乌鲁木齐市城镇居民基本医疗保险门诊统筹的补偿方案研究

The research on compensation plan of Urumqi′s urban residents′ medical insurance

目的研究乌鲁木齐市城镇居民基本医疗保险门诊统筹的补偿方式和补偿标准,重新核定起付线、补偿比和封顶线。方法通过对乌鲁木齐市天山区、沙依巴克区、新市区、水磨沟区4个社区卫生服务机构城镇居民就诊的相关数据资料进行整理分析,测算并核定出相对合理的起付线、补偿比和封顶线。结果经测算得出乌鲁木齐市城镇居民基本医疗保险门诊统筹的起付线为16.6元,补偿比为61%,年封顶线为200元,单日次封顶线为66.67元。结论目前乌鲁木齐市城镇居民的起付线低,应适当上调,以保证医疗资源的充分利用,同时动态调整补偿比。

Objective To reset the lowest pay line, compensation ratio and capping line of compensation on the basis of analysis of data of Urumqi＇s urban residents＇ medical insurance and study of compensation methods and compensation standards. Methods We analyzed Urumqi＇s urban residents＇ medical insurance data from four community health service agencies respectively in Tianshan District, Saybagh District, New municipal District and Shuimogou District. After calculation, we got the result of the lowest pay line, compensation ratio and capping line of compensation. Results The lowest pay line for Urumqi＇s urban res- idents＇ medical insurance was 16.6 Yuan, compensation ratio was 61%, the annual capping line was 200 Yuan, the one-day capping line was 66.67 Yuan. Conclusion To make full of medical resources in Urumqi, the lowest pay line should be raised. Compensation ratio should also be adjusted.