Beijing News (reporter Ma Jinqian) chronic diseases, special diseases (referred to as chronic diseases) because of their serious disease, long treatment time, and huge overall cost, often bring a heavy burden to the patient's family. On November 29, Beijing municipality applied for formal access to the national platform, and the first outpatient chronic disease related treatment fees for insured persons from other places to come to Beijing for medical treatment were recently settled directly at the Cancer Hospital of the Chinese Academy of Medical Sciences.
On December 13, the Beijing Municipal Medical Insurance Bureau interpreted the hot issues related to the direct settlement of outpatient chronic disease related treatment costs across provinces.
Question 1: What is the scope of personnel and diseases reimbursed by the pilot?
The reporter learned from the Beijing Municipal Medical Insurance Bureau that the pilot outpatient chronic disease includes five diseases such as hypertension, diabetes, outpatient treatment of malignant tumors, kidney dialysis, and anti-rejection therapy after organ transplantation.
In view of the different policies of outpatient chronic diseases in various places and the complexity of outpatient chronic disease medical settlement, in order to effectively solve the blockages and difficulties in the direct settlement policy, management and informatization of outpatient chronic diseases, form replicable and generalizable experience, and steadily promote the direct settlement of outpatient chronic diseases, this pilot only includes some outpatient chronic diseases.
In terms of the scope of the pilot population, this inter-provincial settlement pilot is applicable to the insured personnel who have completed the qualification identification of the pilot disease treatment in the insured place and have gone through the direct settlement and filing procedures for outpatient chronic special diseases in different places in accordance with the provisions of the insured place.
Question 2: What is the reimbursement policy for direct settlement of outpatient chronic diseases?
The policy of direct settlement and payment of outpatient chronic diseases implements the "directory of medical treatment and the policy of insured places". That is, the medical insurance drug catalog, medical service items and medical consumables implement the policy of the place of medical treatment; the minimum payment standard, payment ratio, maximum payment limit of the medical insurance fund implement the policy of the place of participation.
The National Medical Insurance Bureau requires that by the end of 2021, at least one co-ordination area in all provinces (cities, districts) across the country will achieve direct settlement of outpatient chronic diseases. Open outpatient chronic disease direct settlement pilot areas and designated medical institutions and other information updates in real time, you can go to the "National Medical Insurance Service Platform" APP for online inquiries.
Question 3: What is the inter-provincial direct settlement process for outpatient chronic diseases?
According to the public information of the Beijing Municipal Medical Insurance Bureau, the main steps include 4.
Complete the qualification recognition of the treatment of pilot diseases in the place of participation; handle the filing procedures for medical treatment in different places across provinces according to the provisions of the place of insurance (the specific filing process needs to consult the place of participation); the insured persons should seek medical treatment in the pilot hospital where the direct settlement service for outpatient chronic disease has been opened; enjoy the direct settlement service for outpatient chronic disease, and the direct settlement of outpatient slow disease shall be carried out in accordance with the principle of "directory of place of treatment and policy of the place of participation".
There are differences in the scope of outpatient chronic diseases in various coordinated areas across the country, and whether the diseases suffered by the insured persons belong to the scope of outpatient chronic diseases needs to be determined according to the medical insurance regulations of the insured place.
Question 4: How can beijing insured persons apply for cross-provincial medical recordal for outpatient chronic diseases?
Flow chart of the filing of medical treatment for insured persons in Beijing across provinces and places. Courtesy of Beijing Municipal Medical Insurance Bureau
The treatment expenses of hypertension and diabetes in Beijing insured persons have been included in the scope of general outpatient reimbursement, and when handling the filing procedures for medical treatment in different places, there is no need to apply for the filing of hypertension and diabetes, and the relevant treatment expenses can continue to be reimbursed according to the original regulations.
Insured persons in Beijing who are undergoing outpatient treatment of malignant tumors, kidney dialysis, and anti-rejection therapy after organ transplantation need to apply for the record of special diseases in different places if they have cross-provincial direct settlement needs. At the same time, in order to further improve the filing information, it is recommended that beijing insured persons who have previously filed for medical treatment in other places should re-apply for the filing procedures for special diseases in different places to ensure that the treatment costs related to outpatient chronic diseases are smoothly and directly settled in different places.
The steps for filing for inter-provincial medical treatment for outpatient chronic diseases are as follows:
1. Handle the filing procedures for medical treatment in different places. The first is online filing. Insured persons in this city can conveniently and quickly handle the filing procedures for medical treatment in different places through the "National Medical Insurance Service Platform" mobile APP or the "National Off-site Medical Recordal" WeChat Mini Program; the second is offline filing. Personnel who meet the requirements for resettlement and retirement, long-term work in the field of work by the unit, and long-term residence in a different place shall go to the social insurance agency of the jurisdiction to which they belong through the unit (through the social security institute of the place where the unit is insured) to handle the filing; the person who is transferred to seek medical treatment shall go to the medical insurance agency of the jurisdiction to handle the filing by himself or the entrusted person.
2. Go to the medical insurance agency in the insured area to handle the filing of special diseases for medical treatment in different places. The insured person holds a social security card, a diagnosis certificate of special diseases issued by a designated medical institution and the "Beijing Medical Insurance Special Disease Filing Declaration Form" to go through the filing procedures at the agency handling the insured area, and selects a local designated medical institution as a designated medical institution for special diseases in the medical recordal coordination area of the special disease. After completing the filing of the "special disease", the district medical insurance agency will return a "filing form" to the insured person.
3. Seek medical treatment at the designated hospital selected by the place of medical treatment. The insured shall seek medical treatment in a designated medical institution selected by the medical record-filing coordination area in his or her own place to seek medical treatment for special diseases.
Question 5: How to file for insured persons from other provinces and cities with pilot outpatient chronic disease to come to Beijing for medical treatment?
At present, Beijing has included the Fuwai Hospital of the Chinese Academy of Medical Sciences and the Cancer Hospital of the Chinese Academy of Medical Sciences into the pilot project, providing outpatient chronic disease direct settlement services for insured persons from other places to come to Beijing for medical treatment. Among them, the diseases that have been opened in fuwai hospital of the Chinese Academy of Medical Sciences are hypertension, diabetes, kidney dialysis and heart transplantation anti-rejection therapy; the diseases that have been opened by the Cancer Hospital of the Chinese Academy of Medical Sciences are outpatient treatment of hypertension, diabetes and malignant tumors.
The first batch of outpatient chronic disease direct settlement pilots in Beijing. Courtesy of Beijing Municipal Medical Insurance Bureau
A few days ago, Beijing completed the reimbursement of the first medical expenses, the insured personnel from Qinghai Province, because of breast cancer, after qinghai province completed the filing procedures, the Chinese Academy of Medical Sciences Cancer Hospital outpatient medical expenses incurred 179.63 yuan, after direct settlement medical insurance fund payment of 129.63 yuan, personal cash payment of 50 yuan.
It should be noted that there are differences in the scope of outpatient chronic diseases in various coordinated areas of the country, and whether the diseases suffered by the insured persons are outpatient chronic diseases need to be determined according to the medical insurance regulations of the insured place. Insured persons from other provinces and cities are required to go through the filing procedures for medical treatment in different places across provinces in accordance with the regulations of the place of participation (the specific filing process needs to consult the place of participation).
Beijing News reporter Ma Jinqian
Trainee Editor Chen Jing Proofreader Wu Yue