Proportion of reimbursement for serious (chronic) diseases in outpatient department

Within one year, the cost of diagnosis and treatment of chronic diseases exceeds that of 500 yuan, and that of two diseases exceeds that of 700 yuan, which is within the scope of medical insurance. Reimbursement of medical insurance fund is 60%, and the scope of reimbursement of serious illness medical insurance: medical expenses exceeding the maximum payment limit of the basic medical pooling fund will be reimbursed by the social security department for 85% below 0-40 thousand yuan and 90% below 40-80 thousand yuan.

Reimbursement scope of serious illness medical insurance: medical expenses exceeding the maximum payment limit of the basic medical co-ordination fund will be reimbursed by the social security department for 85% below RMB 0-40 thousand, 90% below RMB 40-80 thousand and 95% above RMB 80 thousand. The maximum payment limit for each medical year is 6.5438 yuan +0.5 million yuan.

According to the relevant regulations, local enterprises (hereinafter referred to as enterprises) and their employees and retirees who are applicable to cities, districts and counties within the administrative area of this Municipality can enjoy medical insurance for serious illness. Retirees who do not pay the basic medical insurance premium and continue to enjoy the basic medical insurance benefits are not in the "serious illness medical insurance coverage".

Serious illness medical care can be divided into two types from the form of insurance. One is serious illness social insurance, which is a special medical insurance fund set up to ensure the medical needs of urban workers for major diseases. It is used to pay the medical expenses that the insured person has accumulated over the maximum payment limit of the basic medical insurance for urban workers during the year. The other is the serious illness medical treatment in commercial insurance, which is the major illness protection that the insurance company underwrites for a specific insurer according to the insurance clauses.

It should be noted that the explanations of these two serious diseases in the scope of medical insurance are not exactly the same, and consumers should have a choice when insuring and using them.

At present, people are plagued by hypertension, hyperlipidemia, hyperglycemia and fatty liver everywhere, and the age of illness is getting younger and younger. It is reported that the youngest hypertensive patient is only 6 years old! Moreover, some diseases that were originally major diseases began to become common. Many insurance institutions' medical insurance for serious illness has also been adjusted accordingly.

The actual medical expenses incurred in the reimbursement of social security serious illness within the scope of medical insurance need to be invoiced, which can be divided into ordinary outpatient and emergency expenses reimbursement and hospitalization expenses reimbursement, as well as large medical co-ordination, with a certain limit; The serious illness expenses within the medical insurance coverage of commercial insurance are paid in advance, that is, as long as the serious illness on the policy is diagnosed in the hospital, it will be paid in full according to the contract immediately.

Social security ability is limited, and only a low level of security can be given; Commercial insurance can be paid according to the insured amount set by the insurer.

The medical insurance for major diseases does not cover the following areas:

1. See a doctor in a non-designated hospital without approval (except for emergency rescue);

2. Suffering from occupational diseases, work-related injuries or recurrence of old injuries;

3. Injuries caused by traffic accidents;

4. Injuries caused by my illegal acts;

5. Food poisoning caused by accidents;

6. receiving treatment for suicide;

7. Injuries caused by medical accidents;

8. According to the regulations of the state and this Municipality, medical expenses should be taken care of.

legal ground

Notice of the Provincial Health Insurance Bureau and the Provincial Department of Human Resources and Social Security on Doing a Good Job in the Implementation of the National Drug List of Basic Medical Insurance, Work Injury Insurance and Maternity Insurance (No.75 [2019] of Wu Medical Insurance).

First, the individual pays 10% for Class B drugs first, and the balance is reimbursed according to the prescribed proportion of treatment and hospitalization in general outpatient department and serious (chronic) outpatient department.

Two, according to the requirements of the provincial documents, the proportion of drug payment negotiated by the state is 20%. If the original provincial advance payment ratio exceeds 20%, it shall be implemented according to 20%; If the original provincial upfront self-payment ratio is less than 20%, it shall still be implemented according to the original self-payment ratio. When the insured uses the negotiated drugs, he shall pay in advance according to the determined out-of-pocket ratio, and then pay according to Class B drugs. If the original self-payment ratio is not set, it will be paid according to Class B drugs.

3. For the insured patients who started taking drugs before Feb. 3, 2009 and failed to renew their contracts successfully, a transition period of no more than 6 months will be implemented. During the transition period, the medical insurance fund will continue to pay according to the original policy, and designated medical institutions need to do a good job in clinical drug substitution to ensure the continuity of drug use for insured patients.

Four, for the negotiation of drugs suitable for outpatient treatment, long use cycle, high cost of treatment of severe (chronic) diseases, according to the current policy of outpatient treatment.

Five, anticancer drugs and rare disease negotiation drugs continue to implement the management mechanism of designated medical institutions, responsible doctors and designated retail pharmacies.

Six, the negotiation of drugs are specialized drugs, designated medical institutions can be included in the corresponding specialized management in accordance with the principle of specialized drug use, standardized drug use, reasonable treatment.

Seven, designated medical institutions for the rational use of anti-cancer drugs negotiated drugs to implement separate accounting, rational use of other negotiated drugs compliance costs will be given reasonable compensation at the end of the year. All designated medical institutions should ensure the preparation and use of negotiated drugs.