Article 2 The term "serious outpatient illness" as mentioned in these Measures refers to diseases that cannot be cured in a short period of time, need long-term or lifelong outpatient treatment, have high medical expenses, and need subsidies from the overall fund.
Article 3 Serious illness in outpatient service
According to the fund-raising level and guarantee ability, the outpatient diseases of basic medical insurance for urban workers in Yinchuan are tentatively classified into fifteen categories: coronary heart disease, hypertension, diabetes, chronic obstructive pulmonary disease, rheumatoid arthritis, sequelae of cerebrovascular disease, chronic viral hepatitis, chronic glomerulonephritis, chronic nephrotic syndrome, chronic renal failure, organ transplantation, systemic lupus erythematosus, psychosis, aplastic anemia and various malignant tumors.
Article 4 Application and handling of serious illness in outpatient department.
(1) Insured employees suffering from coronary heart disease, hypertension, diabetes and rheumatoid arthritis need to hold the disease diagnosis certificate of medical institutions above level 2 (including level 2) and the corresponding inspection report, ID card and medical insurance card, and fill out the outpatient serious illness approval form at the medical insurance office of designated medical institutions above level 2 (including level 2) in the overall planning area, and handle the outpatient serious illness prescription after approval.
(II) Insured employees suffering from the above-mentioned four kinds of serious outpatient diseases need to hold a copy of the home page of recent hospitalization medical records or a discharge certificate, ID card and medical insurance card, fill in the outpatient serious illness approval form in the designated medical institutions above the second level (including the second level) in the overall planning area, and handle the outpatient serious illness prescription after approval.
(III) Designated medical institutions that examine and approve serious outpatient diseases should set up an expert group for identifying serious outpatient diseases, which is composed of experts above the deputy chief physician, and regularly confirm the insured employees who apply for serious outpatient diseases in accordance with the Technical Standards for Diagnosis of Serious Outpatient Diseases in Yinchuan City (when necessary, require the applicant to have a physical examination). The medical insurance office of designated medical institutions shall, according to the opinions of the expert group, make a conclusion of examination and approval, notify the applicant, issue a "Prescription for Outpatient Serious Illness" to eligible insured workers, and upload the information to the regional medical insurance agency for the record.
(4) Designated medical institutions and medical experts who examine and approve serious outpatient diseases shall confirm and examine and approve serious outpatient diseases in accordance with the principles of openness, justice and fairness. For the outpatient serious illness confirmed by the designated medical institutions in violation of regulations, the medical insurance agency shall immediately terminate the outpatient serious illness treatment enjoyed by the insured employees, and the medical insurance fund will not pay the expenses incurred. The outpatient illness qualification of illegal insured workers shall be re-approved and confirmed according to the procedures stipulated in these measures.
Fifth outpatient serious illness management.
(a) the insured workers should hold outpatient prescription for serious illness, medical insurance card and ID card, and choose 1-2 designated medical institutions for outpatient treatment. The selected designated medical institutions shall sign an outpatient serious illness service agreement with the insured workers, and upload the information to the medical insurance agency of the insured place for the record.
(II) If the insured workers are dissatisfied with the service of the selected designated medical institutions and need to change the designated medical institutions, they shall register with the re-selected designated medical institutions during the period of 65438+February 1 to 3 1 every year, change the medical institutions, re-sign the outpatient serious illness service agreement, and the original outpatient serious illness service agreement will be automatically terminated. The newly selected designated medical institutions upload the information to the medical insurance agencies in the insured areas for the record, and the insured employees will receive medical treatment for serious outpatient diseases in the newly selected designated medical institutions from June 5th to next year 10.
(three) the examination and approval form for outpatient serious illness, outpatient serious illness prescription and outpatient serious illness service agreement shall be uniformly made by the medical insurance agency. After the implementation of these measures, the newly-established and renewed outpatient prescriptions for serious illness should be affixed with two-inch bareheaded color photos of the patient himself in the near future, and stamped with the riding seal of the medical insurance office of the designated medical institution.
(4) When seeing a doctor, the doctor should check the identity of the patient who holds the "outpatient prescription for major diseases" and put an end to impersonation. If the family members of patients with mobility difficulties purchase drugs, they shall require the purchaser to provide the patient's and the purchaser's identity cards.
