Summary

(1)　 The People's Governments of Provinces and Municipalities, Provincial-level Commissions, Bureaus, Departments, and Agencies: To comprehensively implement and carry out the spirit of the State Council's Office on establishing a long-term mechanism for basic medical insurance participation, consolidate and expand the achievements of universal participation, and solidify the foundation of the basic medical insurance system, the following opinions are proposed after approval by the Provincial People's Government, taking into account the actual situation of the province.

(2)　 I. Improve Policy Measures

(3)　 (1) Improve Participation Policy: Promote citizens to participate in basic medical insurance in accordance with the law, and implement the policy of participating in basic medical insurance with valid identification documents. The concentrated payment period for residents' medical insurance is from September to the following February. Encourage areas with conditions to explore organizing participation by family units. Flexible employment personnel, migrant workers, and new employment form personnel can choose to participate in worker medical insurance or resident medical insurance, and those who choose worker medical insurance can choose to pay monthly, quarterly, or annually.

(4)　 (2) Implement Resident Medical Insurance Funding Policy: Dynamically adjust the province's resident medical insurance funding standard in accordance with the national unified deployment and the province's economic and social development level. Provide category-based assistance to difficult groups such as the poor, lowest living guarantee objects, and those who meet the conditions for poverty prevention monitoring, and exempt them from resident medical insurance individual payments. Actively explore ways to provide assistance to low-income difficult groups through charitable aid, public donations, village collective economic income, or project asset income.

(5)　 (3) Implement Worker Medical Insurance Funding Policy: Each unified management area should maintain a relatively stable worker medical insurance funding standard. If adjustments are necessary, they should be reported to the Provincial Medical Insurance Bureau and the Provincial Finance Department. Unemployed personnel who receive unemployment insurance benefits during the period of receiving benefits can pay worker medical insurance (including maternity insurance) fees, which will be paid from the unemployment insurance fund, and they will enjoy the same medical insurance and maternity insurance benefits as employed personnel.

(6)　 (4) Implement Benefits Policy: Strictly implement the medical benefit list system, and by the end of June 2025, each unified management area should complete the policy specifications such as the maximum payment limit for major diseases insurance. On the basis of ensuring the safety of the fund, areas with conditions can use a certain proportion of the newly increased funding for resident medical insurance to strengthen outpatient care and guide people to seek medical treatment at grassroots medical institutions.

(7)　 II. Establish Incentive and Constraint Mechanisms

(8)　 (5) Implement Resident Participation Incentive: From 2025 onwards, for residents who have participated in resident medical insurance for 4 consecutive years, their major disease insurance maximum payment limit will be increased by 4000 yuan each year, and the accumulated increase will not exceed 20% of the original maximum payment limit of the resident major disease insurance in the area. For residents who have not participated in medical insurance and then participate in the following year, their major disease insurance maximum payment limit will be increased by 4000 yuan, and the accumulated increase will not exceed 20% of the original maximum payment limit of the resident major disease insurance in the area.

(9)　 (6) Implement Resident Non-Participation Constraint: From 2025 onwards, except for newborns, dynamically added medical assistance objects, worker medical insurance non-participants who transfer to resident medical insurance within 3 months, retired military personnel, and their families who have not been employed, and other groups, for those who have not participated in resident medical insurance during the concentrated payment period or have not participated continuously, a 3-month fixed benefit waiting period will be set. For those who have not participated continuously, for each year of non-participation, an additional 1-month variable benefit waiting period will be added. Participants can repair variable benefit waiting periods by paying fees, and the payment will be made according to the individual payment standard of the participating area, and each year of payment will reduce the variable benefit waiting period by 1 month. Those who have not participated for 4 years or more will have a fixed benefit waiting period and a variable benefit waiting period of at least 6 months. Medical expenses incurred during the waiting period will not be included in the medical insurance payment.

(10)　 III. Improve Service Quality and Efficiency

(11)　 (7) Accurately Determine Participation Numbers: Establish a "one person, one file" universal participation database, improve the mechanism for dynamic exchange and comparison of data between departments, and grasp the information of permanent residents, registered residents, participating personnel, and non-participating personnel in the area in a timely manner. Leverage the advantages of grassroots networked management to handle separated households, and strengthen coordination between registered residence and permanent residence to implement participation expansion responsibilities. Continuously do a good job in repeated participation governance, optimize new participation registration, and improve participation quality.

