Yancheng medical insurance reimbursement policy

County (city) Medical Security Bureau, City Medical Security Bureau Dafeng Branch, City Medical Insurance Fund Management Center:

In order to further improve the basic medical insurance outpatient special disease (hereinafter referred to as "outpatient special") protection level, and effectively reduce the burden of outpatient medical costs of the insured, according to the "Jiangsu Provincial Bureau of Medical Security on the unification of the basic medical insurance outpatient special disease protection policy notice" (Jiangsu Medical Insurance Development [2022] No. 46) and other documents, combined with the city's actuality, the reimbursement policy of the outpatient special According to the "Jiangsu Provincial Medical Security Bureau on the unification of basic medical insurance outpatient special disease protection policy notice" (Su medical insurance hair [2022] No. 46) and other documents, combined with the city's actuality, the outpatient special protection policy to unify and improve. The relevant matters are notified as follows:

First, the scope of diseases

Mentor refers to the diagnosis is clear, the condition is relatively stable, the cost burden is relatively heavy, suitable for outpatient treatment, more convenient than hospitalization of the disease. The scope of outpatient diseases includes 26 categories of 38 diseases (including treatment modalities), as well as children's type I diabetes mellitus, children's autism, children's growth hormone deficiency 3 diseases (see annex for specific diseases).

Second, treatment guarantee

(a) in the city designated medical institutions outpatient treatment of outpatient medical expenses incurred within the scope of the policy, the reimbursement rate in accordance with the same level of hospitalization reimbursement rate of medical institutions (urban and rural residents in the third-level medical insurance participants in the reimbursement rate of designated medical institutions for the 70%), does not set a starting standard, and hospitalization **** use annual limit. The reimbursement rate for out-of-town care is based on the city's out-of-town care standard and the relevant provisions of the hospitalization out-of-town care.

The medical expenses incurred for blood purification (including hemodialysis, peritoneal dialysis, hemodialysis filtration, hemoperfusion) for insured employees suffering from chronic renal failure are implemented according to the original reimbursement policy.

(2) The basic medical insurance fund pays for outpatient medical expenses in accordance with the national and provincial basic medical insurance drug catalogs, diagnostic and therapeutic items, the scope of medical services and facilities and the implementation of the payment standards, and outpatient medical expenses for other diseases unrelated to outpatient treatment shall not be included in the scope of outpatient coverage.

(C) special medical expenses by the basic medical insurance fund, the individual burden of the medical costs of compliance with the provisions of the major disease insurance, civil service medical assistance and medical assistance, respectively.

Third, service management

(a) the selection of the second level and above the designated medical institutions, in accordance with the clinical path of disease and diagnostic criteria of the insured person to diagnose and identify the door to the special, and will be uploaded in a timely manner to the health insurance information system identification, strengthen the enjoyment of the door to the treatment of personnel under the real-name system of management to ensure that the insured person to enjoy the door to the special treatment. If the designated medical institution violates the rules for the participants to handle the special treatment, the medical insurance fund will not pay for the corresponding special treatment costs incurred by the participants, and the designated medical institution will bear the costs. The medical insurance agency of the participants verified by the special recognition conditions do not meet the door, fraud and other violations of the relevant fraud and insurance, cancellation of the special treatment qualification, involving medical institutions, shall not carry out the special recognition work.

(ii) support eligible designated medical institutions to carry out the corresponding special treatment, the insured should choose to meet the medical needs of designated medical institutions as their own special treatment medical institutions. In accordance with the national and provincial unified deployment arrangements, the functions of the national unified information platform and the provincial unified prescription flow platform will be brought into play, and qualified designated retail pharmacies will gradually be included in the outpatient protection channels to carry out the relevant convenient services. Participants with selected medical institutions, dispensing prescriptions, medical vouchers, in accordance with the provisions of the designated retail pharmacy dispensing and direct settlement.

(C) the establishment of a regular reassessment mechanism for special patients, the implementation of special patients dynamic access and exit, the specific measures by the municipal health insurance agencies to develop separately.

Fourth, the work requirements

(a) strengthen the organization and leadership. The local medical insurance departments should attach great importance to strengthening the responsibility for the strict implementation of the city's unified special protection policy, optimize the level of management services, strengthen interdepartmental collaboration to ensure that eligible patients enjoy timely treatment. At the same time, do a good job of special statistical analysis of the operation of the special fund to prevent and resolve operational risks.

(ii) Strengthen fund supervision. The designated medical institutions should be treated according to the disease, reasonable inspection, reasonable treatment, reasonable use of medication, shall not be prescribed with the patient's condition is not related to the inspection and test items and treatment of drugs, to eliminate the occurrence of over the scope of super-dosage, duplicate prescribing and other irregularities. At the same time, they should do a good job of managing patients' medical information, perfecting patients' outpatient treatment medical records, and ensuring that patients' medical records are accurate, so as to be ready for daily inspections and regular verifications by the medical insurance departments. The medical insurance agency should incorporate the management of outpatient specialties into the scope of the agreement management of the designated medical institutions, incorporate the improvement of patients' medical information into the content of the agreement, and strengthen the day-to-day management and supervision and inspection of outpatient specialties, medical services and other behaviors. The knowledge base and rule base of intelligent monitoring will be improved, and the diagnosis, examination, treatment and medication of specialties will be included in the scope of monitoring. Participants and designated medical institutions should strictly abide by the relevant provisions of the management of special access, the designated medical institutions and individuals in violation of the relevant provisions of the medical insurance regulatory authorities in accordance with the law to give serious treatment.

(C) Strengthen publicity and guidance. All localities should make full use of the WeChat public number, the medical security bureau network platform, health insurance agencies, designated medical institutions lobby bulletin boards and other ways to actively publicize the importance of standardizing the special protection policy and related requirements, especially to strengthen the insured patients, designated medical institutions staff reasonable compliance with the use of the special policy of public opinion guidance to create a good social atmosphere, and to promote the implementation of the work of the smooth.

This notice will be implemented as of January 1, 2023, and any inconsistency between the previous policies and this notice will be subject to the provisions of this notice.