中新网8月30日电 国家发展和改革委员会、卫生部、财政部、人力资源和社会保障部、民政部、保险监督管理委员会《关于开展城乡居民大病保险工作的指导意见》8月30日正式公布。为什么要开展城乡居民大病保险工作？大病保险如何解决“因病致贫、因病返贫”问题？为什么由商业保险机构承办？如何确保取得实效？国家发展改革委副主任、国务院医改办公室主任孙志刚就此作出解读。

Beijing, aug. 30 of the national development and reform commission、The ministry of health、The ministry of finance、Human resources and social security、The ministry of civil affairs、The insurance supervision and management committee《About urban and rural residents to carry out a serious illness insurance work guiding opinions》On August 30, officially announced。Why do you want to urban and rural residents to carry out a serious illness insurance work？A serious illness insurance how to solve“Become financially-difficult、Poverty due to illness”problems？Why the commercial insurance institutions undertaking？How to make sure to make the effective？The national development and reform commission deputy director、Cure of the state council on the SunZhiGang, director of the office of the interpretation。

一、为什么此时出台关于城乡居民大病保险的文件？ a、Why now issued about urban and rural residents a serious illness insurance documents？

　　近年来，随着新医改的持续推进，全民医保体系初步建立。截至2011年底，城乡居民参加三项基本医保人数超过13亿人，覆盖率达到了95%以上。其中，城镇居民医保、新农合参保(合)人数达到10.32亿人，政策范围内报销比例达到70%左右。人民群众“病有所医”有了基本保障，老百姓敢去看病了。

In recent years，With the new reform of continuous propulsion，The medical insurance system has been set up preliminarily。By the end of 2011，Three basic medical insurance for urban and rural residents to participate in more than 1.3 billion people，Coverage rate reached more than 95%。the，Medical insurance for urban residents、New farmers $ginseng(close)Number of students has reached 1.032 billion，Policy to submit an expense account within the range of about 70%。people“BingYouSuoYi”The basic guarantee，Common people dare to go to see the doctor。

　　但我们也看到，目前我国城镇居民医保、新农合的保障水平还比较低，制度还不够健全，比较突出的问题是，人民群众患大病发生高额医疗费用后个人负担仍比较重，存在“一人得大病，全家陷困境”的现象。大病医疗保障是全民医保体系建设当中的一块短板。与此同时，基本医保基金存有不少结余，累计结余规模较大。有必要设计专门针对大病的保险制度，解决群众的实际困难，使城乡居民人人享有大病保障。对此，党中央、国务院高度重视，“十二五”医改规划专门作了明确要求。根据这些要求，国务院医改办会同相关部门经过充分调研和测算，认为开展城乡居民大病保险非常必要、时机成熟，而且具有可操作性。

But we also see，At present our country medical insurance for urban residents、New farmers joint safeguard level is relatively low，It is not enough to improve the system，The problem is more outstanding，People suffer from a serious illness happen after high medical expenses personal burden heavier still，exist“A man a serious illness，Family in difficulty”phenomenon。Medical treatment of a serious illness security is universal medical insurance system of the construction of a piece of short plate。meanwhile，The basic medical insurance fund entities many balance，Accumulated large scale balance。It is necessary to design special for serious illness insurance system，To solve the practical problems of the masses，Everyone has the right to make urban and rural residents a serious illness security。this，The party central committee、The state council attach great importance to，“1025”Medical planning special made clear requirements。According to these requirements，Cure of the state council jointly with the relevant departments to do a full investigation and measurement，That the development of urban and rural residents a serious illness insurance is very necessary、Ripe for，And operable。

　　城乡居民大病保险，是在基本医疗保障的基础上，对大病患者发生的高额医疗费用给予进一步保障的一项制度性安排，可以进一步放大保障效用，是基本医疗保障功能的拓展和延伸，是对基本医疗保障的有益补充。开展城乡居民大病保险，意义重大、影响深远，有利于切实减轻人民群众大病医疗费用负担，解决因病致贫、因病返贫问题；有利于健全多层次医疗保障体系，推进全民医保制度建设；有利于促进政府主导与市场机制作用相结合，提高基本医疗保障的水平和质量；有利于进一步体现互助共济，促进社会公平正义。

