Proportion of reimbursement for chronic special diseases in Nanchang

It is the payment time of medical insurance for urban and rural residents in Jiangxi Province in 2023.

I wonder if the treasure can be seen here.

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Everybody, 350 yuan! In 2023, medical insurance for urban and rural residents in Jiangxi Province began to pay!

Then the oil steamed stuffed bun will ask

How to reimburse my residents' medical insurance?

Can all cases be reimbursed?

Let's get to know each other.

First, under normal circumstances, the reimbursement of medical insurance expenses follows the following rules. As long as the medical expenses are within the scope of these rules, they can be reimbursed according to the proportion or limit:

During normal treatment (medical insurance is not paid off)

Seek medical treatment in designated medical institutions

Meet the "three catalogues" of basic medical insurance (basic medical insurance drug catalogue, diagnosis and treatment items and medical service facilities standards).

Above the deductible line, within the capping line.

Comply with the corresponding treatment policies and regulations such as hospitalization, general outpatient service, outpatient specific diseases and supplementary medical insurance. In contrast, expenses outside the rules cannot be reimbursed.

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Second, how to reimburse Class A and B drugs?

Drugs in the medical insurance drug list are also divided into "Class A" and "Class B". When calculating the reimbursement amount, the proportion of the two types of drugs is also different.

Class A drugs in the medical insurance drug list are necessary for clinical treatment, which are widely used and have good curative effect, and their prices are lower among similar drugs. When the insured uses such drugs, they can all be included in the scope of reimbursement and reimbursed according to the prescribed proportion.

Class B drugs can be used in clinic with good curative effect, and the price of similar drugs is higher than that of class A drugs. When using Class B drugs, the insured must first deduct a certain amount of personal out-of-pocket expenses according to the proportion of 5%, and then include the remaining expenses in the scope of reimbursement and reimburse them according to the prescribed proportion.

"Class A" and "Class B" drugs are included in the national centralized procurement, and the centralized procurement of drugs has corresponding payment standards. The medical insurance fund will be reimbursed in proportion within the payment standards, and the part exceeding the medical insurance payment standards will be borne by individuals.

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First, outpatient special chronic disease treatment

Outpatient treatment of special chronic diseases is managed by designated medical institutions. There is no personal down payment ratio for outpatient examination, diagnosis and treatment and medication within the scope of outpatient special chronic diseases, and the proportion of overall fund payment is implemented with reference to the proportion of hospitalization payment, that is, 90% of designated medical institutions at the first level (including below the first level), 80% of designated medical institutions at the second level and 60% of designated medical institutions at the third level.

There are 30 kinds of special chronic diseases in outpatient clinics of urban and rural residents, which are divided into two categories.

Class I, 8 kinds: malignant tumor, systemic lupus erythematosus, aplastic anemia, Parkinson's syndrome, chronic renal failure (uremia stage), anti-rejection therapy after organ transplantation, hemophilia, thalassemia (including blood transfusion).

Type II, 22 species: psychosis 4000 yuan, hypertension 4000 yuan, diabetes 5000 yuan, tuberculosis 4000 yuan, coronary atherosclerotic heart disease (after coronary stent implantation) 4500 yuan, chronic heart failure (heart with cardiac insufficiency above Grade II) 5000 yuan, chronic atrial fibrillation 5000 yuan, cardiomyopathy (primary) 50000 yuan. The quota is 4,000 yuan for chronic bronchitis, 4,000 yuan for chronic obstructive pulmonary disease, 4,000 yuan for chronic bronchial asthma, 6,000 yuan for liver cirrhosis, 4,000 yuan for chronic nephropathy, 6,000 yuan for stroke sequelae, 5,000 yuan for epilepsy, 6,000 yuan for myasthenia gravis, 4,000 yuan for schistosomiasis, 5,000 yuan for growth hormone deficiency in children, 5,000 yuan for cerebral hemorrhage, cerebral infarction and cerebral thrombosis.

The annual maximum payment limit for Class I diseases shall be implemented according to the annual maximum payment limit of hospitalization pooling fund (including serious illness medical insurance).

Suffering from a variety of outpatient special chronic diseases (excluding Class I and AIDS), the maximum amount is calculated according to the cumulative amount of approved diseases, and the maximum amount does not exceed 7,000 yuan/year.

