Standard Management of Drug Catalog, Diagnostic and Therapeutic Items and Medical Service Facilities of Zhuhai Basic Medical Insurance
Measures for the Standard Management of Drug Catalog, Diagnostic and Therapeutic Items and Medical Service Facilities of Zhuhai Basic Medical Insurance
The Measures for the Standard Management of Drug Catalog, Diagnostic and Therapeutic Items and Medical Service Facilities of Zhuhai Basic Medical Insurance applies to the participants of the city's basic medical insurance as well as to the fixed-point pharmaceutical organizations that provide the services of basic medical insurance. The following is an explanation of the "Zhuhai Basic Medical Insurance Drug Catalog, Diagnostic and Therapeutic Items and Medical Service Facilities Standard Management Measures", welcome to browse!
Part I: Who is covered
I. Who are the targets of the Measures for the Administration of Outpatient Specific Diseases of Zhuhai Basic Medical Insurance (hereinafter referred to as the Measures)?
A: The Measures are applicable to participants who have taken part in the city's basic medical insurance, as well as the designated medical institutions that provide basic medical insurance services.
Part II Basic Medical Insurance Drug Catalog
Second, which drugs can be included in the city's basic medical insurance fund (hereinafter collectively referred to as the coordinated fund) to pay?
A: In line with the "National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog" (hereinafter collectively referred to as the "National Drug Catalog"), "Guangdong Province Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog" (hereinafter collectively referred to as the "Drug Catalog"), "Guangdong Provincial Basic Medical Insurance Ordinary Outpatient Coordinated Use of Drugs" (hereinafter collectively referred to as the "outpatient coordination of the use of drugs"), "Guangdong Province
The drug catalog for outpatient specific diseases with medium cost of basic medical insurance in the city is formulated by the municipal social insurance administrative department.
Third, the national and provincial basic drugs are managed according to the provisions of Class A or Class B drugs?
A: The national and provincial essential drugs are managed according to the provisions of Class A drugs.
Fourth, the participants in the outpatient and inpatient treatment and use of drugs, how to pay the integrated fund?
A: Basic medical insurance participants in outpatient and inpatient treatment using the "National Drug List", "Drug List", "outpatient coordinated use of drugs", "Drug List Compound Drug Scope" of the drugs, as well as the provincial documents issued by the provisions of the drugs to be paid, the integrated fund in accordance with the provisions of the city's basic medical insurance payments. Among them, the use of some of the drugs (see the annex) first by the individual out-of-pocket expenses 10%, and then paid in accordance with the provisions of the city's basic medical insurance.
V. How to manage the therapeutic homemade preparations of designated medical institutions?
A: the designated medical institutions approved by the relevant departments and the approved price of therapeutic homemade preparations, reported to the municipal social insurance agency for the record, included in the scope of payment of the integrated fund, limited to the designated medical institutions in accordance with the provisions of Class A drugs.
Part III: Basic Medical Insurance Diagnostic and Treatment Programs
VI: What are the basic medical insurance diagnostic and treatment programs?
A: basic medical insurance treatment refers to a variety of medical technology labor projects and the use of medical instruments, equipment and medical materials for diagnosis, treatment projects in line with the following conditions:
(a) clinically necessary, safe and effective, the cost is appropriate.
(B) by the price authorities announced the charges.
Seven, the basic medical insurance treatment program is divided into several categories?
A: The basic medical insurance diagnosis and treatment items are divided into two categories: diagnosis and treatment items that are partially paid by the integrated fund, and diagnosis and treatment items that are not paid by the integrated fund.
Eight, the integrated fund to pay part of the cost of diagnosis and treatment programs, participants first out of pocket how much and then pay according to the city's basic medical insurance regulations?
Answer: The diagnostic and therapeutic items that are partially paid for by the integrated fund will be paid for by the insured individually in accordance with the basic medical insurance regulations of the city after a certain percentage of out-of-pocket expenses.
(A) medical technology diagnosis and treatment
The unit price of 300 yuan (including) or more of the examination and testing items, the individual first out-of-pocket expenses 5%.
(2) Treatment items
For treatment items with a unit price of RMB 1,000 (inclusive) or more, the individual pays 5% of the total cost.
(C) material items
unit price of 2000 yuan (including) or more of the one-time material costs, the individual first 10% out-of-pocket expenses.
IX. What are the diagnostic and therapeutic items that are not covered by the integrated fund?
Answer: The medical treatment items that are not paid by the integrated fund:
(1) Service items
1. Registration fee, out-of-hospital consultation fee, various special consultation fees, the cost of medical records, and the cost of various materials.
2. Consultation fees, visiting fees, examination and treatment expediting fees, overtime fees, as well as self-referred care, home health care services, quality premium fees and other special medical services (such as: named surgery, time surgery, named consultation, named examination, named nursing fees, etc.).
(B) non-disease treatment projects
1. A variety of beauty, fitness projects and non-functional cosmetic, orthopedic surgery and other related diagnostic and therapeutic projects (such as: blepharoplasty, breast augmentation, myopic orthopedics, orthopedics, stuttering, treatment of freckles, spots, pigmentation, armpit odors, hair loss, cosmetic scarring, laser cosmetic wart leveling, cosmetic cleaning, dental, orthodontics, discoloration of the dental treatment, etc.). The company's website is a great source of information about the company's services.)