(12)　 (8) Establish Participation Mobilization Mechanism:

Original

(1)　 各州（市）人民政府，省直各委、办、厅、局：

(2)　 为全面贯彻落实《国务院办公厅关于健全基本医疗保险参保长效机制的指导意见》（国办发〔2024〕38号）精神，持续巩固拓展全民参保成果，夯实基本医疗保险制度基础，经省人民政府同意，结合我省实际，现提出以下意见。

(3)　 一、完善政策措施

(4)　 （一）完善参保政策。推动公民依法参加基本医保，全面落实凭有效身份证件参加基本医保政策。居民医保参保集中征缴期为每年9月至次年2月。鼓励有条件的地区探索以家庭为单位组织动员参保。灵活就业人员、农民工、新就业形态人员可以选择参加职工医保或居民医保，参加职工医保的，可以选择按月、按季或按年缴费。推动外地户籍中小学生、学龄前儿童在常住地参加居民医保。鼓励大学生、技工院校学生在学籍地参加居民医保。〔省医保局、省教育厅、省人力资源社会保障厅、省税务局，各州（市）人民政府按照职责分工负责。以下均需各州（市）人民政府负责，不再列出〕

(5)　 （二）落实居民医保筹资政策。根据国家统一部署和我省经济社会发展水平，动态调整全省居民医保筹资标准。对特困人员、最低生活保障对象、符合条件的防止返贫监测对象等困难群众，按规定对居民医保个人缴费给予分类资助。积极探索通过慈善帮扶、公益捐赠、村集体经济收入或帮扶项目资产收益等渠道资助低收入困难群众参保缴费。（省医保局、省民政厅、省财政厅、省农业农村厅、省红十字会按照职责分工负责）

(6)　 （三）落实职工医保缴费政策。各统筹地区应保持职工医保筹资标准相对稳定，确需调整的，应向省医保局、省财政厅报告。失业人员在领取失业保险金期间，缴纳的职工医保（含生育保险）费，由社会保险经办机构按规定从失业保险基金中支付，与统筹地区参保职工同等享受医疗保险、生育保险待遇。（省医保局、省财政厅、省人力资源社会保障厅按照职责分工负责）

(7)　 （四）落实待遇政策。严格落实医疗保障待遇清单制度，2025年6月底前，各统筹地区应完成大病保险最高支付限额等政策规范。在确保基金安全的基础上，有条件的地区可将居民医保年度新增筹资的一定比例用于加强门诊保障，并向基层医疗机构倾斜，引导群众在基层就医。（省医保局、省财政厅、省卫生健康委按照职责分工负责）

(8)　 二、建立激励约束机制

(9)　 （五）实施居民参保激励。自2025年起，对连续参加居民医保满4年的参保人员，之后每连续缴费1年，每年提高大病保险最高支付限额4000元，出现断保的重新累计连续缴费年数。对当年医保基金零报销且次年正常缴费的居民医保参保人员，次年提高大病保险最高支付限额4000元，发生大病报销并使用激励额度后，本人零报销激励额度清零，第2年重新计算零报销激励额度。连续参保和零报销激励额度累计提高不超过所在统筹地区居民大病保险原封顶线的20%。（省医保局、省财政厅按照职责分工负责）

(10)　 （六）实施居民断保约束。自2025年起，除新生儿、动态新增的医疗救助对象、职工医保断保3个月内转居民医保人员、退役军人、随军未就业家属、刑满释放人员等群体外，对未在居民医保集中征缴期内参保或未连续参保的人员，设置参保后固定待遇等待期3个月；其中，未连续参保的，每多断保1年，在固定待遇等待期的基础上，增加变动待遇等待期1个月。参保人员可通过缴费修复变动待遇等待期，缴费按照当年参保地的个人缴费标准执行，每多缴纳1年，可减少变动待遇等待期1个月。连续断缴4年及以上的，修复后固定待遇等待期和变动待遇等待期之和不少于6个月。待遇等待期发生的医疗费用不纳入医保支付。对居民医保断保人员再参保缴费的，降低大病保险最高支付限额，每断保1年，降低居民大病保险最高支付限额3000元，累计降低总额度不超过所在统筹地区居民大病保险原封顶线的20%。（省医保局、省财政厅按照职责分工负责）

(11)　 三、提升服务质效

(12)　 （七）准确摸清参保底数。建立“一人一档”全民参保数据库，完善部门间数据动态交换比对工作机制，及时掌握本地区常住人口、户籍人口、参保人员、未参保人员等信息。发挥基层网格化管理优势，对于人户分离的应参保未参保人员，户籍地和常住地加强配合，共同落实参保扩面责任。持续做好重复参保治理工作，优化新增参保登记，提升参保质量。（省医保局负责）

