Are the reimbursement rates for chronic diseases and special diseases the same?

In most areas, the reimbursement ratios for the two types of diseases are not the same, and the overall reimbursement for special diseases is much higher than that for ordinary chronic diseases.

I have been working at the community medical insurance service post for more than half a year to help residents with reimbursement-related procedures, and I have a good grasp of the matter. Last week, I just helped Aunt Zhang, who lives in Building 3, to check her diabetes outpatient reimbursement form. Her situation can be compared with Uncle Li, a uremic patient in the unit next door. In fact, the logic of delineating chronic diseases and special diseases in the medical insurance catalogs of various places is inherently different. Common chronic diseases are mostly diseases such as hypertension and type 2 diabetes that require long-term medication control but will not cause large medical expenditures in the short term. Special diseases are basically diseases such as radiotherapy and chemotherapy for malignant tumors, uremic dialysis, and anti-rejection after organ transplantation, which have high treatment costs and have a great impact on patients' lives. The insurance positioning itself is different, and the reimbursement benefits are naturally different.

Take our local residents' medical insurance policy as an example. The outpatient reimbursement ratio for common chronic diseases is 55%, and the annual cap is 3,000 yuan. Aunt Zhang's monthly diabetes medication expenses are about 400 yuan, and she pays 180 out of her own pocket after reimbursement. The total reimbursement in a year is just over 2,000 yuan, and will not exceed the limit. But Uncle Li’s monthly dialysis fee is 12,000 yuan. If it is reported as a common chronic disease, the maximum reimbursement is 3,000 yuan a year. The rest has to be paid by himself, which is simply unaffordable. And his uremia is a special disease, and the outpatient reimbursement ratio is directly aligned with the inpatient treatment, which can reimburse 85%. The one-year cap line and hospitalization share a quota of 300,000 yuan. Calculated, he only needs to pay 1,800 yuan a month, which is much less stressful.

Of course, not all places are so stuck. In the past two years, many places have adjusted their benefits on a pilot basis. For example, some coordinating districts have classified diseases such as type 1 diabetes and pulmonary hypertension, which were originally classified as chronic diseases but have high medication costs, into the catalog of special diseases. The reimbursement ratio is the same as that of other special diseases. To be fair, there are still some places that have additional preferences for chronically ill elderly people over 80 years old. The reimbursement ratio can be raised to 70%, which is not much different from the reimbursement for some mild special diseases. However, this is a local pilot policy, and most areas still follow the general principle of "special diseases are reimbursed higher than ordinary chronic diseases."

After all, medical insurance is basically coordinated at the municipal level now, and the policy details of each city are different. If you are not sure what kind of disease your disease belongs to and how much you can claim, it is best to call the service hotline of the local medical insurance bureau directly, or go to the medical insurance window of the government service center to ask a few questions, which is much more accurate than checking the general information online.