Medical Insurance Outpatient Reimbursement Policy for Urban and Rural Residents in Dalian (implemented from June 65438+ 10/)
In order to implement the "Implementation Opinions on Establishing and Perfecting the Outpatient Security Mechanism of Basic Medical Insurance for Employees in the Province" (Liao Zhengban [2021] No.39) and the "Notice on Standardizing the Outpatient Security System for Chronic Diseases and Special Diseases in the Province" (Liao Medical Insurance [2022]17), the basic medical insurance for urban and rural residents in our city (hereinafter referred to as residents' medical insurance).
I. Scope of application
This notice applies to the medical insurance for residents insured in our city.
Second, the general outpatient service as a whole
The general outpatient (emergency) medical expenses (hereinafter referred to as general outpatient medical expenses) incurred by the insured in the general outpatient department in accordance with the medical insurance policy of designated medical institutions shall be paid by the residents' medical insurance pooling fund according to the following standards:
(1) Qifubiaozhun. General outpatient medical expenses incurred by special tertiary hospitals (including the First Affiliated Hospital of Dalian Medical University, the Second Affiliated Hospital of Dalian Medical University, Dalian Central Hospital and Zhongshan Hospital affiliated to Dalian University, the same below), other tertiary, secondary and primary hospitals (community health service centers, health centers and other medical institutions that are not rated according to regulations shall be implemented according to the standards of primary hospitals, the same below), and the annual cumulative deductible standards of the medical insurance pooling fund for minors and college students are 500 yuan and 350 yuan respectively. The annual accumulative qifubiaozhun for adult insured is 1000 yuan, 700 yuan, 300 yuan and 150 yuan respectively. The annual accumulative qifubiaozhun for the general outpatient medical expenses incurred by the insured in the specialized hospitals for infectious diseases and mental diseases is unified as 150 yuan. Personal out-of-pocket expenses reimbursed by the general outpatient co-ordination fund according to regulations are not included in the annual Qifubiaozhun of the insured general outpatient co-ordination.
(2) payment ratio. For general outpatient medical expenses that exceed the above-mentioned Qifubiaozhun incurred by the insured in tertiary (including special tertiary and other tertiary), secondary and primary hospitals, the proportion paid by the residents' medical insurance pooling fund is 50%, 55% and 60% respectively. The general outpatient medical expenses incurred by the insured in the specialized hospitals for infectious diseases and mental diseases shall be uniformly paid by the residents' medical insurance pooling fund, accounting for 60%.
(3) payment limit. The general outpatient medical expenses incurred by the insured, and the annual payment limit of the residents' medical insurance pooling fund is 500 yuan.
(4) preferential treatment. If the insured signed a contract with the family doctor of the primary medical institution to upgrade the service package and went to the primary medical institution for treatment, the payment ratio of the residents' medical insurance pooling fund increased by 5 percentage points.
Three, outpatient chronic diseases and special diseases
(1) treatment policy. The medical expenses incurred by the insured in the outpatient treatment of chronic diseases and special diseases in designated medical institutions within the scope of medical insurance policy shall be included in the coverage of outpatient chronic diseases and special diseases. The catalogue of chronic diseases and special diseases in outpatient department of our city, the duration of treatment and the level of treatment shall be implemented according to the regulations (annex 1). The scope of protection of some chronic diseases and special diseases in the province shall be implemented in accordance with the provisions of Liaoning Province (Annex 2). High-value drugs settled separately by medical insurance are not included in the scope of chronic diseases and special diseases in outpatient clinics.
Insured patients can enjoy a variety of outpatient treatments for chronic diseases and special diseases at the same time, but you can't have both in the same disease category. The outpatient co-ordination treatment of chronic diseases and special diseases and the general outpatient co-ordination treatment can have both. An outpatient medical fee can only be paid for one treatment. The insured person enjoys the treatment of chronic diseases and special diseases in outpatient department, and the maximum payment limit in that year is calculated on a monthly basis. The annual maximum payment limit for outpatient chronic diseases and special diseases is the total payment of basic medical insurance and supplementary medical insurance. Dialysis-related expenses incurred during hospitalization are included in hospitalization expenses and reimbursed according to hospitalization standards.
(2) the duration of treatment. Outpatient chronic special disease treatment period expires, stop enjoying the treatment qualification, still need to continue treatment, should re-apply for identification. Patients with chronic and special diseases have a long-term or five-year treatment period, and if there is no compliance medical expenses for 24 consecutive months after identification, their treatment qualification will be stopped.
