Outpatient co-ordination should set up Qifubiaozhun and maximum payment limit. When the insured uses Class B drugs and medical services in the outpatient department, they should first pay according to the prescribed proportion, and then enjoy the relevant treatment according to the following provisions.
In a natural year, the insured outpatient medical expenses that meet the requirements of basic medical insurance, the expenses below Qifubiaozhun shall be paid by the insured's personal account or cash; The expenses above Qifubiaozhun and below the maximum payment limit shall be shared by the overall fund and individual.
The outpatient department should co-ordinate the implementation of the first diagnosis and referral system based on community health service institutions. Insured persons can be first diagnosed or referred to community-managed medical institutions in designated community health service institutions for urban workers' basic medical insurance; Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral, and emergency rescue is not subject to this restriction. After the outpatient chronic disease subsidy limit is used up, it will be included in the outpatient overall settlement from the next cost, and the original chronic disease does not need to be referred. After the subsidy limit for specific outpatient projects is used up, referral procedures must be handled according to the provisions of outpatient co-ordination, and ordinary medical records can be used to enjoy outpatient co-ordination treatment. Buying medicine in a pharmacy does not enjoy the overall treatment of outpatient service.
Within a natural year, the insured outpatient co-ordinate the medical expenses that meet the requirements, and the expenses below Qifubiaozhun shall be paid by the insured individual; The expenses above Qifubiaozhun and below the maximum payment limit shall be shared by the overall fund and individual.
What is the outpatient co-ordination process?
Insured persons can be first diagnosed or referred to community-managed medical institutions (secondary and below medical institutions) in designated community health service institutions for urban workers' basic medical insurance.
Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral (see the table below for the list of referral hospitals), and emergency rescue is not subject to this restriction.
legal ground
"Guiding Opinions of the General Office of the State Council on Establishing and Improving the Economic Security Mechanism for Outpatients with Basic Medical Insurance for Employees"
Third, strengthen the economic security function of outpatient service. Establish and improve the overall guarantee mechanism for the general outpatient expenses of employee medical insurance, and gradually include the general outpatient expenses of frequently-occurring diseases and common diseases into the payment scope of the overall fund on the basis of doing a good job in the medical security work for chronic diseases and special diseases (hereinafter referred to as outpatient chronic diseases and special diseases) with heavy burden on the masses such as hypertension and diabetes. The general outpatient service covers all insured employees in medical insurance as a whole, and the payment ratio within the policy scope starts from 50%. With the strengthening of the affordability of the medical insurance fund, the level of protection is gradually improved, and the payment of benefits can be appropriately tilted towards retirees. According to the characteristics of outpatient medical service, scientifically calculate the minimum payment standard and maximum payment limit, and make a good connection with the hospitalization expense payment policy. Simultaneously improve the outpatient co-ordination of basic medical insurance for urban and rural residents, and gradually improve the level of protection.
According to the affordability of the medical insurance fund, the scope of chronic diseases and special diseases paid by the overall fund will be gradually expanded, and the outpatient expenses of some diseases with long treatment cycle, great harm to health and heavy cost burden will be included in the * * * economic security, and some special treatments that are suitable for outpatient service and more economical and convenient than hospitalization can be managed with reference to hospitalization. Constantly improve the outpatient service economic security mechanism, and gradually transition from disease security to cost security. Will meet the conditions of the designated retail pharmacies to provide drug protection services into the scope of outpatient services, support the settlement and adjustment of external prescriptions in designated retail pharmacies, and give full play to the convenience and accessibility of designated retail pharmacies. Explore the inclusion of qualified "internet plus" medical services in the scope of protection.