All outpatient special chronic diseases are included in the calculation range of the annual maximum payment limit of hospitalization pooling fund and the annual maximum payment limit of serious illness insurance.

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Second, hospitalization

(a) the proportion of medical expenses within the scope of Qifubiaozhun and policy:

First-class medical institutions

Secondary medical institutions

Tertiary medical institutions

Qifubiaozhun

0 yuan

400 yuan

600 yuan

Payment proportion

90%

80%

60%

The medical expenses within the scope of the policy refer to the part after deducting the expenses paid by individuals, the over-standard bed fee, the minimum payment standard, the out-of-pocket expenses and the over-limit expenses of price-limited materials.

(2) The annual maximum payment limit of basic medical insurance for urban and rural residents is 654.38+10,000 yuan.

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A, outpatient expenses reimbursement processing materials

1. Electronic medical insurance certificate or valid ID card or social security card;

2. Hospital bills;

3. List of outpatient and emergency expenses;

4. If the accidental injury involves a third party, it shall provide the traffic police accident certificate, court judgment, mediation agreement and other relevant certification materials issued by the public security department. If it cannot be provided, a personal commitment letter shall be filled in;

5. Pre-hospital emergency needs to provide emergency diagnosis certificate.

Second, the hospitalization expenses reimbursement materials

1. Electronic medical insurance certificate or valid ID card or social security card;

2. Hospital bills;

3. List of hospitalization expenses;

4. Medical record (discharge record or diagnosis certificate);

5. In case of accidental injury to a third party, it shall provide the traffic police accident certificate, court judgment, mediation agreement and other relevant certification materials issued by the public security law department. If it cannot be provided, a personal commitment letter shall be filled in.

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Slide view:

1, Nanchang Medical Insurance Enterprise Management Office

Tel: 079 1-8663872 1

Address: Floor 2, Human Resources and Social Security Service Center, No.369, Fenghe Kitaoji, Honggutan New District, Nanchang/

2. donghu district Medical Security Service Center

Tel: 079 1-87838942

Address: Floor 2, Administrative Service Center, No.55 Longsha Road, donghu district, Nanchang.

3. Xihu District Medical Security Service Center

Tel: 079 1-86565028

Address: Fusheng Road 168 Wisdom West Lake Courtyard.

4. qingyunpu district Medical Security Service Center

Tel: 079 1-884625 19.

Address: Medical Insurance Window of qingyunpu district Citizen Service Center Building, No.995 Guangzhou Road, qingyunpu district, Nanchang.

5. Qingshan Lake Medical Security Service Center

Tel: 079 1-838592 12.

Address: No.262 Min 'an Road, Qingshanhu District, Nanchang

6. Wanli District Medical Insurance Administration

Tel: 079 1-837697 1, 079 1-83769773.

Address: Floor 2, Administrative Service Center, Lingxiuhu Street 1, Wanli District, Nanchang

7. Honggutan District Medical Security Bureau

Tel: 079 1-838592 12.

Address: 4th Floor, Civic Center Building, No.366 Chayuan Street.

8. New District Medical Insurance Administration

Tel: 079 1-83703856, 1527086030.

Address: Floor 1, Medical Insurance Handling Hall, No.229 Xingguo Road

9. Nanchang County Medical Security Service Center

Tel: 0791-85718618,85720062.

Address: No.542, Hu Cheng East Road, Li Antang Town, Nanchang County.

Jinxian county medical insurance service center 10

Tel: 0791-85667990 85667901

Address: Floor 2, Human Resources and Social Security Bureau, Jinxian County, Nanchang

1 1, Anyi county medical security service center

Tel: 079 1-8770 1527

Address: Floor 2, Medical Insurance Bureau, No.41Chuangye Incubation Street, Anyi County, Nanchang

12, Social Insurance Management Office of Economic Development Zone

Tel: 079 1-83802220

Address: Social Security Agency Hall, 1st floor, No.528 Shuanggang West Street, Human Resources Industrial Park, Economic Development Zone

13, Social Security Department of Organization and Human Resources Department of High-tech Zone

Tel: 079 1-883 12797.

Address: Human Resources Industrial Park, Building 203, Green Rose City, Aixihu North Road 129, High-tech Zone, Nanchang