Urban and rural residents a serious illness insurance，In the basic medical insurance is based on，In patients with serious illness to the high medical treatment charge gives further guaranteed a institutional arrangement，Can be further amplification security utility，Is the basic medical security function development and extension，Is the basic medical insurance beneficial supplement。Urban and rural residents to carry out a serious illness insurance，Is of great significance、far-reaching，To earnestly alleviate people's medical treatment of a serious illness expense burden，Solve become financially-difficult、Poverty due to illness problem；To improve the multi-level medical security system，Advancing the construction of medical insurance system；To promote the government leading with market mechanism combining role，Improve the basic medical insurance level and quality；To further reflected help each other in all aid，Promote social fairness and justice。

　　二、城乡居民大病保险要解决什么问题？ two、Urban and rural residents a serious illness insurance to solve any problem？

　　开展大病保险，对城乡居民因患大病发生的高额医疗费用给予报销，目的是要解决群众反映强烈的“因病致贫、因病返贫”问题，使绝大部分人不会再因为疾病陷入经济困境。

To carry out a serious illness insurance，To urban and rural residents suffering from serious illness happen high medical treatment charge gives to submit an expense account，Purpose is to solve the populace to reflect the strong“Become financially-difficult、Poverty due to illness”problems，Make most people won't because disease in queer street。

　　大病保险的保障对象是城镇居民医保、新农合的参保人，所需要的资金从城镇居民医保基金、新农合基金中划出，不再额外增加群众个人缴费负担。

A serious illness insurance safeguard object is medical insurance for urban residents、New farmers, ginseng protect people，The funds required to urban residents from the medical insurance fund、New farmers joint funds off，No extra increasing the mass individual pay cost burden。

　　在设计大病保险的保障范围和目标时，我们参考了世界卫生组织关于“家庭灾难性医疗支出”的定义。总的想法是，在平均水平上，使个人不得不支出的医疗费用低于家庭灾难性医疗支出的标准。

In the design of a serious illness insurance coverages and goal，Our reference the world health organization about“Family catastrophic medical expenditure”definition。The idea is，In the average level，Make the individual had to spending medical costs less than family catastrophic medical expenditure standard。

　　经测算，各地城镇居民年人均可支配收入或农民年人均纯收入，可作为当地家庭灾难性医疗支出的标准。当参保患者个人负担的医疗费用超过这个标准时，很可能使家庭在经济上陷入困境。大病保险对这小部分人群个人负担的合规医疗费用在基本医保已经报销的基础上再次给予报销，要求实际报销比例不低于50%。这里的合规医疗费用不局限于基本医保政策范围内，但为避免浪费和过度负担，不是基本治疗所必须的项目不列入报销范围。

According to the calculation，In all urban residents per capita disposable income or farmers per capita net income of years，Can be used as the local family catastrophic medical expenditure standard。When ginseng protect patients individual responsibility medical costs more than the standard time，Is likely to make the family in the economic mess up。A serious illness insurance to the small crowd individual responsibility compliance medical expenses in the basic medical insurance has to submit an expense account again on the basis of given to submit an expense account，Request actual expense proportion is less than 50%。Here's the compliance medical expenses is not limited to basic medical insurance policy range，But in order to avoid waste and excessive burden，The basic treatment is not necessary to submit an expense account is not included in the scope of the project。

　　当然，由于每个人家庭能够负担的医疗费用有所差异，开展大病保险，并不能完全确保每一位大病患者都不发生灾难性支出。极少数低收入或发生巨额医疗费用的人，还有可能面临困境。要切实解决这些极少数人的个性化困难，需要通过救助的办法加以解决，在医院、医保和医疗救助机构之间形成信息顺畅、快速应对的工作机制，争取做到发生一例、救助一例、解决一例。我们正在会同有关部门研究这方面的政策措施。

Of course，Because each family can afford medical cost differences，To carry out a serious illness insurance，And cannot be completely to ensure that every a serious illness patients are not catastrophic expenses。A handful of low-income or the occurrence of major medical expenses of the people，And could face difficulties。To solve these few personalized difficult，Need through the relief way to solve，In the hospital、Health care and medical assistance mechanism formed between smooth information、The work of rapid response mechanism，Try to be a case occurred、Salvage case、Solve a case。We are in conjunction with the relevant departments to study the policy measures。

