Zezhou county medical treatment insurance management center

A designated chronic disease refers to a chronic disease that requires long-term outpatient drug maintenance treatment and high medical expenses, which is determined by the local labor and social security administrative department in conjunction with the local financial department.

Second, the local administrative department of labor and social security, in conjunction with the local financial department, will increase the number of designated chronic diseases in stages and batches according to the balance of the medical insurance fund, and formulate corresponding access standards and outpatient specialty drug lists.

Three. If the insured suffers from a designated chronic disease, the designated social insurance medical institution designated by the local labor and social security administrative department shall go through the diagnosis and inspection procedures according to the following procedures: 1 The attending physician shall fill in the diagnosis certificate of chronic diseases designated by medical insurance. , by the corresponding professional subtropical high above the professional and technical titles of doctors or department director signature audit, medical department or medical insurance department to confirm and seal, by the designated medical institutions will "certificate" content input medical insurance information system, passed to the local medical insurance agencies for examination and confirmation. Designated medical institutions shall submit original vouchers to local medical insurance agencies every month. Insured persons who have been diagnosed with a designated chronic disease in the past and continue to take medicine in recent months should provide the attending physician of the designated medical institution with the recent outpatient medical records and the relevant information of the original diagnosis of the disease, and then handle it according to the above procedures. Designated medical institutions shall provide the insured with a "certificate" that meets the designated access standards for chronic diseases. 2. For medical treatment in different places, the insured person shall be issued a "certificate" by the local social insurance designated medical institution or the local medical institution above the second level that I have filed with the local medical insurance agency, and reported to the local medical insurance agency for examination and confirmation.

Four, the insured person suffering from designated chronic diseases, confirmed by the local medical insurance agencies, enjoy the following outpatient medical insurance benefits. If the insured person goes to the local social insurance designated medical institutions for outpatient treatment, or goes to other places for medical treatment according to the regulations, the medical expenses within the scope of the outpatient special drug list corresponding to the chronic diseases shall be paid by the basic medical insurance pooling fund according to the standard of 80% of local community health service institutions (except those established by the headquarters of secondary and tertiary medical institutions) and 60% of other medical institutions. The insured shall have a maximum payment limit for outpatient special drugs for each designated chronic disease. Insured persons with multiple designated chronic diseases can choose at most two of them to enjoy the corresponding outpatient medical treatment. The monthly maximum payment limit standard of the basic medical insurance pooling fund is valid in the current month, and it is not cumulative or cumulative. During hospitalization, the insured person shall not enjoy the medical treatment of designated chronic diseases outpatient service at the same time.

Five, the insured person in the designated medical institutions for medical treatment in the designated chronic disease outpatient specialized drug costs, belonging to the basic medical insurance fund payment, by the designated medical institutions for bookkeeping, monthly summary to the local medical insurance agencies to apply for settlement, belonging to the personal payment, paid by personal medical accounts or cash.

Six, enjoy the designated chronic disease outpatient medical treatment of the insured shall be unified use of local medical insurance special outpatient medical records, and properly keep the medical records and auxiliary examination results for future reference. Problems needing attention

First, the improvement of management mechanism-outpatient patients with medical insurance records, "outpatient specific project cards" and ic cards will all enter the medical insurance information system for management. Designated hospitals should input each specific disease and cost into the medical insurance computer system within the same day, and provide patients with a list of each special cost in time, which should be signed by the insured patients. The patient pays a certain amount of advance payment according to the relevant regulations and quota standards, and the personal payment part is settled according to the medical expenses printed by the hospital at the time of checkout every year. The expenses of outpatient specific projects that should be borne by the overall fund shall be settled by the municipal medical insurance center and designated hospitals, and individuals shall no longer be reimbursed by the medical insurance center.

Outpatient patients with chronic diseases directly report to the designated medical institutions, fill in the files, and the designated medical institutions will be uniformly numbered and registered after preliminary identification, and submitted to the medical insurance agency at a unified time; The organization regularly organizes expert reviews, and after the review, the compliance rate of each medical institution is calculated. When the medical insurance agency makes annual settlement and payment to the designated medical institutions, it will multiply the calculation cost by the compliance rate of each medical institution, which will directly affect the payment of each designated medical institution.

The main feature of chronic disease management is to integrate related medical resources to achieve the goal. The smooth implementation of the disease management plan depends on the cooperation of many departments. At present, the administrative department is vigorously developing community health services. It is foreseeable that community health service institutions will gradually have the ability to diagnose, treat and manage chronic diseases through continuous development and self-improvement. Under the guidance of medical insurance institutions, special chronic disease management plans and medical expenses payment plans can be launched.

Consult social security bureau to manage medical insurance.

Audit and reimbursement of supplementary medical insurance expenses

I. Handling conditions: Insured persons participating in supplementary medical insurance, including

1. Suffering from twelve chronic diseases: diabetes, hypertension (stage II and III), chronic hepatitis (except hepatitis A), malignant tumor, coronary heart disease, Parkinson's disease, sequelae of stroke (including cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage), chronic bronchitis (including bronchial asthma), chronic nephritis (including renal insufficiency), rheumatoid arthritis and systemic diseases.

2, the overall fund to pay the maximum amount of more than 40 thousand yuan of medical expenses.

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