(five) outpatient medical treatment of serious illness should be carried out in strict accordance with the principle of "treatment due to illness, reasonable examination and rational use of drugs".
(six) outpatient serious illness diagnosis and treatment items and drug use scope should be consistent with the autonomous region "basic medical insurance diagnosis and treatment items and medical service facilities and medical consumables payment standard directory" and "basic medical insurance and industrial injury insurance drugs directory".
(7) Designated medical institutions shall make diagnosis and treatment according to the diseases approved in the outpatient prescriptions for serious diseases, which do not belong to the treatment behavior of the approved diseases and non-medical insurance medical expenses, and cannot issue outpatient prescriptions for serious diseases, so they shall issue prescriptions separately and conduct inspection and treatment.
(8) When prescribing the required drugs and treatment items, the attending physician should check and calculate the number of drugs prescribed in the Outpatient Prescription for Serious Diseases. If the medicine prescribed in the previous period has not been used up, it may not be prescribed again.
(nine) the dosage of prescription drugs for serious illness in outpatient department shall not exceed 4 weeks at a time (intravenous infusion shall not exceed 3 days, and Chinese medicine shall not exceed 7 doses). Do not prescribe drugs excessively or prescribe multiple drugs with the same curative effect and repeated inspection items.
(ten) the insured workers are hospitalized due to a serious illness in the outpatient department, and they are not allowed to carry drugs related to serious illness in the outpatient department when they leave the hospital.
Sixth insured workers in the designated medical institutions outpatient treatment of serious illness, in line with the provisions of the outpatient medical expenses. In a medical insurance year, the individual pays 500 yuan first, and the rest is within the maximum payment limit of the overall fund. The individual burden of the employee is 30%, and the overall fund pays 70%.
Seventh the establishment of outpatient serious illness annual maximum payment system. The maximum payment limit of the annual medical insurance fund for various diseases shall be determined and announced by the medical insurance agency in the overall planning area before the end of each year 12.
Article 8 In a year of medical insurance, the hospitalization and outpatient medical expenses that exceed the maximum payment limit of the overall fund shall be solved by means of large medical expenses subsidies.
Ninth insured workers in the designated medical institutions outpatient medical expenses, paid by personal account funds or cash, to be paid by the overall fund, by the medical insurance agencies in accordance with the provisions of the settlement and payment to the designated medical institutions. In violation of the medical insurance policy and medical insurance service agreement, the expenses incurred shall not be paid by the medical insurance fund.
Article 10 The municipal, county (city) administrative department of human resources and social security and the medical insurance agency shall establish a daily inspection system for outpatient serious illness, strengthen the supervision and inspection of the approval, confirmation and service of outpatient serious illness in designated medical institutions, and if violations are found, the administrative department of human resources and social security may, depending on the circumstances of violations, suspend or cancel the prescription right of medical insurance for doctors directly responsible, and suspend or cancel the medical insurance qualification of designated medical institutions; Illegal acts of defrauding medical insurance funds by means of fraud or fraud shall be punished in accordance with social insurance laws and regulations, and if the circumstances are serious, they shall be transferred to judicial organs for handling.
Eleventh outpatient serious illness agreement management and review replacement measures shall be formulated by the municipal medical insurance agency, and implemented after being approved by the municipal human resources and social security administrative department.
Twelfth outpatient diagnosis of serious illness technical standards, diagnosis and treatment items and scope of medication, by the municipal administrative department of human resources and social security in conjunction with relevant departments shall be formulated separately.
Thirteenth outpatient diseases, diagnosis and treatment items and the scope of medication, the municipal administrative department of human resources and social security shall make timely adjustments according to the operation of the overall fund.
Fourteenth retirees and civil servants living in different places are seriously ill, and outpatient medical treatment in different places shall be implemented in accordance with relevant regulations.
Fifteenth these measures shall be implemented as of July 20 1 1 year, and the Trial Opinions on the Management of Specific Diseases in Outpatients of Basic Medical Insurance for Urban Employees in Yinchuan shall be abolished at the same time. If the policy of serious illness in outpatient service of basic medical insurance for urban workers that has been introduced in the original overall planning area is inconsistent with the provisions of these measures, these measures shall prevail.
Legal basis:
"People's Republic of China (PRC) Social Insurance Law" Article 29 The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.