　　三、为什么由商业保险机构承办？ three、Why the commercial insurance institutions undertaking？

　　以往，基本医保经办通常有两种形式，主要是事业单位直接经办，也有些地方委托一些专业机构提供部分环节的服务，如审核单据、稽查服务行为等。为进一步转变政府职能，创新公共服务管理，提升服务效率，新一轮医改明确提出要探索“委托具有资质的商业保险机构经办各类医疗保障管理服务”。近几年，不少地方(例如广东湛江、江苏太仓、河南洛阳等地)积极探索了政府主导与市场机制相结合的创新形式，拿出部分资金，由政府制定基本政策，进行大病保险，商业保险机构以保险合同方式承办，自负盈亏。实践证明，不仅这些地方的群众享受到更高水平的大病报销待遇，医疗保险的服务质量和水平有所提高，由于对医疗机构和医疗服务的管控更为严格，医疗服务行为也更趋合理，总体看放大了基本医保的保障效用。

In the past，The basic medical insurance handling usually has two forms，Mainly is the institution directly handling，Also some places entrust some professional institutions to provide part of the link service，Such as audit documents、Audit service behavior, etc。For further transform government functions，Innovation public service management，Improve service efficiency，A new round of reform, clearly put forward to explore“Entrust has the qualification of commercial insurance agency orgnaization of all kinds of medical insurance management service”。In recent years，Many places(For example, zhanjiang, guangdong、Jiangsu taicang、Henan luoyang, etc)Actively explore the government leading with market mechanism combining the innovation form，Out part of the funds，The government has formulated the basic policy，For serious illness insurance，Commercial insurance institutions to insurance contract the way，Responsible for their own profits and losses。Practice has proved，Not only the local people enjoy a higher level of a serious illness to submit an expense account treatment，Medical insurance service quality and improved，The medical institutions and medical service control more strictly，Medical service behavior is more reasonable，Overall see magnifies the basic medical insurance safeguard utility。

　　在总结地方经验和反复研究论证的基础上，城乡居民大病保险采取了政府主导、商业保险机构承办的方式。相比而言，商业保险机构以保险合同形式承办大病保险，主要具有几个优势：第一，能够充分发挥商业保险机构的专业特点，加大对医疗机构和医疗费用的制约。第二，可以借助商业保险机构在全国范围内统筹核算的经营特点，间接提高大病保险的统筹层次，增强抗风险能力，提高服务水平，放大保障效应。第三，利用商业保险机构专业化管理优势和市场化运行机制，有利于促进提高基本医保的经办效率。此外，这也有助于促进健康保险业发展，推动构建多层次医疗保障体系。

At the conclusion of the local experience and repeated on the basis of research，Urban and rural residents a serious illness insurance to take the government leading、Commercial insurance institutions undertaking way。compared，Commercial insurance institutions to insurance contract form undertaking serious illness insurance，Mainly has several advantages：The first，To give full play to the commercial insurance institutions professional characteristics，Increase of medical institutions and medical cost restriction。The second，Can use commercial insurance institutions across the country as a whole accounting business characteristics，Indirect improve serious illness insurance plan as a whole level，Increase its ability to resist risks，Raises the service level，Amplification security effect。The third，Use of commercial insurance institutions professional management advantages and market operation mechanism，To promote the improvement of the basic medical insurance orgnaization of efficiency。In addition，It also helps to promote the healthy development of the insurance industry，Push for the establishment of an multi-level medical security system。

　　大病保险的这种承办方式，是在中国特色社会主义基本理论指导下，结合中国当前国情，对公共服务管理和运行模式所作的大胆探索与创新，国际上先例并不多。采用这种方式的基本想法是，在以保公平为基础和目标的前提下，更好地发挥市场竞争在提升效率和优化资源配置方面的作用。

A serious illness insurance for this way，In socialism with Chinese characteristics under the guidance of the basic theory，According to China's current national conditions，For the public service management and operation mode of the bold exploration and innovation，International precedent is not much。Using this kind of basic idea is，In order to protect fair as the foundation and the premise of target，Better to play the market competition in promote efficiency and optimize the allocation of resources the role。

