Measures of Shenzhen Municipality on the Administration of Serious Diseases in Social Medical Insurance Outpatients
Shenzhen Labor Association [2008] 1 1
Article 1 In order to ensure that the social medical insurance insured persons in our city (hereinafter referred to as the insured persons) suffer from serious and serious outpatient diseases for medical treatment and standardize management, these measures are formulated according to the relevant provisions of the Measures of Shenzhen Municipality on Social Medical Insurance and the Guiding Opinions on the Management of Specific Diseases in Outpatients of Basic Medical Insurance in Guangdong Province (Yue Lao She Han [2006]1446).
Article 2 The major outpatient diseases mentioned in these Measures refer to:
The first category includes: hypertension (stage II and III), coronary heart disease, chronic cardiac insufficiency, liver cirrhosis (decompensated stage), chronic viral hepatitis (types B and C, active stage), moderate or above chronic obstructive pulmonary disease, rheumatoid arthritis, systemic lupus erythematosus, diabetes, thalassemia or marine anemia, aplastic anemia, hemophilia and Parkinson's disease.
The second category includes: outpatient dialysis for chronic renal insufficiency (uremia), organ transplantation (anti-rejection therapy), outpatient chemotherapy, radiotherapy and radionuclide therapy for malignant tumors.
Anti-rejection therapy after kidney, heart valve, cornea, bone, skin, blood vessels and bone marrow transplantation is suitable for the insured with basic medical insurance; Anti-rejection therapy after heart and liver transplantation is suitable for local supplementary medical insurance participants.
The municipal administrative department of labor and social security will increase the number of serious outpatient diseases in stages according to the income and expenditure of the fund.
Article 3 The insured of comprehensive medical insurance shall be subject to the relevant provisions of the first category of outpatient serious illness in these Measures; The relevant provisions of the second kind of outpatient serious illness in these Measures shall apply to the insured persons of comprehensive medical insurance, hospitalization medical insurance and migrant workers' medical insurance.
Article 4 The insured person suffering from serious outpatient illness shall go through the diagnosis and inspection procedures in the diagnosis hospital designated by the municipal labor and social security administrative department (see Annex 1 for the specific list) according to the following procedures:
(1) Specialist attending physicians fill in the Diagnosis Certificate of Serious and Extraordinary Diseases in Shenzhen Social Medical Insurance Outpatient (hereinafter referred to as the Certificate), which is reviewed and signed by two doctors in the corresponding specialist diagnosis group (one of whom is the head of the diagnosis group), and confirmed and sealed by the medical insurance office. Designated medical institutions will input the contents of the Certificate into the medical insurance information system and transmit it to the municipal social insurance institution for review and confirmation. The original and photocopy of the relevant disease proof materials shall be reported to the city by the diagnostic hospital on a monthly basis.
If the insured person has been diagnosed as a serious outpatient disease in the past and has been taking medicine for nearly 1 month, he should provide the attending physician of the diagnosis hospital with the recent outpatient treatment records and relevant information of the original diagnosis of the disease (check the original and keep a copy), and then handle it according to the above procedures.
The diagnosis hospital should provide proof to the insured according to the admission standard of outpatient serious illness.
(two) the insured who meets the conditions of medical treatment in different places shall be issued a "certificate" by the local diagnostic hospital or the local medical institution at or above the second level, which shall be reported to the municipal social insurance institution for examination and confirmation.
The diagnosis hospital shall report to the municipal social insurance institution the list of experts and doctors related to outpatient serious diseases, and the team leader and members of the diagnosis team shall be on-the-job personnel with the title of deputy chief physician or above; When there are personnel changes in the diagnosis team, the diagnosis hospital should report the changes to the municipal social insurance institution in a timely manner.
Article 5 After the insured suffers from a major outpatient disease and is confirmed by the municipal social insurance institution, he/she shall go to the designated medical institution in our city for medical treatment with his/her social security card, special outpatient medical records of major diseases in Shenzhen social medical insurance clinic and certificates. Not to the designated medical institutions in our city for medical treatment, the fund will not pay the corresponding social medical insurance benefits, except for the following circumstances:
(a) the occurrence of emergency rescue;
(II) Retirees who receive monthly pensions from social insurance institutions in this Municipality live in other areas of China (excluding Hong Kong, Macao and Taiwan, the same below) for a long time, and choose three local medical insurance designated medical institutions as medical institutions for serious and serious diseases (category I) at their places of residence, and go through the filing formalities with the municipal social insurance institutions;
(III) The insured registered permanent residents in other cities in China (excluding Hong Kong, Macao and Taiwan, the same below) choose three local designated medical institutions for medical insurance as medical institutions for serious and serious diseases (category I) and file with the municipal social insurance institutions.
