficultieswithintherangeofpolicies.五、建立健全防范和化解因病致贫返贫长效机制V.Establishingalong-termmechanismforthepreventionandresolutionofsinkingbacktopovertyduetodiseases（七）强化高额医疗费用支出预警监测。实施医疗救助对 象信息动态管理。分类健全因病致贫和因病返贫双预警机 制，结合实际合理确定监测标准。重点监测经基本医保、 大病保险等支付后个人年度医疗费用负担仍然较重的低保 边缘家庭成员和农村易返贫致贫人口，做到及时预警。加 强部门间信息共享和核查比对，协同做好风险研判和处 置。加强对监测人群的动态管理，符合条件的及时纳入救 助范围。7. Strengtheningthewarningandmonitoringofexpensivemedicalexpenses.Theinformationofmedicalassistancetargetsshallbemanagedinadynamicmanner.Twoseparatewarningmechanismsshallbeestablishedforpeoplefallingintopovertyandpeoplesinkingbacktopovertyduetodiseases,andthestandardsofmonitoringshallbereasonablydeterminedaccordingtotheactualconditions.Importanceshallbeattachedtothemonitoringoffamiliesapproachingsubsistenceallowancestandardsandtheruralpopulationpronetofallingbackintoorbeingcausedtofallintopovertywithaheavyburdenofpersonalmedicalexpensesevenafterthepaymentofbasicmedicalinsuranceandseriousillnessinsurance,soastogiveearlywarningsinatimelymanner.Effortsshallbestrengthenedtoshare,verifyandcompareinformationbetweendepartments,andcoordinatetheanalysisandhandlingofrisks.Thedynamicmanagementofmonitoredpopulationsshallbeenhanced,andthosethatmeetcertainconditionsshallbeincludedinthescopeofassistanceinapromptmanner.（八）依申请落实综合保障政策。全面建立依申请救助机 制，畅通低保边缘家庭成员和农村易返贫致贫人口、因病 致贫重病患者医疗救助申请渠道，增强救助时效性。已认 定为低保对象、特困人员的，直接获得医疗救助。强化医 疗救助、临时救助、慈善救助等综合性保障措施，精准实 施分层分类帮扶。综合救助水平要根据家庭经济状况、个 人实际费用负担情况合理确定。8. Implementingcomprehensiveinsurancepoliciesuponapplication.Amechanismofprovidingmedicalassistanceuponapplicationshallbecomprehensivelyestablished,andchannelsforfamiliesapproachingsubsistenceallowancestandards,theruralpopulationpronetofallingbackintoorbeingcausedtofallintopoverty,andpatientsfallingintopovertyduetoseriousdiseasestoapplyformedicalassistanceshallbekeptunimpeded,soastoensurethatassistancecanbeprovidedinamoreeffectivemanner.Thosehavingbeenidentifiedaspeoplelivingonsubsistenceallowanceandtheimpoverishedshalldirectlyreceivemedicalassistance.Comprehensiveinsurancemeasuressuchasmedicalassistance,temporaryassistanceandcharityassistanceshallbeenhancedsoastoprovidespecificsupporttodifferenttargetpopulations.Theamountofcomprehensiveassistanceshallbereasonablydeterminedaccordingtothefinancialsituationsoffamiliesandth