央视网消息：据国家医保局微信公众号消息，医保基金是人民群众的"看病钱""救命钱"，其规范合理使 用关系着广大参保群众的切身利益。前期，国家医保局发布首期7起个人骗取医保基金典型案例。为进 一步彰显对欺诈骗保行为的"零容忍"态度，强化法治宣传和警示教育，引导全社会共同维护医保基金安 全，现发布第二期11起个人骗取医保基金典型案例。 案例一 江苏省泰州市参保人景某等倒卖医保药品骗保案 2023年3月，江苏省泰州市医保部门在对定点医疗机构申报的医药费用审核时发现，本市参保人景某存 在频繁跨院挂号并超量开具他克莫司等高价药品的异常行为，随即会同公安机关开展联合查办。经查， 景某利用享受特殊疾病医保待遇便利，通过虚构用药需求、重复挂号就诊等方式，在多家医院超量购取 医保药品，随后以低价转卖给收药中间人刘某。刘某明知药品系骗保所得，仍长期收购并通过唐某某等 人搭建跨省销售渠道，形成"骗药—收购—跨省倒卖"的完整犯罪链条。该案共造成医保基金损失28万余 元，其中景某非法获利4万元，刘某、唐某某共同获利3.5万元。 2025年7月，泰州医药高新技术产业开发区人民法院以诈骗罪判处景某有期徒刑3年，缓刑3年6个月，并 处罚金3万 ...

人民财讯9月27日电，9月26日上午，国家医保局开展医保基金管理突出问题专项整治工作第三次全国视 频调度，总结上一阶段专项整治进展成效，并对开展"百日行动"作出部署。部署要求，此次"百日行 动"要聚焦医保领域突出违法违规问题，紧盯倒卖医保回流药、违规超量开药、生育津贴骗保三大重点 任务，开展集中攻坚、精准整治，依法依规、严查严打，力争在全国范围内基本肃清倒卖医保回流药等 问题，深度净化医保基金运行环境。 ...

Core Points - The National Healthcare Security Administration (NHSA) issued the "National Long-term Care Insurance Service Project Directory (Trial)" on September 25, which mandates strict adherence to the directory for new long-term care insurance regions [1] - The directory includes a total of 36 service items categorized into daily living care and medical care, with 20 items under daily living care and 16 items under medical care [3] - NHSA plans to explore the inclusion of intelligent services and supportive assistive devices related to long-term care into the payment scope at the national level [5] Summary by Category Service Items - The directory specifies 36 service items, divided into two main categories: daily living care and medical care [3] - Daily living care includes 20 items aimed at assisting individuals in maintaining basic living abilities, covering areas such as dietary care, hygiene, and safety monitoring [3] - Medical care consists of 16 items, including general nursing, basic care, specialized care, and rehabilitation services [3] Implementation Guidelines - New regions implementing long-term care insurance must strictly follow the directory and cannot arbitrarily adjust or change the service scope [1] - Existing pilot cities with their own long-term care service project directories are required to align with the national directory within approximately three years [1]

Group 1 - The National Healthcare Security Administration (NHSA) has initiated a "100-day action" to address prominent issues in medical insurance fund management, focusing on illegal practices such as the resale of medical insurance drugs and fraudulent prescriptions [1] - The NHSA has launched a special investigation into excessive prescription practices, monitoring abnormal prescription behaviors and mismatches between prescriptions and diagnoses [1] - The NHSA is also targeting fraudulent claims related to maternity benefits [1] Group 2 - The NHSA has released a trial version of the "National Long-term Care Insurance Service Project Directory," which standardizes service items and payment scope for long-term care insurance [3] - The directory categorizes services into two main types: daily living care and medical care, with specific activities outlined under each category [3] - Regions starting new long-term care insurance programs must adhere strictly to the directory and cannot arbitrarily change the service scope [5] Group 3 - The NHSA is exploring the inclusion of intelligent services and supportive assistive devices related to long-term care in the payment scope [6] - Currently, nearly 190 million people are enrolled in China's long-term care insurance, with over 100 billion yuan accumulated in funds and expenditures exceeding 85 billion yuan [8] - During the 14th Five-Year Plan period, the program has benefited over 2 million individuals with disabilities [8]

