Chronic disease outpatient reimbursement ratio

Chronic disease outpatient reimbursements for employee medical insurance are generally in the 60%-90% range, and residents' medical insurance (including New Rural Cooperative Medical System) are generally in the 40%-70% range. The specific values ​​will fluctuate depending on the policy of the insured area, the classification of chronic diseases, and the level of the medical institution where they are treated. Some special groups can also enjoy additional proportional inclines.

My aunt is a retired employee in Jining, Shandong Province. She has suffered from high blood pressure for 12 years, which is a common chronic disease in the local area. She can get 90% of the reimbursement when taking medicine at the community health service center. Last month, she prescribed valsartan for 32 yuan, and she only spent 32 yuan out of pocket.； If you go to a local tertiary hospital to prescribe the same medicine, the reimbursement rate will drop to 70%, and you will have to pay 9.6 yuan out of pocket, which is more than three times the difference.

Why are the reimbursement ratios for the same disease and the same medicine so different? The first thing to be affected is the "family wealth" of local medical insurance pooling funds. In areas with sufficient medical insurance balances such as Jiangsu, Zhejiang and Shanghai, the reimbursement ratio and amount of chronic diseases are generally higher. For many common chronic diseases covered by employee medical insurance in Suzhou, community reimbursement can reach 90%, and the annual cap is 10,000 yuan. ； However, the employee medical insurance in some central and western counties may only cover 65% of similar chronic diseases, with a cap of only 3,000 yuan a year.

In addition to region, the classification of chronic diseases themselves will also vary the ratio. Most regions now divide the diseases included in the chronic disease category into ordinary chronic diseases and special chronic diseases. For special chronic diseases that require large treatment costs, such as kidney dialysis, outpatient radiotherapy and chemotherapy for malignant tumors, and anti-rejection of organ transplants, the reimbursement ratio is generally 10%-20% higher than that of common chronic diseases such as hypertension and diabetes, and the annual cap line can even be increased more than ten times. Last year, I helped a friend in Wuhan handle chronic lung cancer registration. He is covered by employee medical insurance, and the reimbursement ratio for outpatient targeted drugs can reach 90%. The annual cap is 300,000 yuan, which is completely different from the cap of several thousand yuan for ordinary chronic diseases. If your family has elderly people over 65 years old, people living on subsistence allowances, or people with disabilities, you can also enjoy an additional 5%-10% preferential ratio. My grandma is 73 years old. Under the resident medical insurance in Hanzhong, Shaanxi Province, the diabetes rate can be reimbursed at 75% when taking medicine at the town health center, which is 10 points higher than that of ordinary adult residents.

While talking about this, we have to mention a disagreement that has been quarreling in the industry for a long time, regarding how to set a reasonable slow-door reimbursement ratio. One group's view is to continue to widen the reimbursement gap between medical institutions at different levels. For example, community reimbursement is 30% higher than that of tertiary hospitals. Patients should be guided to go to grassroots hospitals, which will not only reduce the outpatient pressure of tertiary hospitals, but also save medical insurance funds. But the opposition from the other group is also very real: many primary medical institutions now have incomplete chronic disease drug lists and are not equipped to deal with complex chronic disease complications. It is useless to rely solely on reimbursement ratio guidance. I met a friend with type 2 diabetes in the past two months. His commonly used semaglutide community has been out of stock for more than three months, and he can only go to the top three A’s to get it. Originally, he could get 80% rebate at the community, but only 60% rebate at the top three A’s. A box costs more than 120 yuan, which is equivalent to a disguised increase in the cost of his medication. Both sides are reasonable, and there is no unified solution until now.

In the past few years, I have helped three or four elderly people in my family to apply for slow-gate registration, and I have also stepped through many pitfalls. I would like to give you two practical reminders: Many people don’t know that after registering for slow-gate, as long as you apply for long-term residence registration for medical treatment in another place, outpatient clinics in other places can be settled directly according to the proportion of the insured place, without having to advance money yourself and then go back to your hometown for reimbursement. Last year, my aunt helped her cousin take care of her children in Shenzhen. Before, we sent her antihypertensive medicines to her hometown. Later, we applied for registration in a different place. Now we can get 85% of the medicines directly from the social welfare in Shenzhen, which is exactly the same as the ratio in our hometown. It saves a lot of trouble. There is another point that is easy to make mistakes: most of the slow doors in most areas have an annual minimum payment line, which usually ranges from 100 to 300 yuan. You have to save enough slow door fees within a year before the excess will start to be reimbursed. When I just applied for a slow door for my dad The first time I took the medicine, I paid 180 out of pocket. I thought the registration was not successful, so I went to the medical insurance bureau three times. They said I could apply for the medicine after taking two more medicines to make up the 200 payment threshold. Then the second time I took the medicine, I paid directly, which wasted a lot of time.

In fact, there has never been a one-size-fits-all standard answer to the slow-care reimbursement ratio. Policies in various places may be adjusted every year based on the operation of the fund. Instead of searching for outdated information from several years ago on the Internet, it is better to call the 12393 national medical insurance service hotline directly and state your insured place, insured type and specific disease. You can ask for the latest accurate ratio in two minutes. If you often go to a hospital near your home, you can find out by just asking at the medical insurance window next to the consultation desk, which is much more reliable than trying to figure it out on your own.