　　四、对商业保险机构承办大病保险有哪些明确要求？ four、To commercial insurance institutions undertaking serious illness insurance what clear requirements？

　　为保障大病保险工作顺利开展，确保商业保险机构为参保群众提供优质的大病保险保障，《指导意见》指出，开展城乡居民大病保险坚持政府主导，政府负责基本政策制定、组织协调、筹资管理以及监管指导。商业保险机构按照政府的要求，为参保群众提供大病保险保障。

To ensure a serious illness insurance work smoothly，Ensure that commercial insurance institutions to join the masses to provide high quality serious illness insurance，《Guiding opinions》Pointed out that，Urban and rural residents to carry out a serious illness insurance adhere to the guidance of the government，The government is responsible for the basic policy、Organization and coordination、Financing management and supervision guide。Commercial insurance institutions shall, in accordance with the requirements of the government，To join people with serious illness insurance。

　　对商业保险机构的要求具体包括三个方面：一是制定了商业保险机构的基本准入条件。要求承办大病保险的商业保险机构必须在中国境内经营健康保险专项业务5年以上；具备完善的服务网络和较强的医疗保险专业能力；配备医学等专业背景的专职服务人员；能够实现大病保险业务单独核算等等。二是规范大病保险招标投标与合同管理。要求遵循收支平衡、保本微利的原则，合理控制商业保险机构盈利率，建立起以保障水平和参保人满意度为核心的考核办法。三是要求商业保险机构不断提升大病保险管理服务的能力和水平。提供“一站式”即时结算服务，确保群众方便、及时享受大病保险待遇。发挥商业保险机构全国网络等优势，为参保人提供异地结算等服务。

To commercial insurance agency requirements specific includes three aspects：A is formulated the commercial insurance agencies access to basic conditions。Requirements for serious illness insurance business insurance institutions within the territory of China must be in business health insurance special business five years；Has perfect service network and strong medical insurance professional ability；Equipped with medical and other professional background professional service personnel；Will be able to realize the serious illness insurance business accounted for separately, etc。The second is a serious illness insurance standard tender and bid and contract management。Request to follow a balance、Break-even meager profit principle，The reasonable control of commercial insurance institutions rate of return，Set up to safeguard level and ginseng protect people satisfaction assessment method as the core。Three is to require commercial insurance institutions continuously improve serious illness insurance management service ability and level。provide“one-stop”Instant settlement services，Ensure that the masses convenient、Enjoy a serious illness insurance treatment in time。Play commercial insurance institutions such as the national network advantage，To join people provide different settlement and other services。

　　五、如何实施有效监管？ five、How to implement the effective supervision？

　　城乡居民大病保险惠及全民，要把这件好事办好，加强监管尤为重要。这项工作涉及到多个部门、多个环节、多方利益，要形成部门联动、全方位的监管机制。

Urban and rural residents a serious illness insurance benefit all the people，To put this good thing to do good，Strengthening the supervision of particularly important。The job involves many departments、Multiple link、multi-stakeholder，To form department linkage、A full range of supervision mechanism。

　　第一，加强行业监管。保险监管部门要从行业监管的角度，做好从业资格审查、服务质量与日常业务监管等行业监管。对无故拒绝赔付等情况，要坚决加大查处力度。

The first，Strengthen the industry regulator。Insurance supervision departments should proceed from the Angle of supervision industry，Completes the practice qualification examination、Service quality and daily business supervision etc supervision。For without cause refused to compensate, etc，With the increasing investigation dynamics。

　　第二，注重部门协同。相关部门要各负其责，配合协同，加强对商业保险机构承办大病保险的监管。卫生、人力资源社会保障部门督促商业保险机构按合同要求提高服务质量和水平，并维护参保人信息安全，防止信息外泄和滥用。财政部门要制定相应的财务列支和会计核算办法，加强基金管理。审计部门按规定进行严格审计。

The second，Pay attention to department coordination。Related departments to individual，Work together，Strengthen the commercial insurance institutions undertaking serious illness insurance regulatory。health、Human resources social security departments supervise and urge the commercial insurance institutions according to the contract requirements to improve service quality and level，And maintain ginseng protect people information security，Prevent information disclosure and abuse。Financial department should formulate corresponding financial recovery and the accounting method，Strengthening fund management。Audit department according to the provisions of the audit strictly。