这是产生误会最重要的一点。医保基金的每一分钱都是所有参保人的共同财富，因此它必须确保用在最合理、最必需的地方，这就决定了它不能覆盖所有 医疗费用。 下面梳理了一份群众就医报销"必备知识"，希望能帮助大家更顺畅地就医，减少因不了解政策而产生的误解和麻烦。 "三个目录"要清楚：医保报销严格遵循《基本医疗保险药品目录》、《诊疗项目目录》和《医疗服务设施标准》。这意味着： 不是所有药都能报：进口药、特效药、保健品等可能不在目录内，需要自费。 不是所有检查治疗都能报：一些先进的、非必需的诊疗项目可能需要自费。 您在医生开具的账单上看到的"自费"项目，很多是由于不在目录内，而不是医保局不给报。 很多人生病到医院就医，遇到了报销环节的问题和困惑，这时候往往会责怪医保局。医保局因为参与了相关政策的制定者和基金的管理，很容易成为群众 就医不满的"焦点"，但很多时候，问题是多方因素共同造成的。 第一件事：医保不是"全能保险"，它有报销范围 很多人误以为医保局直接管着每一笔报销。其实，报销是一个涉及医院、医保系统、医保局三方的流程。 医院的角色： 第二件事：主动沟通，就医前先"三问" 很多误会发生在医院环节。由于医院也受医保协议管 ...

转自：北京日报客户端 务项目包括序号、项目代码、项目类别、项目名称、项目内涵、 服务要点等。其中,生活照护类项目包括为长期护理保险待遇享 受对象提供的日常生活照料及帮助维持其基本生活能力的服务; 医疗护理类项目包括为长期护理保险待遇享受对象提供的与基本 生活照料密切相关的基础医疗护理服务。各地要结合实际细化项 目服务内容,与国家目录保持代码、名称、内涵一致,根据实际 做好生活照护类和医疗护理类项目分类管理。 三、规范长护服务目录管理 国家医保局组织制定、调整和发布《长护服务项目目录》, 编制统一的项目代码。国家医保局根据长期护理保险基金运行情 况和失能人员需求发展变化探索建立长护服务项目目录动态调整 -2 - 机制,定期组织目录调整发布,各地根据国家政策要求同步调 整。符合《长护服务项目目录》的服务费用,按照规定由长期护 理保险基金支付。各地要依据《长护服务项目目录》,结合长护 待遇享受对象的实际需求,指导相关机构合理制定长期护理服务 计划,精准提供适宜服务。各地特别是实行城乡差异化缴费的地 区,要根据筹资情况、参保人需求、技术劳务复杂程度等因素合 理测算,确定相关项目服务时长以及参保人可享受的服务频次 等, ...

Core Points - The National Healthcare Security Administration (NHSA) issued the "National Long-term Care Insurance Service Project Directory (Trial)" on September 25, 2023, which outlines the services that must be provided to insured individuals in regions that have newly implemented long-term care insurance [1] - Existing pilot cities with established long-term care service project directories are required to align their original directories with the new national directory within approximately three years [1] - The directory includes a total of 36 service items, categorized into daily living care and medical care, with 20 items under daily living care and 16 items under medical care [1] Summary by Category Long-term Care Insurance Implementation - New regions implementing long-term care insurance must strictly adhere to the "Long-term Care Service Project Directory" and cannot arbitrarily adjust or change the service scope [1] - Pilot cities must ensure their existing directories are mapped to the new national standards within a three-year timeframe [1] Service Project Directory Details - The directory consists of 36 service items, divided into two main categories: - Daily living care includes 20 items such as dietary care, toileting care, hygiene care, dressing assistance, functional maintenance, symptomatic care, vital signs monitoring, and safety care [1] - Medical care includes 16 items related to basic medical care services closely associated with daily living support, including general examination care, basic care, specialized care, and rehabilitation [1]