If the insured person needs outpatient hemodialysis due to chronic renal insufficiency (uremia stage), he shall conduct hemodialysis in the designated medical institutions in our city (see Annex II for the specific list).
The insured person should use the outpatient medical records of Shenzhen social medical insurance for serious diseases when seeking medical treatment, and properly keep the medical records and auxiliary examination results for future reference. If the insured suffers from a variety of serious outpatient diseases at the same time, he will no longer receive the Special Outpatient Medical Record of Shenzhen Social Medical Insurance Outpatient for Serious Diseases when confirming the second serious outpatient diseases.
The medical records of the special outpatient clinic of Shenzhen social medical insurance for serious illness can be obtained by my social security card, ID card and certificate at the municipal social insurance institution or the diagnostic hospital of this city, and the old medical records of the special outpatient clinic of Shenzhen social medical insurance for serious illness should be provided for future reference when replacing. If the insured person loses the "Certificate" or "Shenzhen Social Medical Insurance Outpatient Medical Record of Serious Diseases", he should apply for a replacement (collar) with his social security card and ID card to the original diagnosis hospital medical insurance office or the municipal social insurance institution.
Designated medical institutions shall submit the medical records of the insured to social security institutions for the record.
Sixth comprehensive medical insurance insured persons suffering from major outpatient diseases (category I), confirmed by the municipal social insurance institutions, enjoy the following outpatient medical insurance benefits:
The expenses of medicines in the catalogue of basic medical insurance and local supplementary medical insurance and the expenses of diagnosis and treatment items in the catalogue of diagnosis and treatment items shall be paid by individual accounts; If the personal account is insufficient to pay, the expenses of outpatient basic medical insurance and local supplementary medical insurance in a medical insurance year exceed 5% of the average annual salary of employees in the previous year, which belongs to the scope of outpatient specialty corresponding to serious illness, and 70% of them are included in the accounting scope of basic medical insurance pooling fund and local supplementary medical insurance pooling fund respectively. Outpatient large-scale equipment inspection and treatment projects are not included in the accounting scope stipulated in this article.
Article 7 The insured persons of comprehensive medical insurance, hospitalization medical insurance and migrant workers' medical insurance, due to serious outpatient illness (Category II), are approved by the municipal social insurance agency, and their basic medical expenses are included in the scope of payment of the basic medical insurance serious illness pooling fund by 90%, and the local supplementary medical expenses are paid by the local supplementary medical insurance fund by 80%.
Eighth insured outpatient serious illness (category I) medical expenses according to the annual review of medical insurance reimbursement, and gradually implement separate accounting.
Article 9 The special outpatient medical expenses incurred by the insured person of comprehensive medical insurance in designated medical institutions due to major outpatient diseases (Category I) belong to the part paid by the basic medical insurance pooling fund and the local supplementary medical insurance fund, which shall be accounted for by the designated medical institutions, and the part paid by individuals shall be paid by personal accounts or cash, and the cash paid by insufficient funds in personal accounts shall also be accounted for.
The dialysis expenses incurred by the insured due to chronic renal insufficiency (uremia) in outpatient dialysis belong to the basic medical insurance expenses and local supplementary medical insurance expenses, which shall be accounted for by designated medical institutions according to regulations.
Article 10 In any of the following circumstances, the insured person may go to the municipal social insurance institution for review and reimbursement as required:
(1) Outpatient peritoneal dialysis, organ transplantation (anti-rejection therapy), outpatient chemotherapy, radiotherapy and radionuclide therapy for malignant tumors in designated medical institutions in our city due to chronic renal insufficiency (uremia stage);
(two) the three situations stipulated in the first paragraph of Article 5 of these Measures.
Eleventh designated medical institutions charge outpatient serious illness fees every month, and apply for settlement to the municipal social insurance agency.
Article 12 The insured is confirmed to have major outpatient diseases (category I) and enjoys the treatment of major outpatient diseases (category I) as stipulated in these Measures for a period of two years. If the disease has not been cured and needs to continue outpatient treatment, it shall go through the identification procedures again within three months before the expiration of the validity period.
Thirteenth in the process of outpatient serious illness identification, the diagnosis hospital, the insured fraud, the identification is invalid, the insured should re-identify the outpatient serious illness.
Article 14 These Measures shall be implemented as of April 6, 2008.
Article 1 These Measures are formulated in accordance with the Measures of Shenzhen Municipality on Social Medical Insurance (hereinafter referred to as the "Measures") in order to protect the rights and interests of social medical insurance participants in our city, standardize the medical treatment behavior of the insured and rationally use the medical insurance fund.
