Source: Xiao Liu Nag Medical Insurance
Since the establishment of the medical insurance system, the financing amount of medical insurance has been rising, and then the reimbursement scope of medical insurance has been expanding, and the corresponding medical insurance policies will be adjusted with the development of the economy and society. The agricultural medical insurance established in 2003 was called rural medical insurance at that time, and later called the New Rural Cooperative Medical System, and then it became the basic medical insurance for urban and rural residents after integrating the urban residents' medical insurance. At the beginning, the individual payment amount of agricultural medical insurance was 10 yuan, of which only 2 yuan went into the overall fund, and the remaining 8 yuan was returned to the personal account of the medical insurance card for outpatient treatment and drug purchase in pharmacies.
Employee medical insurance was established earlier, and its financing method is composed of individual payment and unit payment, of which individual payment only occupies a small part, and the unit bears the lion's share. Generally speaking, the proportion of basic medical insurance contributions for employees is about 8% of the wage base, of which the individual payment only needs to bear 2%, while the unit payment bears 6% of the wage base; This adds up to 8%. 3.2% of this part of the medical insurance cost is also allocated to the medical insurance card of the insured employee as a personal account, which is used for outpatient treatment and drug purchase in pharmacies, which can fully protect the medical needs of the insured employees.
With the great changes in the national disease spectrum and the upgrading and iteration of medical technology, the national basic medical insurance policy has also been adjusted accordingly. In 2019, the National Health Insurance Administration cancelled the personal accounts of urban and rural residents' medical insurance and comprehensively carried out outpatient co-ordination. In 2023, the national medical insurance will carry out the outpatient mutual aid reform of employee medical insurance, adjust the allocation ratio of employee medical insurance personal accounts, and increase the general outpatient reimbursement policy of employee medical insurance.
Prior to this, medical insurance reimbursement policies for outpatient chronic diseases were stipulated in various places earlier. Each region will be based on the local economic development level, the amount of medical insurance financing, and the statistics of common chronic diseases; Dozens of chronic diseases that can be reimbursed by medical insurance are stipulated, and certain application conditions are set. Reimbursement can be made after the approval is passed, and the medical insurance reimbursement policy for chronic diseases is earlier than that of ordinary outpatient clinics. Relatively speaking, chronic disease reimbursement requires a procedure, that is, it is necessary to apply for filing in advance, and it is also necessary to meet the corresponding conditions and prepare relevant materials; Slightly more troublesome.
Since both chronic diseases and general outpatient services can be reimbursed, chronic diseases still need to be applied for reimbursement; So when you have a chronic disease, why not just use the general outpatient reimbursement without applying. This will involve a difference in the reimbursement of chronic diseases and general outpatient medical insurance.
General outpatient: general outpatient medical reimbursement is often said to be outpatient co-ordination, residents' outpatient co-ordination reimbursement ratio is low, basically around 60%, some places will be higher, but it has one of the biggest restrictions is that it can only be reimbursed for medical treatment in primary medical institutions, that is, in township health centers, community health service centers, clinics and other medical institutions at the level and below can be reimbursed. Although the general outpatient clinic of employees does not limit the level of medical institutions, its reimbursement ratio is low, and there are problems such as the starting line and the cap line, even in the grassroots medical institutions, the reimbursement ratio is only about 65-70%, which is the limitation and disadvantage of ordinary outpatient reimbursement.
Chronic disease outpatient clinics: Chronic disease outpatient clinics generally have the same reimbursement ratio as hospitalization, and the higher the level of hospitals, the lower the reimbursement ratio, which can basically reach more than 90% in grassroots institutions. And outpatient chronic diseases generally do not set the starting line, the ceiling line is also higher than the ordinary outpatient line, so relatively speaking, the treatment is better, in the primary medical institutions, chronic disease outpatient and general outpatient reimbursement ratio can be up to 30% difference, a year of 2,000 yuan of medical expenses, their own money will be about 600 yuan, so eligible need to apply for outpatient chronic diseases, with chronic disease reimbursement can be more saving.
Nowadays, there are many people who seek medical treatment in other places across provinces, and when these people seek medical treatment in other places outside the province, if they have filed for medical treatment in other places in advance, the outpatient clinic can also be directly reimbursed. A small number of people will make a mistake, when buying drugs for chronic diseases, they choose the reimbursement policy of general outpatient clinics, which not only affects the reimbursement ratio, but also crowds out the reimbursement amount of ordinary outpatient clinics, so the choice is very important, and it is necessary to inform medical institutions to choose chronic disease reimbursement.