今年前7个月 全国医保钱包转账达1.16亿元 据了解，以往职工医保个人账户里的资金只能本人使用，很多人由于就医买药花费少，甚至没有花费，导致大量个人账户资金"沉睡"，仅2024 年，我国职工医保个人账户累计结余就超过1.44万亿元。 近年来，国家医保局积极推动医保个人账户家庭共济，职工医保个人账户资金可以用于支付被共济的近亲属： 您平时关注职工医保个人账户余额吗？近期，随着医保便民服务升级，如果参保人参加职工医保，且个人账户上有富余资金，即便参与共济的 家人在外地，只要家人在当地参加基本医保，参保人就可以使用医保钱包向家人转账，实现个人账户资金跨省共济使用。 医保钱包家庭共济 缓解患者经济负担 医保钱包应该如何开立？医保钱包实现跨省共济，会对我们平时就医买药有什么影响？ 成都居民薛女士患有干燥综合征4年多，需要长期就诊，定期检查、开药。薛女士3年前还做过肺癌手术，每半年需做一次检查，最近一次检查 费用就达2000多元，而薛女士每月个人账户收入仅200元，远不够日常门诊开支。而在云南生活的父母，个人账户余额长期未使用。最近，薛 女士的母亲开通了医保钱包，将自己账户中的余额转到了薛女士的医保钱包。 薛女士表示，" ...

Core Points - The new healthcare policy in China will take effect from October 2025, significantly altering the reimbursement landscape for various medical expenses [1][3][4] - The policy aims to alleviate pressure on the medical insurance fund, which has been strained by rising healthcare costs and an increasing number of insured individuals [1][10] Summary by Categories Changes in Reimbursement Policy - Six categories of expenses will no longer be reimbursed by medical insurance starting October 2025, including non-essential nutritional supplements, special medical services, cosmetic surgery, non-therapeutic diagnostic tests, expensive traditional Chinese medicine, and services provided by non-medical institutions [3][4][5][8][10] - Non-medical essential nutritional supplements, such as vitamins and protein powders, will now be self-paid [3][4] - Special medical services that offer enhanced comfort and reduced wait times will also be excluded from reimbursement [4] - Cosmetic procedures aimed at improving appearance will not be covered, reinforcing previous regulations that were not strictly enforced [4][5] - Preventive diagnostic tests requested by individuals rather than prescribed by doctors will not be reimbursed [5][6] - Certain high-cost traditional Chinese medicine items will be removed from the reimbursement list, continuing a trend observed in previous adjustments [8] Implications for Healthcare Financing - The new regulations are expected to reduce the financial burden on the medical insurance fund, which has been under pressure due to rising medical expenses [5][10] - The healthcare market, particularly in cosmetic procedures, has seen significant growth, with the market size exceeding 450 billion yuan in the first half of 2025, indicating a shift towards self-funded healthcare options [5][8] - The policy reflects a broader challenge of balancing the sustainability of the medical insurance fund with the growing healthcare demands of an aging population [10] Public Awareness and Response - A significant portion of the insured population is unaware of the specifics of their medical insurance coverage, with surveys indicating that 67% do not understand the reimbursement scope [10][12] - Recommendations for the public include planning for medical expenses, considering supplementary commercial health insurance, and staying informed about policy changes to avoid unexpected costs [10][12]

政策普惠提高参保扩面的"温度"。参保扩面，不仅让人"进来"，还要把人"留住"。徐州通过政策创 新，增强医保吸引力。为促进灵活就业人员参加职工医保，徐州出台一系列优惠政策：灵活就业人员参 加职工医保，缴费比例在单位职工缴费比例基础上降低1个百分点。执行"医保家庭共济"政策，职工医 保的个人账户余额可以支付家庭成员城乡居民参保费用、就医费用，提高了医保基金使用效率，增强了 个人参保获得感。此外，还对困难群体实行分类资助参保政策：对特困人员给予全额资助，对低保对象 等给予定额资助，全市困难群体基本实现应保尽保。截至目前，地方财政已为符合条件的特困人员、低 保对象、重残人员等困难群体资助参保费用超过亿元，确保其无后顾之忧。 截至8月21日，徐州职工医保参保199.56万人，较上年底增加1.68万人，占比较上年底增加0.52个百 分点。截至7月，徐州市基本医疗保险参保人数已达918万，基本实现常住人口应保尽保。 医保覆盖面的扩大，关系千家万户的幸福安康。近年来，徐州医保部门创新工作方法，深入群众、 精准动员、优化服务，参保扩面工作取得显著成效。越来越多的市民被纳入医保"安全网"，获得健康保 障。 数据赋能提高参保扩面的 ...