　　第三，加强社会监督。将与商业保险机构签订协议的情况，以及筹资标准、待遇水平、支付流程、结算效率和大病保险年度收支情况等向社会公开，接受社会监督。

The third，Strengthening social supervision。Will and commercial insurance agency agreement situation，And financing standard、Treatment level、Payment process、Settlement efficiency and serious illness insurance annual balance and so on to the public，Accept social supervision。

　　第四，强化医疗费用管控。相关部门和机构通过多种方式加强监督管理，防控不合理医疗行为和费用，并保障医疗服务质量。卫生行政部门要加强对医疗机构、医疗服务行为和质量的监管。商业保险机构要充分发挥医疗保险机制的作用，与卫生、人力资源社会保障部门密切配合，加强对相关医疗服务和医疗费用的监控。

The fourth，Reinforcement of medical cost control。Related departments and institutions through a variety of means to strengthen supervision and management，Prevention and control unreasonable medical behavior and cost，And guarantee medical service quality。The public health administrative departments should strengthen the medical institutions、Medical service behavior and quality supervision。Commercial insurance institutions should give full play to the role of the medical insurance system，And health、Human resources department of social security close cooperation，Strengthen the related medical service and medical cost monitoring。

　　六、如何开展好城乡居民大病保险工作？ six、How to develop good urban and rural residents a serious illness insurance work？

　　考虑到大病保险是一项创新的工作，且我国区域差异较大，《指导意见》对开展大病保险工作的原则、资金来源、保障内容、承办方式和监督管理等只是提出了原则性、框架性要求，具体工作需要充分结合地方实际，以地方为主，发挥地方的能动性。例如，出资金额、分段报销比例等都要进行科学测算和细化，对商业保险机构招标、合作与监督办法，更需逐步摸索与完善。因此，为保障大病保险工作的有序推进，有几项工作要求：

Considering the serious illness insurance is an innovative work，And regional differences，《Guiding opinions》To carry out a serious illness insurance work principle、Capital source、Security content、The way and the supervision and management of principle is put forward、Framework requirements，Specific work requires full combination of local actual，Mainly in place，Play to the initiative of the place。For example，Investment amount、Section ratio to submit an expense account to the scientific measurement and refining，Commercial insurance institutions for bidding、Cooperation and supervision methods，Need more gradually grope and perfect。therefore，To ensure a serious illness insurance work orderly propulsion，There are several job requirement：

　　第一，必须统一思想，充分认识开展大病保险工作的重要性。这是一件惠民利民的大事，是健全全民医保体系的重要工作。要求各地高度重视，精心谋划、周密部署，制定相应的实施方案。

The first，Must unify their thinking，Fully understand the importance of work to carry out a serious illness insurance。This is a great country and we，Is the perfect medical insurance system of the important work。Requires all attach great importance to，Carefully plan、Careful deployment，To formulate relevant implementation plan。

　　第二，要加强协作，各地要建立由多部门组成的大病保险工作协调推进机制。各部门要按照职责分工抓好落实，细化配套措施，并加强沟通协作，形成合力。中央有关部门将加强对城乡居民大病保险工作的指导协调。

The second，To strengthen cooperation，The various localities should set up by many departments of a serious illness insurance work coordination promoting mechanism。All departments shall, in accordance with the division of responsibilities in implementation，Refining supporting measures，And strengthen communication and coordination，To form the joint effort。The relevant departments will strengthen the urban and rural residents of a serious illness insurance work guidance and coordination。

　　第三，要先行试点，逐步推开。已经开展大病保险试点的省份要及时总结经验，逐步扩大实施范围。尚未开展试点的省份可以选择几个地(市)进行试点。

The third，To first pilot，Gradually pushed。Have launched a serious illness insurance pilot provinces to summarize the experience，Gradually expand the scope of implementation。Has not begin pilot provinces can choose some land(city)Pilot project。

　　第四，加强对大病保险政策的宣传和解读，增强全社会的保险责任意识，为大病保险实施营造良好的社会环境。

The fourth，To strengthen a serious illness insurance policy propaganda and reading，Enhance the whole society insurance responsibility consciousness，For serious illness insurance implementation to build a good social environment。