(3) Handling service. The insured can enjoy the treatment of chronic diseases and special diseases in outpatient service only after being confirmed by clinical examination. The municipal medical security service center is responsible for handling services such as disease identification and medical settlement in accordance with the unified outpatient chronic disease identification standards and handling service processes in the province.
(4) Dialysis settlement method. The settlement method with the resident medical insurance outpatient dialysis designated medical institutions shall be implemented with reference to the relevant regulations on the management of employee medical insurance, and the monthly lump sum amount of the resident medical insurance co-ordination fund shall be 6000 yuan per person.
Four. any other business
(1) Treatment consolidation. Residents' medical insurance for outpatients with hypertension and diabetes will be retained and continued to be implemented. Not included in the scope of outpatient chronic diseases and special diseases, the original outpatient prescribed diseases, outpatient fixed-point drug supply, emergency rescue and discharge treatment will be merged into general outpatient co-ordination treatment, and unified cost guarantee will be implemented. Among them, the insured persons who have been recognized as enjoying the treatment of the first kind of diseases (except schizophrenia) and chronic heart failure diseases stipulated by the original outpatient service enjoy the transitional treatment of diseases: the annual payment limit of ordinary outpatient service is raised to 2000 yuan.
(2) seek medical treatment in different places. In accordance with the provisions of long-term residence in different places, residents' medical insurance insured persons enjoy the treatment of chronic diseases and special diseases in general outpatient clinics according to the treatment standards of this Municipality. Residents' medical insurance insured persons temporarily seek medical treatment in different places, and they do not enjoy the overall treatment of residents' medical insurance general outpatient service at the place where they seek medical treatment. Outpatient chronic diseases and special diseases enjoy treatment according to the treatment standard of this Municipality. The insured in different places dialysis treatment, according to the monthly reimbursement limit of 6000 yuan.
(3) Other circumstances. When the insured distributes drugs in the Internet medical prescription circulation pharmacy, the payment standard of the residents' medical insurance pooling fund is determined according to the level of the designated medical institution that issues prescriptions. The outpatient medical expenses incurred by the insured in the designated Internet medical institutions are combined with the offline outpatient medical expenses, and the payment standard of the residents' medical insurance pooling fund is determined according to the level of the designated medical institutions supported by the designated Internet medical institutions. If the insured person enjoys the overall treatment of general outpatient service midway, the Qifubiaozhun and payment limit shall be implemented according to the annual standard.
(4) time of execution. The provisions of this notice shall be implemented as of June 1 day, 2023. Notice of Dalian Medical Security Bureau on Issues Related to Overall Payment of Medical Expenses in Medical Insurance Outpatients of Urban and Rural Residents in Dalian (19 [2065438]) and Notice of Dalian Medical Security Bureau on Issues Related to Fixed-point Drug Supply in Outpatients of Recombinant Cytokine Gene Derived Protein (No.42, 2020), Notice of Dalian Medical Security Bureau on the diagnosis and treatment standards of chronic heart failure (NYHAII and above) and related issues of designated medical units (Da Medical Insurance Fa [2020] No.45) and Notice of Dalian Medical Security Bureau on Adjusting the diagnosis and treatment time of outpatient diseases such as malignant tumors (Da Medical Insurance Fa [2020] No.46), Notice of Dalian Medical Security Bureau on Adjusting Payment Standard of Medical Insurance for Outpatient Dialysis Treatment of Patients with Severe Uremia (Dabaofa [2020] No.70) and Notice of Dalian Medical Security Bureau on Adjusting Relevant Provisions on Examination and Diagnosis of Outpatient Diseases (Dabaofa [2020]103), Notice of Dalian Medical Security Bureau on medical insurance payment for outpatient emergency rescue (1 1 1) and notice of Dalian Medical Security Bureau on doing a good job in medical security for tuberculosis prevention and treatment in our city (1 17). Notice of Dalian Medical Security Bureau on Adjusting the Annual Payment Limit of Hemophilia Outpatient Medical Insurance Co-ordination Fund (No.50 [202 1]), Notice of Dalian Medical Security Bureau on Issues Related to Medical Insurance Payment for Endocrine Therapy in Malignant Tumor Outpatient (No.54 [202 1]) and Notice of Dalian Medical Security Bureau on Issues Related to Medical Insurance Payment for Minor Residents' Outpatient Rehabilitation.
Attachment:
1. Treatment table for chronic diseases and special diseases in residents' medical insurance outpatient department
2. The coverage of some disease expenses (for Trial Implementation)
Dalian Medical Security Bureau
65438+February 2, 2022
(This work is released to the public)
Attachment 1
Annex 2
Treatment table for chronic diseases and special diseases in residents' medical insurance outpatient department
Coverage of treatment for some diseases (for Trial Implementation)
I. Malignant tumor
1. The coverage of radiotherapy, chemotherapy, endocrine therapy and analgesic therapy for malignant tumors all includes adjuvant therapy. Those who receive radiotherapy and chemotherapy can receive endocrine and analgesic therapy, and those who receive endocrine therapy can receive analgesic therapy.
