Reimbursement ratio for chronic disease medicines

At present, there is no unified national reimbursement ratio for chronic disease medication (i.e., outpatient medication for chronic diseases) in my country. The conventional reimbursement range is between 50% and 90%. The specific ratio will fluctuate based on the four major factors of insurance type, region, type of chronic disease, and level of medical institution.

A while ago, I helped my relative Aunt Zhang in Qingdao, Shandong Province, calculate the cost of medicines: She was covered by the retired employee medical insurance and had been diagnosed with diabetes. She went to the community health service center downstairs to get metformin. The original price of a box was 24 yuan, and she only paid 2.4 yuan for 90% of the reimbursement.； If you go to the city's top tertiary hospital to prescribe the same medicine, the reimbursement rate will be reduced to 80%, and you will have to pay 4.8 yuan. If you forget to bring the receipt and settle the bill as a general outpatient clinic, you can only reimburse 50%, and you will have to pay 12 yuan, which is not even a little bit different.

First of all, the impact of insured status is most intuitive. The reimbursement ratio of employee medical insurance is generally 10%-20% higher than that of residents’ medical insurance: the regular reimbursement ratio of chronic disease drugs in employee medical insurance is 70%-90%, and it will be about 5% higher for retirees.； The reimbursement ratio of residents’ medical insurance (including the new rural cooperative medical insurance) is mostly between 50% and 80%. Last year, I helped a distant relative in my hometown of Heilongjiang to get a high blood pressure clinic. He paid 380 yuan per year for residents’ medical insurance. The reimbursement for taking medicines at the county hospital was 65%, and the reimbursement for the same medicine at the village clinic was 75%. This is because the local policy favors grassroots medical institutions.

In addition to insurance types, differences in disease types will also directly increase the reimbursement ratio. Nowadays, most areas divide chronic diseases into two categories: ordinary chronic diseases and special chronic diseases: common chronic diseases with high incidence and low medication costs, such as hypertension and diabetes, the reimbursement ratio is mostly within the conventional range mentioned above, and the annual reimbursement upper limit is mostly between 1,000-5,000 yuan. ； For special chronic diseases such as outpatient radiotherapy and chemotherapy for malignant tumors, anti-rejection of organ transplants, hemophilia, and ALS, which are expensive to treat and require long-term medication, the reimbursement ratio is generally 5% to 15% higher than that of ordinary chronic diseases. In many areas, it can reach more than 90%. The annual reimbursement limit will also be relaxed to be consistent with hospitalization treatment. A quota of hundreds of thousands can basically cover the need for medication. I have been in contact with a patient with ALS in Jiangsu before. It is a disease listed in the local rare disease catalog. The reimbursement rate for riluzole is 90%, and the annual quota is 400,000. Basically, you don’t have to pay much out of pocket.

There is actually quite a lot of controversy in the industry over "the difference in reimbursement ratios between hospitals at different levels". The medical insurance policy side that supports widening the gap believes that primary medical institutions can fully guarantee the commonly used drugs for common chronic diseases. Increasing the reimbursement ratio at the grassroots level can not only divert the pressure on large hospitals, but also reduce unnecessary expenditures of medical insurance funds. It is a win-win choice. ； However, many patients with severe chronic diseases and rare diseases do have difficulties: many specialized drugs are only available in top-level hospitals, and are not available at the grassroots level. The reimbursement ratio based on level has only increased the burden on these people. Many places are now starting to pilot adjustments. For example, Shanghai has stipulated that for special chronic diseases such as malignant tumor outpatient medication and dialysis treatment, the reimbursement ratio will be uniform no matter what level of hospital you go to. The ratio will not be reduced just because you go to a tertiary hospital. This is also an attempt to balance different needs.

If you really want to check your own specific reimbursement ratio, don't search for general answers on the Internet. It is most accurate to directly call the 12393 medical insurance hotline to ask. Just tell three pieces of information clearly: whether you are an employee or a resident medical insurance, which type of disease you are covered by, and which level of hospital you plan to go to to get the medicine. The reported number is basically not much different from the actual proportion of your money. By the way, don’t forget to take the initiative to show the receipt of the gatekeeper’s certification when picking up the medicine. Many people forget this and settle the bill as an ordinary outpatient clinic, which is a huge loss.