In order to implement the decisions and deployments of the CPC Central Committee and the State Council, deepen the reform of direct settlement of basic medical insurance for cross-provincial medical treatment in different places, and strive to solve the problems of inconvenient registration of medical treatment in different places, the National Medical Insurance Administration and the Ministry of Finance jointly issued the "About Further Doing a Good Job" today. Notice on Direct Settlement of Basic Medical Insurance for Cross-province Medical Treatment in Different Places.
Q: What is the current progress of the direct settlement of inter-provincial and non-local medical treatment, and what is the work goal at the end of the 14th Five-Year Plan?
A: Since last year, on the basis of fully realizing the direct settlement of hospitalization expenses across provinces, all co-ordinated regions have realized the cross-province direct settlement of general outpatient expenses and cross-provincial handling of medical records in different places. A pilot program for direct settlement across provinces of 5 outpatient chronic diseases related treatment costs, including radiotherapy and chemotherapy for malignant tumors, dialysis for uremia, and anti-rejection treatment after organ transplantation.
As of the end of June 2022, there were 246,700 designated medical institutions in the inter-provincial network, basically achieving the goal of at least one designated medical institution in each county being able to directly reimburse medical expenses including outpatient fees. The fund paid 201.976 billion yuan.
According to the requirements of the "Notice", before the end of 2025, the direct settlement system and handling management service system for cross-provincial medical treatment in different places will be more perfect, the supporting role of the unified national medical insurance information platform will continue to be strengthened, and the national settlement capacity for medical treatment in different places will be significantly improved.
Specifically, first, the inter-provincial direct settlement rate of hospitalization expenses has increased to more than 70%; second, the number of designated medical institutions in the cross-provincial network of general outpatient clinics has doubled to about 500,000; third, hypertension, diabetes, malignant tumors On the basis of the full coverage of 5 outpatient chronic and special diseases, such as outpatient radiotherapy and chemotherapy, uremic dialysis, and anti-rejection treatment after organ transplantation, the cross-provincial direct settlement and overall coverage of the overall area will gradually cover other outpatient chronic and special diseases that are in high demand and are widely carried out in various places. Relevant treatment expenses are included in the scope of inter-provincial direct settlement; fourth, the filing of medical treatment in different places is standardized and convenient;
Q: How can the insured pay directly for medical treatment across provinces and other places?
A: Simply put, it is to file a record first, select a point, and seek medical treatment with a code card.
The first is to record first.
Before insured persons seek medical treatment in different places across provinces, they can go through online and offline channels such as the National Medical Insurance Service Platform APP, the national medical treatment filing mini-program, the client-side mini-program of the State Council, or the window of the handling agency in the insured place.
The second is the selected point.
After the insured person completes the record for medical treatment in different places, all the inter-provincial networked designated medical institutions opened in the record place can enjoy the inter-provincial direct settlement service for hospitalization expenses; Where the insured person is required to choose a certain number or to purchase medicines at a designated cross-provincial networked medical institution at a designated level, the regulations of the insured place shall be followed.
The third is to seek medical treatment with a code card.
Insured persons are required to present valid certificates such as medical insurance electronic vouchers or social security cards during admission registration, discharge settlement and outpatient settlement.
Cross-provincial networked designated medical institutions provide reasonable and standardized diagnosis and treatment and direct settlement services for medical expenses for outpatient (emergency) diagnosis and inpatient patients who meet the requirements of the medical treatment place.
Q: Who can apply for a medical record in a different place?
Answer: The purpose of implementing the remote medical treatment filing management system is to confirm the identity of the insured persons, distinguish the types of insured persons going out for medical treatment, and determine the corresponding medical insurance benefits. The success rate of inter-provincial direct settlement.
At the same time, the implementation of record management for medical insurance personnel going out for medical treatment is also to implement the requirements of the state for hierarchical diagnosis and treatment, and to guide reasonable and orderly medical treatment.
In the past, there were only four types of people who filed for cross-provincial medical treatment in different places: retirees who were placed in different places, long-term residents in different places, resident staff in different places, and people who were referred in different places. The people who seek medical treatment in different places are divided into two categories: long-term residents living in different places across provinces and people who temporarily go out to seek medical treatment in different provinces, and are further subdivided into 6 types of personnel.
Among them, inter-provincial and long-term residents in different places include retirees who are resettled in different places, long-term residents in different places, resident staff in different places and other people who work, live and live outside the insured province for a long time; inter-provincial people who go out for medical treatment temporarily include those who are referred for medical treatment in other places. , emergency rescue personnel in different places due to work, travel and other reasons, and other people who temporarily go out to seek medical treatment across provinces.
Q: What is the payment policy for the direct settlement fund for cross-provincial medical treatment?
Answer: The medical expenses for inpatient, general outpatient and outpatient chronic and special diseases that are directly settled for cross-provincial medical treatment in different places shall, in principle, be subject to the payment scope and relevant regulations stipulated by the medical treatment place (basic medical insurance drugs, medical service items and medical consumables, etc. payment scope), Implement relevant policies such as the basic medical insurance fund minimum payment standard, payment ratio, maximum payment limit, and the scope of chronic and special diseases in outpatient clinics stipulated by the insured place.
Simply put, it is the directory of medical treatment places and the policy of insured places.
Example: A retired employee in Langfang City, Hebei Province, on July 1, 2022, went to Beijing for inter-provincial medical treatment and directly settled outpatient chronic and special disease expenses.
The total cost is 64.29 yuan, and the fund pays 48.89 yuan.
There are two medicines for this fee. According to the list of medical treatment places, the payment scope is as follows: Acarbose tablets, a class A drug, 32.52 yuan, all within the scope of the fund; and repaglinide tablets, a class B drug, 31.77 yuan, of which 28.59 yuan is eligible for the fund. The scope of payment, 3.18 yuan is the first payment for Class B.
According to the scope of medical treatment, the total expenses within the scope of the basic medical insurance fund are 61.11 (32.52+28.59) yuan, the first-class self-payment amount is 3.18 yuan, according to the payment ratio of the insured place 80%, the fund pays 48.89 (61.11*80% )Yuan.