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Notice on the Reimbursement Scope of the New Rural Cooperative Large Disease Insurance
EWT [2013] No. 162
Cities, prefectures, and counties health bureaus:
According to the "Guiding Opinions on Carrying Out Large Disease Insurance Work for Urban and Rural Residents" of six ministries and commissions, such as the National Development and Reform Commission (NDRC [2012] No. 2605) and the "Provincial Government General Office on the Issuance of the Notice on the Implementation Program of Major Disease Insurance Work for Urban and Rural Residents in Hubei Province (for Trial Implementation) (E Zhengban Fa [2013] No. 6), the relevant provisions of the major disease insurance compliant medical expenses refer to the actual incurred medical expenses that are in line with diagnostic and treatment norms, necessary for treatment, and reasonable. According to the financing standards and actual operation of the New Rural Cooperative Medical Insurance (NRCM) in our province, the scope of reimbursement of major disease insurance for NRCM in 2013, i.e., the scope of compliant medical expenses, is stipulated as follows:
I. The hospitalization compensation for NRCM in the year of enrollment has been enjoyed by the participants, and the individual out-of-pocket compliant hospitalization expenses after the compensation of NRCM are included in the scope of reimbursement of major disease insurance; and the major diseases that are included in the province for improving the management of major diseases of the medical insurance level for rural residents are as follows Patients with end-stage renal disease, hemophilia, chronic granulocytic leukemia, type I diabetes and other four kinds of special chronic diseases, the outpatient out-of-pocket expenses after reimbursement by the New Rural Cooperative Fund at a rate of not less than 70% are included in the scope of reimbursement of major disease insurance.
Secondly, the costs of national essential drugs, non-essential drugs supplemented by the province, and drugs within the scope of the fourth edition of the New Farmers' Cooperative Reimbursement Drug Catalog, which are in line with the reimbursement policy of the New Farmers' Cooperative, are included in the scope of reimbursement of the insurance; and the medicines determined by the cities (states) as necessary and reasonable for the treatment of the 22 kinds of major diseases are included in the scope of reimbursement of the insurance for the major illnesses.
Third, the routine testing and inspection items included in the reimbursement scope of the New Rural Cooperative Medical Insurance are all included in the reimbursement scope of the insurance for major diseases, and the cost of new and expensive special tests, such as PET-CT and various types of capsule microscopy, are not included in the reimbursement scope of the insurance for major diseases for the time being.
Four, into the new rural cooperative reimbursement scope of the varieties of consumables, single or annual cumulative costs in the city (state) within the standards set by the part of the medical cost statistics into the scope of the major medical insurance, the standard above the part is not included.
Fifth, the following costs are not included in the scope of the major medical insurance compliance medical costs:
1, the other party's responsibility for accidental injuries, injuries due to fighting, alcoholism, drug abuse, self-inflicted injuries, suicides, traffic accidents, criminal offenses, smoking cessation, detoxification, and occupational diseases incurred in the medical costs; should be covered by the Workers' Compensation Insurance, as well as other medical costs involving third-party liable persons.
2, a variety of non-functional plastic, orthopedic and cosmetic, infertility and other medical costs; should be borne by the public **** health program and the national and provincial subsidies have been subsidized by the policy of the disease treatment costs; medical costs have been reduced or exempted from the part of the health care institutions; medical malpractice or identification of medical malpractice disputes have been generated by the medical costs have not yet been identified; medical costs incurred outside the country to seek medical treatment; All kinds of scientific research, clinical verification of the cost of diagnosis and treatment programs.
3. Expenses for medicines and consumables incurred by non-medical organizations.
4. Medical expenses exceeding the price of medical service items.
5. Medical expenses incurred in the same hospitalization for inpatient deliveries (including cesarean sections) that are entitled to fixed subsidies under the New Rural Cooperative.
6. Bed charges incurred in excess of the reimbursement provisions of the New Rural Cooperative Medical Program, and other medical service facility charges that are not included in the reimbursement scope of the New Rural Cooperative Medical Program.
7. Organ sources and tissue sources for all kinds of organ and tissue transplants.
8. Charges for medicines, examinations and consumables not related to the treatment of the current disease.
6. The out-of-pocket expenses of the participating patients who have implemented the single-disease flat-rate payment and per-bed-day payment are all included in the scope of the compliant medical expenses of the major disease insurance, and are not subject to the limitations of the relevant catalogs.
Seven, this major disease insurance reimbursement scope of the provisions of the temporary one year, the future with the operation of the major disease insurance, changes in financing standards and other circumstances adjusted in due course.
Hubei Provincial Department of Health
April 16, 2013