Article 2 These Measures shall apply to those who have participated in social medical insurance (including comprehensive medical insurance, hospitalization medical insurance, medical insurance for migrant workers and maternity medical insurance).
Article 3 When an insured person goes to a designated medical institution for medical treatment, he/she shall present a social security card as a voucher for the insured person to keep accounts and reimburse for medical treatment. At the same time, with the unified format of outpatient medical records of the municipal public health administrative department, treatment due to illness and rational use. The condition, examination, treatment and medication during treatment should be recorded in the outpatient medical record in detail.
Article 4 The insured persons of inpatient medical insurance and migrant workers' medical insurance shall choose a community health center in this Municipality in accordance with the following provisions, and seek medical treatment in the outpatient department of the selected community health center:
(a) the on-the-job insured of inpatient medical insurance and the insured of migrant workers' medical insurance shall be selected by the employer to the nearest community health service center or community medical service station;
(two) rural urbanization personnel to the village or joint-stock company as the unit of insurance, by the village or joint-stock company to the nearest community health service center or community medical service station to choose;
(three) other personnel according to the domicile to the nearest community health service center or community medical service station to apply for transfer.
Article 5 The medical expenses incurred by the insured in using the list drugs, diagnosis and treatment items and medical service facilities of basic medical insurance and local supplementary medical insurance in designated medical institutions shall be paid by the basic medical insurance fund and local supplementary medical insurance fund in accordance with the provisions of the Measures.
When the insured goes to the designated medical institutions for medical treatment, the basic medical insurance fund shall not pay the medical expenses listed in Annex 1 of these Measures.
The medical expenses incurred by the insured of maternity medical insurance for medical treatment shall be paid by the maternity medical insurance fund, which belongs to the provisions of Annex II to these Measures.
Sixth insured to the designated medical institutions for outpatient treatment, in accordance with the following provisions:
(a) outpatient medical records, my social security card;
(two) when the insured person suffers from a serious outpatient illness, he should hold the special outpatient medical records of the social medical insurance clinic in this Municipality;
(III) The insured person shall not lend the social security card to others for use when seeking medical treatment in the outpatient department, and shall not ask for over-dose prescription of non-therapeutic drugs, revision of medical records, and shall not change medicine, exchange medicine for things, or withdraw cash.
Seventh insured persons to designated medical institutions for medical treatment, shall be implemented in accordance with the following provisions:
(a) I should provide my social security card and identity card when going through the admission formalities, and I or my family members should sign the admission certificate and fingerprint it;
(2) If the social security card cannot be provided at the time of admission, it shall be provided within three days from the date of admission. If it is not provided within the time limit, the hospitalization expenses will not be recorded;
(three) during hospitalization, should cooperate with the doctor to actively treat;
(four) no hanging bed, false hospitalization, no minor illness;
(five) meet the discharge conditions, and shall not delay discharge;
(6) When discharged from the hospital, you are not allowed to take too many medicines and bring medical items, and the expenses for inspection and laboratory tests made by the insured after discharge are not recorded in the hospital accounts;
(seven) medical insurance for migrant workers should be hospitalized in the selected social health center settlement hospital;
(eight) migrant workers medical insurance insured due to illness need referral, should be issued by the original settlement hospital referral certificate step by step referral, or referral to the city at the same level or a level of expertise in medical institutions.
(nine) the insured shall not violate the medical principles and put forward other unreasonable medical and drug requirements;
Article 8 When the insured handles the referral outside the city, the following provisions shall apply:
(a) the disease can be diagnosed and treated in this city, and no referral from outside the city is required;
(two) referral outside the city should be treated according to the referral project, and if it is referred again, it is necessary to issue a referral certificate;
(three) the referral certificate or letter of introduction of designated medical institutions in different places shall not be used many times;
(four) the referral certificate or letter of introduction of designated medical institutions in different places, and one course of treatment is valid; Need to go back to the original medical institution for hospitalization and follow-up, you don't have to go through the transfer procedures, but you should go through the follow-up filing procedures at the social insurance institution before the follow-up; Need to be referred to the city for medical treatment again, need to re-apply for referral approval procedures;
(five) the transfer hospital should be a local non-profit designated medical institution above the third level.
Article 9 Insured persons who have stayed in other cities in China for a long time or lived in other cities in China after retirement shall enjoy local treatment according to the following provisions:
(a) the insured choose three local designated medical institutions as local medical institutions and file with the municipal social insurance institution;
(two) the insured person in the local selected medical institutions for medical treatment, according to the provisions of the "measures" to enjoy medical insurance benefits; The medical expenses incurred by the insured in the local medical institutions before filing shall be regarded as medical treatment outside the city;
(three) if the insured person returns to work or settle in this city, he shall cancel the record with the municipal social insurance institution in time.
