The "three catalogs" define the scope of basic medical insurance and ensure that insured people enjoy basic medical protection.
I. Drug Catalog for Medical Insurance
The National Drug Catalog for Basic Medical Insurance, Workers' Compensation Insurance, and Maternity Insurance (the Drug Catalog for Medical Insurance) is the standard for payment of drug costs by the basic medical insurance, workers' compensation insurance, and maternity insurance funds.
Since the establishment of the basic medical insurance system, the former Ministry of Labor and Social Security and the Ministry of Human Resources and Social Security released four versions of the medical insurance drug catalog in 2000, 2004, 2009 and 2017***. The medical insurance drug catalog currently in use in our province is the 2019 version of the national medical insurance drug catalog.
The Interim Measures for the Administration of Basic Medical Insurance Drugs, which will come into effect on September 1, 2020, were issued by the National Health Insurance Bureau. The measures specify that the following eight categories of drugs will not be included in the Drug Catalog: 1. drugs that mainly play a tonic role; 2. drugs containing national precious and endangered wildlife and plant herbs; 3. health care drugs; 4. preventive vaccines and contraceptive drugs; 5. drugs that mainly play a role in enhancing sexual function, treating hair loss, weight loss, cosmetology, smoking cessation, and cessation of alcoholism; 6. drugs that can't be charged individually for reasons such as inclusion in the diagnostic and treatment program; 7. wine preparations; and 7. Drugs; 7. Alcohol preparations, tea preparations, all kinds of fruit-flavored preparations (except for children's medicines under special circumstances), oral containers and oral effervescent preparations (except for special circumstances), etc.; 8. Other medicines that do not comply with the provisions of the basic medical insurance medication.
Two, diagnostic and therapeutic items (medical consumables) catalog
1. Diagnostic and therapeutic items catalog
The scope of diagnostic and therapeutic items for which the state stipulates that no fees are to be paid and part of the fees are to be paid. The province adopts the access method to formulate the catalog of diagnostic and therapeutic items, and each coordinating area can formulate the specific self-payment ratio.
The scope of the medical insurance does not pay for the cost of treatment items:
(1) service items: registration fees, out-of-hospital consultation fees, medical records cost, consultation fees, examination and treatment of expedited fees, surcharge on the name of the surgery, high quality premiums, special nurses and other special medical services.
(2) Diagnostic and therapeutic equipment and medical materials: application of positron emission tomography (PET), electron-beam CT, ophthalmic excimer laser therapy instrument and other large-scale medical equipment for the examination and treatment of the project; eyeglasses, prosthetic teeth, prosthetic eyes, prosthetic limbs, hearing aids and other rehabilitative devices; a variety of health care for their own use, massage, checking and treatment equipment; the price departments of the provinces can not be separate charges for Disposable medical materials.
(3) non-disease treatment programs: a variety of beauty, fitness programs and non-functional plastic surgery, orthopedic surgery, etc.; a variety of weight loss, weight gain, height projects; a variety of health checkups; a variety of preventive, health care diagnostic and therapeutic programs; a variety of medical consultation, medical appraisal.
(4) therapeutic projects category: all kinds of organ or tissue transplantation of organ source or tissue source; except for kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplantation of other organs or tissues; myopic orthopedics; qigong therapy, music therapy, health care nutrition therapy, magnetic therapy and other auxiliary treatment projects.
(5) Other: various infertility (pregnancy), sexual dysfunction diagnosis and treatment programs; various scientific research, clinical verification of diagnosis and treatment programs.
Medicare to pay part of the cost of diagnosis and treatment program scope:
(1) diagnostic and treatment equipment and medical materials: the application of χ-ray computed tomography (CT), stereotactic radiography (γ-knife, χ-knife), cardiac and angiographic χ-ray machine (including digital subtraction equipment), nuclear magnetic resonance imaging (NMRI) and digital subtraction equipment (DSI). Digital subtraction equipment), magnetic **** vibration imaging device (MRI), single photon emission computer scanning device SPECT), color Doppler, medical linear gas pedal and other large-scale medical equipment for examination, treatment projects; extracorporeal shock wave lithotripsy and hyperbaric oxygen therapy; pacemakers, artificial joints, artificial crystals, vascular stents, such as the body of the replacement of artificial organs, the body of the material placed; the provinces Pricing department of the provisions of the disposable medical materials can be charged separately.
(2) therapeutic projects: hemodialysis, peritoneal dialysis; kidney, heart valves, cornea, skin, blood vessels, bone, bone marrow transplantation; cardiac laser perforation, anti-tumor cellular immunotherapy and fast neutron therapy projects.
(3) Examination and treatment items of expensive medical instruments and equipment and medical materials as stipulated by the provincial medical insurance administration.
2. Catalog of Medical Consumables
There are more than 600 medical consumables that can be charged separately by medical institutions, of which about 360 are included in the medical insurance payment. Those not included are mainly orthopedic, plastic, transplantation and some other non-essential medical consumables.
Medical consumables that medical institutions can not charge separately, are not allowed to charge the patient, does not involve medical insurance payment: routine instruments and low-value medical consumables, (such as disposable sterile wipes, disinfectant drugs, rinse saline, general sutures, dressings, etc.) have been included in the pricing of medical services to be taken into account in the cost factors of medical service items, are not separately priced. Test reagents.
Medical institutions can charge patients for consumables: transvascular intervention using guidewires, catheters, balloons, stents, filters, etc.; special medical consumables required in the procedure, such as special puncture needles, ablation electrodes, ablation needles and accessories, special guidewires, catheters, stents, balloons, titanium clips, titanium butyl, titanium plates, dilators, anastomoses, sutures, fixators; artificial crystals, pacemakers, artificial joints, etc.
3. Scope of medical service facilities
Medical service facilities refer to the living service facilities provided by the designated medical institutions, which are necessary for the participants in the process of receiving diagnosis, treatment and care.
The cost of medical service facilities mainly includes the cost of inpatient beds and outpatient hospitalization beds. The basic medical insurance will not pay for the daily necessities, water and electricity that have been included in the inpatient bed fee or outpatient hospitalization bed fee, and the designated medical institutions shall not charge the insured persons separately.
Medical service facilities use the exclusion method to stipulate the scope of non-payment of the cost of living services and service facilities.
Provinces set the catalog of medical service facilities, and each coordinating area sets the payment standards.
The costs of living services and service facilities that are not paid by the basic medical insurance fund mainly include:
(1) transportation fees for consultation (referral) and emergency vehicle fees;
(2) air-conditioning fees, TV fees, telephone fees, baby warmer fees, food warmer fees, electric stove fees, refrigerator fees, and compensation for damages to public property;
(3) escort fees, nurse fee, cleaning fee, outpatient medicine fee;
(4) meal fee;
(5) recreational activities and other special needs living services.