You can take a look at the following documents: on the issuance of "on the implementation of the Huainan City basic medical insurance major illnesses, special diseases outpatient medical treatment and purchase of medicines management of the interim measures> the implementation of the intention of the trial)" Notice 2001-6-22 Issuing unit: Huainan City Health Care Reform Office Date of issue: 2001-6-22 Implementation date: 2001-6-22 the insurance units, designated hospitals, designated Pharmacy:
On the issuance of the "Interim Measures for Implementing <Huainan City Basic Medical Insurance Interim Measures for the Management of Outpatient Purchase of Medicines for Major Diseases and Special Diseases," the specific implementation of the views (for trial implementation) are hereby issued to you, please follow them. Huainan Municipal Healthcare Reform Office June 22, 2001 Copy: Provincial Healthcare Reform Office Municipal Party Committee, Municipal People's Congress, Municipal Government, Municipal People's Political Consultative Conference on the implementation of "Interim Measures for the Administration of Huainan Basic Medical Insurance for Major Diseases and Special Diseases Outpatient Visits for Purchasing Drugs" (Trial Implementation) For the purpose of implementing "Interim Measures for the Administration of Huainan Basic Medical Insurance for Major Diseases and Special Diseases Outpatient Visits for Purchasing Drugs," Huafu [2001] No. 14 (hereinafter referred to as "Interim Measures"), the Interim Measures are hereby promulgated. (hereinafter referred to as the "Interim Measures"), the following implementation opinions are hereby formulated for the outpatient medical purchase and settlement of outpatient medication for insured employees with major diseases and special diseases: - Scope of Application and Principles (a) The Implementation Opinions are applicable to those who have taken part in the basic medical insurance for urban workers in Huainan City, who have paid the medical insurance premiums on time and in full, and who, after being declared by themselves, have been qualified by the city's medical expert group, and who have been issued the "Huainan Basic Medical Insurance" certificate by the administrative department of labor security. Security Administrative Department to issue "Huainan City Basic Medical Insurance Outpatient Medical Certificate for Major Diseases and Special Diseases" (hereinafter referred to as "Outpatient Medical Certificate") to the insured employees. (b) Outpatient medical treatment for patients with major diseases and special diseases is based on the principle of "three definitions", i.e., define the type of disease, define the medication, and define the hospital. Fixed types of diseases refers to the "Interim Measures" stipulated in the ten types of diseases: fixed drugs refers to the application of this disease in the basic medical insurance drugs issued by the state catalog of drugs: fixed hospitals refers to a disease can only choose a designated hospital outpatient clinic, two types of diseases can be selected a designated hospital can be selected, the designated hospitals can be divided into types of diseases to choose a designated hospital clinic to purchase medicines. The "three fixed" shall not be changed within one insurance year. Second, outpatient medical treatment and purchase of drugs (c) the designated hospitals should be based on the actual hospital, in line with the simplification of procedures, to facilitate access to medical care, to provide quality service, to facilitate the settlement of the principle of management, the development of major diseases, special diseases, patients access to medical care, purchase of medicines, registration and settlement of a set of procedures, and in a conspicuous position, set up a flow chart of the guide, and seriously do a good job in the publicity and explanation of the policy of the health insurance management approach. (d) When an insured employee visits an outpatient designated hospital, he/she must bring his/her Basic Medical Insurance Certificate (hereinafter referred to as the Certificate) and Outpatient Medical Care to the special window of the medical insurance to register, and receive a special duplicate prescription and Outpatient Medical Care Record for Major Diseases and Special Diseases (hereinafter referred to as the Outpatient Medical Care Record) before he/she can seek medical treatment. (e) Doctors should carefully verify the identity of the patients when they receive the patients, and strictly implement the provisions of the "three definitions" for major and special diseases. For insured employees who are eligible for this type of disease, the designated outpatient hospitals can issue the examination, treatment and medication documents related to their diseases, or else they shall be handled as self-payment. (f) If an insured employee goes to a designated retail pharmacy to purchase medicines with an external prescription from the designated hospital, the prescription must be stamped by the hospital's medical insurance office with a "special seal for medical insurance" before the employee purchases medicines; otherwise, he/she has to pay for the medicines at his/her own expense. (g) The Outpatient Medical Card is for the use of the insured employee himself/herself, and shall not be lent to others or altered. If any irregularity is found, the designated hospital shall promptly notify the relevant departments to take back the card and stop his/her enjoyment of the outpatient medical treatment. In case of loss, it should be reported to the unit in time, and the unit will go to the municipal labor security administrative department for replacement procedures. (h) The medical audit of major and special diseases is based on the "Three Catalogs" formulated by the State and the relevant provisions of the "Provisional Measures", and the provisions of "Defined Diseases, Defined Medicines and Defined Hospitals" are strictly enforced, and carefully reviewed, so that the integrated fund will not pay for any medical expenses in violation of the medical insurance policy. (ix) At the beginning of the first week of each month, the designated hospitals shall submit the relevant settlement materials to the medical insurance center for review. Settlement materials shall include the following: special receipts for Huainan Basic Medical Insurance, special prescriptions, expense settlement statements, expense lists, application forms for special examinations and special treatments, expense summary forms, and expense registration forms. All of the above