In other words, the catalogue of medical insurance drugs, the catalogue of medical treatment items (medical consumables) and the scope of medical service facilities are what we often call the "three catalogues" of medical insurance.
The "three catalogues" of medical insurance define the scope of basic medical insurance and ensure that the insured enjoy basic medical insurance.
First, the medical insurance drug list
The national drug list of basic medical insurance, industrial injury insurance and maternity insurance (hereinafter referred to as the medical insurance drug list) is the standard for the payment of drugs by the basic medical insurance, industrial injury insurance and maternity insurance funds.
Since the establishment of the basic medical insurance system, the former Ministry of Labor and Social Security and Ministry of Human Resources and Social Security published four editions of the medical insurance drug list in 2000, 2004, 2009 and 2017 * *. At present, the list of medical insurance drugs used in our province is the 20 19 version of the national medical insurance drug list.
The Interim Measures for the Administration of Medication in Basic Medical Insurance promulgated by the National Medical Insurance Bureau will be implemented on September 1 2020. This method clarifies that the following eight categories of drugs are not included in the drug list. 1. Drugs with nourishing effect; 2. Drugs containing national precious and endangered wild animals and plants; 3. Health care drugs; 4. Preventive vaccines and contraceptives; 5. Drugs with the functions of enhancing sexual function, treating alopecia, losing weight, beautifying, and quitting smoking and drinking; 6 drugs that cannot be charged separately due to reasons such as inclusion in medical treatment projects; 7. Wine preparations, tea preparations, various fruit preparations (except children in special circumstances), oral preparations, oral effervescent agents (except in special circumstances), etc. ; 8 other drugs that do not meet the requirements of basic medical insurance.
Second, the diagnosis and treatment project (medical consumables) directory
1. Directory of diagnosis and treatment items
The scope of diagnosis and treatment projects prescribed by the state shall not pay the fees, but pay part of the fees. Our province adopts the access method to formulate the catalogue of diagnosis and treatment projects, and each co-ordination area can formulate specific out-of-pocket proportions.
The scope of medical treatment items for which medical insurance does not pay fees: (1) Services: special medical services such as registration fee, consultation fee outside the hospital, medical record making fee, visit fee, expedited fee for examination and treatment, surcharge for roll call operation, high quality and good price fee, and self-invited special care. (2) Diagnosis and treatment equipment and medical materials: inspection and treatment items with large medical equipment such as positron emission tomography (PET), electron beam CT and ophthalmic excimer laser therapeutic apparatus; Rehabilitation appliances such as glasses, dentures, artificial eyes, artificial limbs and hearing AIDS; All kinds of self-use health care, massage, examination and treatment equipment; Disposable medical materials that cannot be charged separately as stipulated by the provincial price department. (3) Non-disease treatment projects: various beauty and bodybuilding projects, as well as non-functional plastic surgery and orthopedic surgery; All kinds of weight loss, weight gain and height increase projects; Various health checks; Various preventive health care diagnosis and treatment projects; All kinds of medical consultation and medical appraisal. (4) Treatment items: organ sources or tissue sources of various organ or tissue transplants; Transplantation of organs or tissues other than kidneys, heart valves, corneas, skin, blood vessels, bones and bone marrow; Orthopedic surgery for myopia; Qigong therapy, music therapy, health nutrition therapy, magnetic therapy and other auxiliary treatment projects. (5) Others: diagnosis and treatment of various infertility (pregnancy) and sexual dysfunction; Various scientific research and clinical verification diagnosis and treatment projects.
The scope of medical treatment items covered by medical insurance: (1) Medical equipment and medical materials: X-ray computed tomography (CT), stereotactic radiotherapy device (γ knife, X knife), cardiac angiography machine (including digital subtraction equipment), magnetic resonance imaging device (MRI) and single photon emission computerized scanning device SPECT. Extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy; Artificial organs and implant materials, such as pacemakers, artificial joints, intraocular lenses and vascular stents; Disposable medical materials that can be charged separately as stipulated by the provincial price department. (2) Treatment items: hemodialysis and peritoneal dialysis; Kidney, heart valve, cornea, skin, blood vessels, bone and bone marrow transplantation; Cardiac laser drilling, anti-tumor cellular immunotherapy and fast neutron therapy projects. (three) the inspection and treatment items and medical materials of valuable medical instruments and equipment as stipulated by the provincial medical insurance management department.
2. Catalogue of medical consumables
There are more than 600 medical consumables that medical institutions can charge separately, of which about 360 items are included in medical insurance payment. What is not included is mainly some non-basic medical consumables such as orthopedics, plastic surgery and transplantation.
Medical consumables that cannot be charged separately by medical institutions shall not be charged to patients, and medical insurance payment is not involved: conventional instruments and low-value medical consumables (such as disposable sterile towels, disinfectants, washing saline, ordinary sutures, dressings, etc.). ) are included in the cost factors of medical services when pricing, and are not priced separately. Test reagent.
Consumables that medical institutions can charge patients: guide wires, catheters, balloons, stents, filters, etc. Used for vascular intervention; Special medical consumables needed in operation, such as special puncture needle, ablation electrode, ablation needle and accessories, special guide wire, catheter, stent, balloon, titanium clip, titanium dice, titanium plate, dilator, stapler, stapler, fixator, etc. Artificial lens, pacemaker, artificial joint, etc.
3. Scope of medical service facilities
Medical service facilities refer to the life service facilities provided by designated medical institutions and necessary for the insured in the process of diagnosis, treatment and nursing.
The cost of medical service facilities mainly includes inpatient bed fee and outpatient observation bed fee. The basic medical insurance will not be paid separately for the daily necessities, water, electricity and other expenses that have been included in the hospital bed fee or outpatient observation bed fee, and the designated medical institutions will not charge the insured separately.
The exclusion method is adopted for medical service facilities, and the scope of life service items and service facilities fees that will not be paid is stipulated.
Each province shall formulate a catalogue of medical service facilities, and each overall planning area shall formulate payment standards.
The expenses of life service items and service facilities that are not paid by the basic medical insurance fund mainly include: (1) outpatient (transfer) transportation expenses and emergency transportation expenses; (2) Air conditioning fee, TV fee, telephone fee, baby incubator fee, food incubator fee, electric stove fee, refrigerator fee and compensation fee for public property damage; (3) Escort fee, nursing fee, washing fee and outpatient decocting fee; (4) meals; (5) Hospitality and other special life service expenses.