Class A drugs: drugs that are necessary for clinical treatment, widely used, have good therapeutic effects, and are low-priced in their category. When using these medicines, the insured can be reimbursed for the full amount and the reimbursement will be made according to the stipulated percentage.
Category B drugs: drugs that can be used for clinical treatment, have good therapeutic effects, and are more expensive than Category A drugs in the same category. When a participant uses Category B drugs, a certain amount of personal out-of-pocket expenses will be deducted according to the proportion (set by each region), and then the remaining expenses will be included in the scope of reimbursement and reimbursed according to the prescribed proportion.
Why are the reimbursement rates different?
Because of the different levels of health insurance financing in different parts of China, in order to ensure the basic medical use of medicines for the insured, the Basic Medical Insurance Drug List is divided into Class A and Class B catalogs for management, with the purpose of clarifying the graded use of medicines to achieve the best cost-effective results. For the graded use of drugs and improve resource efficiency.
Category A drugs are all reimbursed proportionally. Class B drugs are partly paid out-of-pocket and partly reimbursed, with the specific out-of-pocket percentage varying according to local policies and specific drugs (in Harbin, for example, medical expenses incurred by the use of Class B drugs are first paid by the individual at 20% out-of-pocket).
How is the reimbursement for Class A and B medical insurance calculated?
After a participant's visit to the doctor, he or she incurs expenses for medicines, diagnosis and treatment, of which the medicines include Class A and Class B. The method of reimbursement is as follows: the cost of Class B medicines after deducting the out-of-pocket expenses, plus the full cost of Class A medicines, plus the costs of diagnosis and treatment that conform to the provisions of the medical insurance. For expenses exceeding the threshold, the patient will be reimbursed at a prescribed rate based on the type of insurance and the level of hospitalization.
The formula is as follows: Medical insurance reimbursement amount = (the total cost of Class A drugs + the cost of Class B drugs after deducting the out-of-pocket expenses + other costs in line with the provisions of the medical insurance) - the starting line × the corresponding reimbursement rate.
For example, in Harbin City, the urban workers in the old Liu a visit to the third-class hospital, hospitalized in the medical insurance directory within the scope of the diagnosis and treatment of the cost of 3000 yuan, the cost of drugs in Category A 2000 yuan, the cost of drugs in Category B 2000 yuan, Category B drugs, out-of-pocket expenses of 20%, the starting line is 720 yuan, the urban workers' health insurance in the hospital at this level of reimbursement rate of 90%.
Then the reimbursement method is: the full cost of Class A drugs 2000 yuan, plus the rest of the cost of Class B drugs deducted from the out-of-pocket expenses of 1600 yuan (Class B drugs out-of-pocket part of 2000 × 20% = 400 yuan), plus the cost of diagnosis and treatment in line with the provisions of the medical insurance of 3,000 yuan, a total of 6,600 yuan. After deducting the $720 threshold, the expenses covered by reimbursement are $5880.
The medical expenses of the old Liu, the health insurance can reimburse 5880 × 90% = 5,292 yuan, the old Liu only need to bear 1,708 yuan (the starting line of 720 yuan + 400 yuan of Class B drugs out-of-pocket + 588 yuan proportionally borne by the individual within the scope of the policy of the health insurance).