(13)　 （八）健全参保动员机制。坚持基本医保全民参保常态化宣传与每年9月全民参保集中宣传相结合，依托各级经办服务机构、村（居）委会、医保延伸办服务点、定点医药机构等建立长期宣传服务点，常态化做好宣传动员。充分发挥家庭医生作用，积极向签约居民开展参保动员。广泛发动有关部门及企事业单位开展宣传动员，充分发挥传统媒体和新媒体作用，宣传医保的惠民政策、经办流程、缴费标准和便民措施，用好典型案例，让群众全面了解政府投入情况以及基本医保在抵御疾病风险、减轻医药费用负担方面的积极作用，普及医疗保险互助共济、责任共担、共建共享的理念。（省医保局、省教育厅、省民政厅、省人力资源社会保障厅、省农业农村厅、省卫生健康委、省退役军人事务厅、省总工会、省妇儿工委办、省残联、省税务局按照职责分工负责）

(14)　 （九）提升医保服务能力。深入推进“高效办成一件事”，持续优化医保服务流程，实现基本医保参保登记和缴费“一件事”联办。推动出生医学证明、户口登记、医保参保、社会保障卡申领等“出生一件事”集成化办理，做实新生儿“出生即参保”。拓展个人缴费及纳入医保结算的医药费用查询渠道，为参保人员提供线上线下多样化、便捷化的参保缴费等服务。（省医保局、省人力资源社会保障厅、省卫生健康委、省税务局按照职责分工负责）

(15)　 （十）改善群众就医体验。推进集采药品进定点零售药店、民营医疗机构，巩固基层医疗机构配备集采药品成效，方便居民就近看病就医，更好推进分级诊疗。加强定点医药机构监管，严厉打击欺诈骗保行为，用好医保基金，减轻群众医药费用负担。大力推动医保码（医保电子凭证）、社会保障卡（含电子社保卡）、移动支付等数字化医保服务应用。（省医保局、省人力资源社会保障厅、省卫生健康委按照职责分工负责）

(16)　 四、加强协同联动

(17)　 （十一）完善联动机制。省医保局牵头健全完善部门共治、社会参与、全民共享的基本医保参保长效机制，各有关部门按照职责分工协同抓好工作推进。公安部门配合医保部门做好参保人员信息与户籍人口信息比对。财政部门按照职责对基本医保基金的收支、管理情况实施监督，审核并汇总编制基本医保基金预决算草案，并落实各级财政补助资金。卫生健康部门合理编制区域卫生规划，促进优质医疗资源扩容下沉和区域均衡布局，加强医疗机构行为监管。税务部门做好征收和缴费服务工作。教育部门配合医保部门，依托省级数据共享交换平台等渠道，加强工作协同与数据共享，不断提高学生基本医保参保水平，不得以任何形式强制或变相强制学生购买商业保险产品。医保部门与人力资源社会保障部门共同支持社会保险业务协同联动，协助做好领取失业保险金人员缴纳职工医保费工作；与卫生健康部门联动，推动医疗费用增长合理有度且与经济社会发展水平、医保筹资水平和群众承受能力相适应。（省医保局、省教育厅、省公安厅、省财政厅、省人力资源社会保障厅、省卫生健康委、省税务局按照职责分工负责）

(18)　 （十二）畅通信息共享。医保部门要及时掌握参保人员变动信息，加强与教育、公安、民政、司法行政、财政、人力资源社会保障、农业农村、卫生健康、退役军人事务、市场监管、工会、妇儿工委办、残联、税务等部门信息共享，为扩大参保覆盖面和治理重复参保提供数据支撑。各有关部门在符合国家数据安全管理和个人信息保护有关规定的前提下，与医保部门及时共享公民出生、死亡以及医疗救助对象、在校学生、退役军人、就业人员、服刑以及刑满释放人员、强制隔离戒毒在所人员、企业设立变更注销、基本养老保险、医疗保险等信息。（省医保局、省直有关部门按照职责分工负责）

(19)　 五、强化组织保障

(20)　 （十三）加强组织领导。各地各有关部门要高度重视，加强基本医保参保工作的组织领导，兼顾当前和长远，坚持尽力而为、量力而行，常态化推进参保扩面工作，及时研究和协调解决信息数据共享和参保扩面工作中遇到的问题，确保各项政策落实落地、基金运行安全平稳可持续。各州（市）不制定配套文件，州（市）有关部门参照省直部门分工抓好落实。（省医保局负责）

(21)　 （十四）强化资金保障。各地要切实履行政府支出责任，确保居民医保财政补助资金及时足额到位。有条件的统筹地区可根据参保计划完成情况及参保质量等给予激励，充分调动基层积极性。省财政厅、省医保局将各地参保工作等绩效情况作为分配中央财政医疗服务与保障能力提升补助资金（医疗保障服务能力建设部分）的调节系数。（省医保局、省财政厅按照职责分工负责）

(22)　 云南省人民政府办公厅

(23)　 2024年12月23日

(24)　 （此件公开发布）