2. The cost of various weight loss, fat gain, height gain programs.
3. All kinds of health checkups, such as pre-marital checkups, travel checkups, occupational checkups, outbound checkups, etc.
4.
4. A variety of preventive health care treatment programs (such as: a variety of vaccinations, disease screening and treatment, tracking fees, etc.).
5. A variety of medical consultations, medical identification (such as: psychological counseling, health counseling, sexual counseling, marriage and parenting counseling, disease prediction fees, medical malpractice identification, forensic identification of mental illness, all kinds of injury and disability level identification, labor capacity identification and pregnant women to do the identification of the sex of the fetus, paternity testing, genetic identification, and so on).
6. The cost of health care full-body massage.
7. Various kinds of health care treatment costs, the use of daily life and recreational goods for rehabilitation treatment and the cost of supplies.
(C) diagnostic and therapeutic equipment and medical materials
1. The application of positron emission tomography (PET-CT), electron beam CT, ophthalmic excimer laser therapy, human information diagnostic equipment, such as inspection and treatment costs.
2. Eyeglasses, dentures, eye prostheses, prosthetic limbs, hearing aids (except for electronic cochlear implants) and other rehabilitative devices.
3. A variety of self-use health care, massage, inspection and treatment equipment (such as: massagers, wheelchairs, crutches, a variety of home testing and treatment equipment, leather and steel back armor, waist, steel head and neck, stomach, kidney, uterus, hernia belt, knee belt, testicular belt, brain, pillows, cushions, hot packs, the Shen Gong Yuanqi bag and other costs).
4. Provincial and municipal price authorities that can not be charged separately disposable medical materials.
(D) treatment program category
1. Various types of organ or tissue transplantation ` organ source, tissue source (except skin grafts for burn patients).
2. In addition to kidney, heart valve, cornea, skin, blood vessels, bone, bone marrow, transplantation of other organs or tissues.
3. Liver transplantation (including transplant hepatectomy + retransplantation).
4. Strabismus correction.
5. Music therapy (except for psychiatric patients), qigong therapy, nutritional therapy for health care, psychotherapy (except for psychiatric patients) and other treatment programs.
(E) Other
1. Various infertility (pregnancy), sexual dysfunction diagnosis and treatment program costs.
2. Various teaching, scientific research and clinical verification of the cost of diagnosis and treatment programs.
3. Other types of insurance premiums (e.g., premiums for pacemaker and other artificial organ implantation surgeries), late fees, and so on, that are charged during the period of hospitalization.
4. Other diagnostic and therapeutic items that are not covered by the Social Insurance Fund as stipulated by the relevant national, provincial and municipal authorities.
The fourth part of the basic medical insurance medical service facilities standards
10, the basic medical insurance medical service facilities refers to what?
A: Basic medical insurance medical service facilities refers to the designated medical institutions to provide, the insured in the process of receiving diagnosis, treatment and care of the necessary living service facilities.
Eleven: What is the main scope of payment for basic medical insurance medical service facilities?
A: The scope of payment for basic medical insurance medical service facilities mainly includes: inpatient bed fees and outpatient and emergency observation bed fees (including daily necessities, in-hospital transportation supplies and water, electricity and other costs that have been included in the inpatient bed fees or outpatient and emergency observation bed fees).
Twelve, the integrated fund according to what standard payment of hospital bed charges?
A: The integrated fund pays for hospital beds according to the following criteria. Participants hospitalized during the actual bed cost is lower than the corresponding payment standard, according to the actual bed cost; higher than the corresponding payment standard, according to the standard payment, exceeding the part of the insured person at his own expense.
(A) tertiary hospital inpatient bed fee
1. General ward: 43 yuan / day.
2. Laminar flow clean room: RMB 270/day.
3. Laminar Flow Clean Room: RMB 100/day.
4. Custodial Ward: $70/day.
5. Special protection ward: $ 70 / day.
(b) second-class hospitals, hospital beds in first-class hospitals, respectively, according to the above standards down 10%, 20% implementation.
Thirteen: What are the costs of living services and service facilities that are not paid by the integrated fund?
A: The costs of living services and service facilities that are not payable by the fund mainly include:
(a) transportation fees for consultation, ambulance consultation fees, and ambulance consultation fees for stretcher bearer.
(b) air-conditioning, television, telephone, food warmer, electric stove, gas, refrigerator and damage to public property compensation, bring their own fan electricity, shampooing plus hairdryer fee.
(c) escort fee, companion bed fee, nurse fee, cleaning fee, outpatient medicine fee, diaper fee.
(d) Meals (including nutritious meals and medicinal meals).
(e) Books and newspapers, recreational activities and other special living services.
(6) various costs not directly related to the diagnosis and treatment (such as washbasin fees, mouth cups, cutlery, dental fees, daily cleaning and sanitation costs, sanitary plastic bags, slippers, toilet paper, urination and defecation appliances, sewage charges, bottle charges, etc.).
(7) other costs that are not paid by the municipal social insurance administration.
Part V Other
Thirteen, when will the measures come into force?
A: These Measures shall come into force from February 1, 2017 onwards.
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