2. Adjuvant treatment of malignant tumor includes the following scope of protection: drugs related to diagnosis and treatment of malignant tumor (including some benign tumors), diagnosis and treatment items (examination and laboratory tests) and medical consumables. Drugs include western medicine and Chinese patent medicine in the national medical insurance drug list; Western medicine does not contain parenteral nutrient solution (injection, XB05BA), while Chinese patent medicine is limited to drugs in the drug list (classification code ZC). Medicare payment drugs should be strictly implemented in accordance with the limited scope of the national medical insurance drug list.
Second, dialysis.
1. Hemodialysis: including routine hemodialysis (HFHD and LFHD), hemodiafiltration (HDF) and hemoperfusion (HP).
2. Peritoneal dialysis: including automatic peritoneal dialysis and continuous ambulatory peritoneal dialysis; Peritoneal dialysis replaces extracorporeal short tube and peritoneal dialysis solution.
3. The scope of auxiliary drugs
(1) Drugs restricted for dialysis (or renal failure) patients in the medical insurance catalogue: such as XA 12 mineral supplements, calcium and phosphorus metabolism regulators (phosphorus-reducing drugs, etc. ) and other drugs limited to dialysis (or renal failure);
(2) Drugs suitable for dialysis (or renal failure) patients in the medical insurance catalogue: such as XB03 anti-anemia drugs, XB0 1AB heparin drugs, potassium-lowering drugs, vitamin D and its analogues (calcitriol, etc. ), XC02 antihypertensive drugs and other conventional or basic drugs.
4. Diagnosis and treatment projects
Including but not limited to the following medical services and routine examination items required for the treatment of dialysis (or renal failure):
Hemodialysis and peritoneal dialysis;
Routine hematuria, blood sugar, blood lipid, serum uric acid, blood electrolyte, liver function and renal function were measured, and parathyroid hormone and iron index (ferritin, serum iron, etc.) were determined. ), C-reactive protein, electrocardiogram, echocardiography; Peritoneal balance experiment and dialysis related clinical monitoring and other projects.
Screening of infectious diseases, such as hepatitis virus markers, human immunodeficiency virus antibodies, syphilis serological indicators and other inspection items.
5. Medical materials and disposable consumables: including dialysis tubes, blue clips and iodophor caps that can be charged separately within the scope of medical insurance payment.
6 in the insured area designated medical institutions dialysis, designated hospitals should provide outpatient hemodialysis filtration at least once a month according to the patient's condition, and gradually increase the number of dialysis in Qualcomm. In principle, the expenses of auxiliary drugs and medical consumables should be controlled within a reasonable range of the total monthly dialysis expenses (accounting for no more than 25%). Compliance expenses that are not included in the scope of dialysis expenses can be included in the scope of general outpatient payment according to regulations.
Third, organ transplantation anti-rejection therapy
Including heart, liver, lung, kidney, bone marrow and other organs transplantation and anti-rejection treatment of small intestine, pancreas, islet and hematopoietic stem cells. The scope of protection mainly includes necessary western medicines such as anti-rejection drugs limited to organ transplantation in the medical insurance catalogue and routine inspection and testing items.
Only anti-rejection drugs after organ transplantation: including but not limited to XL04AA selective immunosuppressants and XL04AX other immunosuppressants;
Other essential drugs: hormones, etc.
Detection items: cyclosporine blood concentration monitoring, FK506 blood concentration monitoring, blood routine, blood sugar, blood lipid, uric acid, coagulation, blood analysis, renal function, liver function, hepatitis virus, color Doppler ultrasound, chest X-ray, etc.
Four. Rehabilitation treatment (minors)
Including visual impairment rehabilitation treatment, hearing impairment rehabilitation treatment, speech training, hemiplegic limb comprehensive training, cerebral palsy limb comprehensive training, spinal cord injury comprehensive training, exercise therapy equipment training, swallowing dysfunction training, cognitive sensory dysfunction training, balance training, exercise therapy, occupational therapy, acupuncture and massage therapy of traditional Chinese medicine and related evaluation medical services. The specific scope is as follows:
Psychiatric scale test, special psychiatric examination and psychiatric treatment with the provincial diagnosis and treatment project code 3 1 15; 340 1 physical therapy, 3402 rehabilitation therapy, 43 acupuncture, 44 moxibustion and 45 massage therapy.