城镇居民基本医疗保险门诊统筹补偿比例测算模型的构建与应用

Construction and Application of Model of Urban Resident Basic Medical Insurance Compensation Ratio Calculation

目的在对乌鲁木齐市城镇居民基本医疗保险门诊统筹相关数据整理分析的基础上,测算乌鲁木齐市城镇居民医疗保险体系的人均筹资标准、补偿比、起付线和封顶线,为政府相关部门下一阶段门诊统筹方案的修订和相关配套政策的制定提供依据和参考。方法运用模型法和平衡系数法,对城镇居民门诊医疗保险相关标准进行了测算。结果乌鲁木齐市城镇居民医疗保险的人均筹资标准应为112.89元,补偿比应为61%,起付线和封顶线分别为16.6元和200.6元。结论根据乌鲁木齐市经济发展水平现况,应考虑加大筹资力度、合理制定补偿比和适度上调起付线。

Objectives To estimate per capita funding criteria, compensation proportion, pay line and capping line of Urumqi urban resident medical insurance system basing on the data analysis of out-patient co-ordination of the basic medical insurance for urban residents, ant to provide the basis and reference for the relevant government departments to amend out-patient co-ordination program and formulat supporting policy at the next stage. Methods The model method and the balance coefficient method were used to calculate relevant standards of outpatient medical insurance for urban residents. Results The funding criteria of Urumqi urban residents medicare should be 11Z. 89 yuan per capita, compensation proportion should be 61%, the pay line and cap line should be 16.6 yuan and 200.6 yuan respectively. Conclusions According to the economic level of Urumqi city, strengthening financing, establis hing reasonable compensation proportion and escalating pay line properly should be considered.