How to reimburse chronic disease outpatient services

The core logic of outpatient reimbursement for chronic diseases is to "qualify first, then seek medical treatment at a designated location, and finally reimburse according to policy proportions." At present, most coordinating areas in China support real-time settlement at designated medical institutions. Only a few cases such as medical treatment in other places and missed receipts require manual reimbursement after travel.

A while ago, I helped Aunt Zhang downstairs get the chronic disease qualification for type 2 diabetes. She has been ill for 5 years and has peripheral neuropathy. Before the chronic insurance, it cost more than 400 per month to prescribe medicine. Last year, I accompanied her to get nearly half a year's medical records, complication examination reports and diagnosis certificates from the hospital. I went to the medical insurance window of the community health service center to fill out the application, and it was approved in less than 10 days. She chose the community hospital and the district central hospital downstairs from her home. Now every time she goes to get metformin and nerve-nutrition drugs, she scans the medical insurance code and can go directly to the unified reimbursement. As long as she pays less than 100 yuan, it is equivalent to saving more than 70% of the drug cost.

Of course, not all chronic diseases can go through this reimbursement channel. The reimbursement catalogs for special chronic diseases vary widely across regions. High-risk chronic diseases such as hypertension, diabetes, and chronic obstructive pulmonary disease are basically included in the catalog nationwide. However, some relatively niche diseases, such as psoriasis, are included in the reimbursement of special chronic diseases in some areas, and some areas are not yet covered. There has been discussion on whether to unify the catalog of chronic diseases across the country. Supporters believe that a unified catalog can avoid excessive differences in the treatment of patients insured across regions, especially the elderly who live in different places without having to go back and forth to determine eligibility. Opponents believe that the medical insurance funds in different regions The ability to withstand different pressures is different. Adjusting the catalog based on local prevalence can save money wisely. At present, local policies are still implemented in various places. Before applying, call the 12393 medical insurance hotline to ask whether your disease is on the catalog and what materials you need to prepare. This can save a lot of mistakes.

Don’t panic if you encounter a situation where medical treatment in another place cannot be settled in real time. Last month, Aunt Zhang went to live with her son in Shanghai for two months. When she prescribed medicine at a designated hospital in Shanghai, she was not covered by medical insurance. After returning, she collected the outpatient medical records, payment invoices, and drug prescriptions and submitted them to the community medical insurance window. The reimbursement money was credited to her social security card financial account in less than two weeks. The only thing you need to pay attention to is that all receipts must be kept original. Most places will not replace them if they are lost. I have encountered someone before who put the receipt in his pocket and washed it, and the receipt was not paid after three trips.

Many people mistakenly believe that as long as a chronic disease is diagnosed, they can apply for reimbursement. In fact, this is not the case. Each disease has a clear threshold for recognition. For example, high blood pressure must reach level 3 or heart, brain, and kidney-related complications. It does not mean that you can apply just after you are diagnosed with high blood pressure. There was a young man who just worked before who went to submit the materials after his physical examination showed that he had level 1 hypertension. However, when he was not approved, he thought it was blocked by the medical insurance department. In fact, he did not meet the recognition standards. Checking the requirements in advance can also avoid a wasted trip.