Can residents’ medical insurance use state-negotiated drugs?

Starting from March 1, the 2020 version of the national medical insurance negotiation drug outpatient medication guarantee mechanism will be implemented in Chongqing. Who is protected by this mechanism? What is the scope of medicines? On March 12, the relevant person in charge of the Municipal Medical Insurance Bureau interpreted the "Notice on Establishing a National Medical Insurance Negotiation Drug Outpatient Medication Guarantee Mechanism". At present, Chongqing has included 102 kinds of drugs in the scope of outpatient drug coverage negotiated by the national medical insurance.

“Since there are many types of state-negotiated drugs, most of them are relatively expensive, their applicable diseases are clear, and their use conditions are high, it is difficult for all medical institutions to be equipped with state-negotiated drugs.” The relevant person in charge of the Municipal Medical Insurance Bureau People said that in order to promote the better implementation of the drugs negotiated by the national medical insurance, our city has established an outpatient medication guarantee mechanism for the drugs negotiated by the national medical insurance based on the actual situation.

The targets protected by this mechanism are patients insured by the city’s employee medical insurance and resident medical insurance who are diagnosed and need to use state-negotiated drugs and meet the disease scope restricted by drugs. Specifically, insured persons suffering from certain diseases.

The scope of drugs in the outpatient drug guarantee mechanism of national medical insurance negotiated drugs includes two categories. One is the nationally negotiated drugs that fall within the scope of reimbursement for special diseases (hereinafter referred to as "nationally negotiated outpatient drugs for special diseases"); the second is nationally negotiated drugs. Among the drugs, those that are not covered by special disease protection in our city’s outpatient clinics but are suitable for outpatient treatment, have a long use period, and have high treatment costs, as well as drugs that have clear clinical pathways and clear applicable diseases (hereinafter referred to as “National Outpatient Guaranteed Drugs”). There are currently 102 types of drugs included in the scope of protection. In the future, the scope of drugs will be dynamically updated based on the status of national drug negotiations.

According to the relevant person in charge of the Municipal Medical Insurance Bureau, patients can buy state-negotiated drugs at the following places and be reimbursed in real time. The first is a hospital designated by the state for drug negotiation; the second is a medical insurance designated pharmacy that meets the conditions. As of February 25, there are 25 pharmacies in our city that provide drug services to patients receiving guaranteed medication from the national outpatient service. For specific information, please consult the local medical insurance office. The third is Chongqing Fourth People's Hospital (Emergency Center), the Third Affiliated Hospital of Chongqing Medical University (Jier Hospital), Children's Hospital Affiliated to Chongqing Medical University, University Town Hospital Affiliated to Chongqing Medical University, Chongqing Mingbo Hospital, etc. "Internet" medical insurance designated hospital.

In terms of reimbursement, outpatient use shall be implemented in accordance with the city's outpatient special disease reimbursement policy; inpatient patients who need to purchase from designated pharmacies under special circumstances shall be settled according to the hospital's inpatient reimbursement policy for that hospitalization, such as If the patient purchases medical expenses while he is hospitalized in a tertiary hospital, reimbursement will be based on the reimbursement ratio of the patient in the tertiary hospital.

In terms of the deductible payment standard, when insured persons who do not fall within the scope of special diseases use the national outpatient guaranteed medicines in outpatient services, they will be charged according to the outpatient special disease deductible standard of the designated hospital. If the deductible payment standard is exceeded, the payment will be prorated. to reimburse. For example: if the employee medical insurance insured uses the outpatient service of a tertiary hospital, it will be the same as the special disease outpatient deductible of the employee medical insurance patient at the tertiary hospital, and will only be counted once in the year; the outpatient service of the insured falling within the scope of special disease When using drugs for special diseases in the National Outpatient Clinic, the minimum payment standards for special disease outpatient clinics and the National Outpatient Clinic are calculated together, and charged once according to the highest designated hospital level. For example, if patients under the employee medical insurance are assigned to a second-level hospital for special diseases, and the state-controlled outpatient medicines for special diseases are assigned to a third-level hospital, the minimum payment standard will be calculated according to the third-level hospital.

Let’s look at the reimbursement ratio. The reimbursement ratio for employees’ medical insurance outpatient clinics is 80% when they use the national outpatient insurance. If the cumulative reimbursement reaches a large amount for employees, it will be reimbursed according to the current employee large-amount medical policy, that is, the reimbursement ratio is: 100; The reimbursement ratio for outpatient medical insurance for outpatients using national outpatient insurance shall be based on the reimbursement ratio for major diseases among special outpatient diseases, which is the same as the inpatient reimbursement ratio for resident medical insurance of the hospital; if the cumulative reimbursement for residents' serious diseases is based on the current residents' critical illness insurance policy to reimburse.

When patients settle at designated hospitals or designated pharmacies, they only need to pay the portion that should be borne by the individual according to regulations.