Article 10 The insured who has long been resident in other cities in China or lives in other cities in China after retirement shall choose designated medical institutions in the local area according to the following provisions:
(a) to fill in the "Shenzhen social medical insurance insured designated medical institutions registration form" (in triplicate);
(2) Select three local public medical institutions above the town (township) level as their medical institutions, and report them to the local social security agency for examination and seal after being sealed by the medical institutions;
(three) by the insured unit or I hold the registration form stamped with the official seal of the unit to the social insurance institution for the record;
(four) in line with the conditions of local medical records, the social insurance institution shall issue a record certificate.
Eleventh confirmed by the municipal social insurance institutions for outpatient illness insured medical treatment, according to the provisions of the "Shenzhen social medical insurance outpatient illness management measures".
Twelfth maternity medical insurance, in line with the family planning policy of perinatal prenatal examination, delivery hospitalization, postpartum visit, family planning surgery (excluding baby costs), should be implemented in accordance with the following provisions:
(a) issued by my social security card, my ID card, medical records, marriage certificate and family planning service certificate (family planning certificate) when seeking medical treatment in the designated medical institutions in this Municipality;
(II) Procedures for personnel to seek medical treatment in the Mainland (II) (((IX) If prenatal examination, delivery hospitalization, postpartum visit and family planning operation (excluding baby expenses) are carried out in other cities in China, it shall be implemented according to the Measures for the Administration of Cash Reimbursement of Social Medical Insurance in Shenzhen.
Thirteenth insured person in any of the following circumstances, the municipal social insurance institutions can conduct an investigation, the insured person shall cooperate, truthfully reflect the situation, and provide relevant materials:
(1) The total number of general outpatient visits per month is greater than 15; (once every four hours)
(two) for three consecutive months, the number of general outpatient visits has exceeded 30 times; (once every four hours)
(three) outpatient medical expenses accumulated more than 6000 yuan within one month;
(four) in the same medical insurance year, the total medical expenses of general outpatient service exceeded 20 thousand yuan.
(5) The total outpatient expenses of the insured exceed those of 800 yuan in a medical insurance year.
(six) the monthly outpatient expenses of tumor radiotherapy and chemotherapy are more than 6.5438+0 million yuan;
(seven) the monthly outpatient expenses of uremia dialysis are more than 6.5438+0.5 million yuan;
(8) Monthly outpatient expenses for anti-rejection treatment after renal transplantation10.5 million yuan or more;
(nine) to participate in insurance by fraud;
(10) Lending my social security card to others for use, and fraudulently using another person's social security card;
(eleven) my social security card is stored in designated medical institutions or designated retail pharmacies;
(twelve) to report acts in violation of the provisions of the Measures;
(thirteen) other violations.
Article 14 If the insured person is under any of the circumstances in Article 13 of these Measures, the social insurance institution may notify the insured person to bring his social security card, ID card, medical record, medical expense receipt and other materials to the social insurance institution to explain the situation within 10 working days. If the insured fails to explain the situation within the time limit or the reasons are insufficient, the social insurance institution may file an investigation, suspend its social medical insurance bookkeeping from the date of filing the investigation, and notify the insured in writing.
The insured who has suspended the bookkeeping of social medical insurance still enjoys the benefits of social medical insurance, but it is settled in cash, and the medical expenses paid in cash are reviewed and reimbursed according to the provisions of the Measures for the Administration of Cash Reimbursement of Social Medical Insurance in Shenzhen.
The municipal social insurance institution shall complete the verification within 90 days from the date of suspension of social medical insurance bookkeeping, and deliver it within 10 working days.
Fifteenth after investigation and verification, the municipal social insurance institutions will be dealt with according to the following provisions:
(a) did not violate the provisions of social medical insurance, within 5 working days from the date of verification, to restore its social medical insurance bookkeeping;
(two) in violation of the provisions of social medical insurance, the municipal social insurance institution shall investigate and deal with it according to the relevant provisions of these measures;
(three) if the insured person is suspected of committing a crime, the municipal social insurance institution shall transfer it to the judicial organ for handling.
The medical management of sixteenth retired personnel and one to six disabled soldiers shall be implemented with reference to these measures.
Seventeenth these Measures shall come into force as of April 6, 2008+0. The original "Measures for the Administration of Medical Treatment for the Insured of Social Medical Insurance for Urban Workers in Shenzhen" (Shen She Bao Fa [2003] No.82) shall be abolished as of the date of implementation of these Measures.