information on medical treatment for major diseases and special diseases shall be stamped with a special seal for major diseases and special diseases, and the data shall be summarized and tabulated separately. (J) The Outpatient Medical Record must contain detailed and standardized medical history records: the Certificate Record must truthfully record the expenses incurred each time in accordance with the provisions of the medical insurance. (XI) Hospitals provide a detailed list of costs, drug prescriptions and other documents, the charges should be recorded in detail and signed by the patient or family members to recognize. (xii) The diagnostic and therapeutic behavior of the hospital should be based on the patient's condition and follow the principle of "reasonable examination and rational use of medication", with no indiscriminate examination, abuse of medication, and strict control of the dosage of medication. (xiii) medical insurance center in the audit if problems are found, timely notification of hospitals, hospitals, medical insurance office should be within two: working days (holidays postponed) and the medical insurance center medical section of the joint four, the scope of payment of the integrated fund, the standard and settlement methods (xiv) major diseases, special illnesses, patients with outpatient medical expenses included in the scope of outpatient medical expenses paid for by the integrated fund of the medical expenses must be in line with the basic medical insurance, "the three directories" of the management of the provisions of medication, diagnosis and treatment and services. (xiv) The scope of outpatient medical expenses for patients with major diseases and special diseases included in the payment of medical expenses by the integrated fund must be in accordance with the standards of medication, diagnosis and treatment, service facilities and relevant regulations of the "Three Catalogs" of basic medical insurance. (xv) Within one insurance year, the expenses incurred for outpatient medical treatment and purchase of medicines for a single disease shall be subject to a maximum limit for a single disease, and the expenses exceeding the limit shall be paid by the insured employee personally. 1. Coronary heart disease (with a history of myocardial infarction) shall be subject to a maximum payment limit of 3,000 yuan for this disease in a year (including the percentage of out-of-pocket payment, not including the percentage of deductibles). (Including the out-of-pocket percentage, excluding the individual starting standard: the same below) 2, hypertension III 3000 yuan. 3, diabetes 3000 yuan. 4, mental illness recovery period & lt; have a history of hospitalization) 1500 yuan 5, systemic lupus erythematosus 3500 yuan. 6, Parkinson's syndrome 2500 yuan. 7, aplastic anemia 4000 yuan. 8, malignant tumors radiotherapy, chemotherapy; chronic renal dysfunction Insufficiency: organ transplantation of the anti-rejection of three diseases, single disease according to the basic medical insurance hospitalization medical fee co-ordination fund maximum payment limit standards. 2001, major diseases, special diseases outpatient medical costs in accordance with the "Interim Measures", implemented from March, the individual starting standard and the maximum limit of a single disease is calculated according to the standard of seven months. (xvi) The outpatient medical expenses incurred by insured employees suffering from major and special diseases shall be paid by the individual first, and after the accumulated outpatient medical expenses exceeded the individual's starting standard in 2001, 80% of the actual medical expenses incurred within the maximum limit shall be paid by the integrated fund, and 20% of the out-of-pocket expenses shall be paid by the individual. At the time of settlement, the individual out-of-pocket part of the costs (including the individual's out-of-pocket part) will be collected by the designated hospital, and the part paid by the integrated fund will be refunded to the individual after the settlement between the designated hospital and the medical insurance center. (xvii) Outpatient medical expenses incurred by insured employees who are entitled to outpatient treatment within the same insurance year can be added up and settled in accordance with the regulations. (xviii) In principle, outpatient medical expenses for major and special diseases are settled once a month.1 Within a month, outpatient medical expenses for major and special diseases can be settled when they reach more than 3,000 yuan (including 3,000 yuan), and within 3,000 yuan, they need to be accrued to more than 3,000 yuan and then be settled by the hospitals at which they are designated for reporting.2 Where the limit for a single disease is less than 3,000 yuan, outpatient medical expenses will also be settled when they have reached the maximum limit for that disease.3 A single disease will also be settled when the limit for that disease is less than 3,000 yuan. If a person declares two kinds of special diseases and is approved, the starting standard and the maximum limit of a single disease are calculated separately. 4. After the end of an insurance year, the accounts should be settled in time, no matter whether the maximum limit is reached or not. (xix) If an insured employee who is entitled to outpatient medical treatment needs to be hospitalized due to deterioration of illness during outpatient treatment of major illness or special illness, the hospitalization expenses shall be implemented in accordance with the hospitalization regulations of the basic medical insurance. The outpatient and hospitalization expenses within the insurance year are calculated together, and medical expenses exceeding the maximum payment limit of the integrated fund are entitled to large medical insurance. Fifth, file management (20) designated hospitals must be built: the establishment of major diseases, special disease file management system, should be built file by file, special management, proper storage of all kinds of related information, shall not be lost, or else the responsibility shall be borne by the hospital. (XXI) designated hospitals should take the initiative to cooperate with the medical insurance center to do a good job of major diseases, special disease file spot checks, reviews and other work. Other (xxii) The relevant policies and regulations of this implementation opinion can be adjusted according to the actual situation after the end of a participation year. The health care reform office of Huainan City
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