Source: Consumer Life
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The basic medical insurance established in the early days of the mainland was mainly aimed at covering hospitalization expenses, and both urban and rural residents' medical insurance and urban employees' medical insurance had personal accounts for different reimbursements. The medical insurance fund is mainly used for the reimbursement of hospitalization expenses, while the personal account is used for the reimbursement of outpatient expenses. However, as the number of people with chronic diseases increases, so does the cost of treating them. To address this issue, the NHSA has introduced a new reimbursement policy for chronic diseases, which stipulates reimbursable treatment costs for some common chronic diseases.
In the initial stage of the chronic disease medical insurance compensation policy, due to the difference in the fundraising and balance of the medical insurance fund, the chronic disease medical insurance declaration policies and procedures in various regions are inconsistent. In some places, the application process is complex, requiring a lot of materials and time. However, in the past few years, the state has made new optimizations in government services. So, let's take a closer look at the situation of outpatient chronic disease medical insurance today.
What is an outpatient chronic disease?
"Outpatient chronic disease" is not a medical conceptual classification, but a term in the framework of medical insurance. Different regions have similar names for them, such as outpatient chronic diseases, outpatient special diseases, outpatient prescribed diseases, outpatient serious diseases, outpatient co-ordinated diseases, etc.
Outpatient chronic illness refers to medical programs that meet the requirements for serious and chronic illnesses that are treated on an outpatient basis and can be reimbursed in the same way as a hospital inpatient.
As we all know, the main reimbursement of medical insurance in the mainland is basically subordinate to the cost of hospitalization. However, for some serious and long-term diseases such as cardiovascular and cerebrovascular diseases, hypertension, coronary artery disease, diabetes, uremia and malignant tumors, they can also be treated on an outpatient basis because they do not require hospitalization.
In order to help these patients with such diseases reduce the pressure of seeking medical treatment, the reimbursement of outpatient chronic diseases has been derived.
Criteria for the filing and confirmation of outpatient chronic diseases
According to the national perspective, the identification criteria of outpatient chronic diseases mainly adopt qualitative and quantitative methods. In some areas, the standard description is vague and mainly quantitative.
In other regions, they set very specific guidelines that will be granular to the symptoms of the disease, including signs, test indicators, comorbidities, and so on. That is, there are differences in the criteria for distinguishing outpatient chronic diseases in different regions. Therefore, people who need to inquire must go to the local area to find out the standard requirements of their own area, and do not simply believe what is said on the Internet.
The filing process and the requirements for application materials will be specified by the outpatient clinics for specific chronic diseases in each region.
Generally, the process involves bringing your social security card, ID card, diagnosis certificate, and medical related documents to the specific chronic disease designated medical institution of your choice, and then you need to fill out the form according to the requirements of the designated medical institution and file the declaration with the medical insurance office or local medical insurance department.
Once you have successfully filed for the record, you benefit from outpatient reimbursement for specific chronic conditions. However, for a clearer application process, please consult with the designated medical institution or your local health insurance department.
How is reimbursement made?
Generally speaking, the diseases that are included in the management of "outpatient chronic diseases" will be adjusted accordingly in terms of the minimum payment line, the maximum line and the reimbursement ratio. For example, Mente-related drugs and diagnosis and treatment items can enjoy reimbursement with hospitalization standards, and other outpatient reimbursement expenses can also be calculated together with hospitalization expenses, and the cap line will also be determined according to hospitalization standards.
For example, in October 2019, the National Health Insurance Administration and other departments issued the scope of application of the "two diseases" outpatient policy, which included hypertension and diabetes in the coverage of outpatient chronic special diseases at the national level:
Insured objects: participants of urban and rural residents' medical insurance, and patients with "two diseases" who take drug therapy.
It should be noted that the protection objects referred to here do not include the employee medical insurance population. Because the employee medical insurance group adopts a unified account combination model, they can solve most of the outpatient drug costs through their personal accounts, which has been institutionally arranged. With the implementation of the personal account reform, employees will be able to cover outpatient expenses through the upcoming outpatient mutual aid.
Reimbursement ratio: Based on primary medical facilities of level 2 and below, the proportion of payment stipulated in the policy should reach more than 50%.
Scope of protection: It covers the antihypertensive and hypoglycemic drugs in the national basic medical insurance drug list.
At the regional level, while meeting the national minimum standards for "two diseases", each region should combine the characteristics of its own endemic chronic diseases and the affordability of medical security funds to expand the types of common chronic diseases. In addition, there is a maximum limit or no maximum limit depending on the individual needs.
Therefore, the coverage of chronic diseases, the proportion of reimbursement, the minimum payment standard, and whether to set a cap line in different regions are different. For more information, please contact your local health insurance provider.
With the advancement of the Internet, a large number of online diagnosis and treatment services can be carried out in a large number of places, and reimbursement can be completed. It is believed that the continuous innovation of medical insurance policies will make medical services for the elderly more convenient.