the payment standard of medical insurance drugs refers to the benchmark for the basic medical insurance fund to pay the expenses when the insured person of the basic medical insurance uses the medical insurance project. The part within the payment standard is shared by the insured and the medical insurance fund in proportion, and the part outside the payment standard is paid by the insured. For example, when a patient buys this box of medicine, the 8 yuan is shared by the insured and the medical insurance fund according to the reimbursement ratio, while the 2 yuan medical insurance that exceeds the medical insurance payment standard is not borne by the patient.
specific implementation of payment standards for medical insurance drugs
1. Negotiation of medical insurance catalogue drugs
Every year, when the national medical insurance adjusts the catalogue, it will carry out drug negotiation for the exclusive varieties reviewed by experts. On-the-spot negotiations between the medical insurance provider and the enterprise representatives were finally included in the medical insurance drug list at a price acceptable to both parties, and the negotiated price was determined to be the national unified medical insurance payment standard. In this year's catalogue adjustment work, the National Medical Insurance Bureau issued the Contract Renewal Rules for Negotiated Drugs, which clarified for the first time three contract renewal rules for negotiated drugs, including regular catalogue management, simple contract renewal and renegotiation, and correspondingly clarified their respective methods for determining medical insurance payment standards:
For "including regular catalogue management", the previous condition was "the original negotiated drugs became non-exclusive varieties". This year, the new condition of "exclusive drugs whose payment standard and payment scope have not been adjusted for two consecutive agreement cycles" was added. At the same time, it was clear that the current payment standard, that is, the price negotiated in that year, will be temporarily implemented for this part of exclusive drugs included in the regular catalogue.
"Simple renewal" means that for the varieties whose exclusive drugs have been successfully included in the medical insurance drug list through negotiation, the fund expenditure does not exceed 2% of the budget, and the fund expenditure will increase reasonably in the next two years, and the market environment will not change significantly, the medical insurance payment standard will be re-calculated according to the actual fund expenditure and the fund expenditure budget and the changes in the added value of the fund expenditure budget caused by adjusting the payment scope, and the validity period will be renewed for two years.
2. National Centralized Drug Acquisition
Since the establishment of the National Medical Insurance Bureau, seven batches of drugs have been purchased with centralized quantity organized by the state, and a total of 294 drugs have been successfully purchased. In addition, different forms of provincial and inter-provincial alliances have been carried out simultaneously in various places, and the purchased varieties cover three major fields: chemical drugs, Chinese patent medicines and biological agents.
in March, 219, the national medical insurance bureau issued the "opinions on supporting measures for centralized drug procurement and pilot medical insurance use organized by the state", which made it clear that the payment standard of medical insurance should be coordinated with the purchase price. In September of the same year, this measure was clarified again in the "Implementation Opinions on the National Organization of Centralized Drug Purchase and Use Pilot to Expand Regional Scope" issued by nine ministries and commissions, including the National Medical Insurance Bureau. Specifically, the methods to determine the national medical insurance payment standard for centralized drugs are as follows: selecting drugs, and taking the selected price of centralized drugs as the medical insurance payment standard for the generic name; For drugs whose price is higher than the payment standard, the patient pays for the part that exceeds the payment standard, and encourages non-selected enterprises to take the initiative to reduce prices and converge to the payment standard; Drugs whose price is lower than the payment standard shall be paid at the actual price.
it should be noted, however, that the winning price can be different because the winning rule of national centralized purchasing allows multiple manufacturers to win a single variety. Therefore, in the actual implementation, all provinces take the price of the products selected by the supply enterprises in the province as the local medical insurance payment standard, which also leads to the situation that the medical insurance payment standard of the same variety of drugs in different provinces is different.
3. Non-exclusive varieties to be included in the medical insurance catalogue
Non-exclusive varieties in the medical insurance catalogue were not covered by the medical insurance payment standard in the past. After the promulgation of the Interim Measures for the Administration of Medication in Basic Medical Insurance, this year's medical insurance catalogue adjustment also puts forward the bidding rules for non-exclusive varieties for the first time, and at the same time, it is clear that the varieties that have been successfully bid for inclusion in the medical insurance catalogue will simultaneously determine their medical insurance payment standards.
according to the bidding rules for non-exclusive drugs published in this catalogue adjustment, medical insurance will calculate and determine the willingness to pay for medical insurance, that is, the expected price of medical insurance. When the price quoted by at least one enterprise is not higher than the expected price of medical insurance, the drug can be included in the regular catalogue of medical insurance. Medical insurance will take the higher price of the lowest quotation of the enterprise and 7% of the expected price of medical insurance as the medical insurance payment standard of the drug, which is valid for 2 years. At the same time, the quotation enterprises are required to promise that the supply price to the designated medical institutions of medical insurance in China will not be higher than the enterprise quotation within two years, so as to reduce the out-of-pocket payment caused by patients exceeding the payment standard.
In the past, because the drug price was set by enterprises independently, not only the price difference of the same drug among different manufacturers was large, but also the price difference of the drug from the same manufacturer among different provinces, which to some extent caused the medical insurance department to be unable to accurately predict the fund expenditure impact after the drug was included in medical insurance. This catalogue adjustment will change this situation. By forming a unified national medical insurance payment standard for non-exclusive drugs, this part of drugs will be included in the payment management scope, further promoting the return of more drug prices to a reasonable range.
4. Drugs in other medical insurance catalogues
There are 2,86 drugs in the current 221 version of the drug catalogue. Except for 275 drugs negotiated during the agreement period, there is no unified national medical insurance payment standard for the remaining 2,585 drugs. These drugs have also become the targets of the pilot reform of medical insurance payment standards in various places.
According to incomplete statistics, up to now, more than 2 provinces have carried out the pilot work of payment standards for medical insurance drugs, mainly determining the payment standards for medical insurance for 3 varieties in the catalogue pointed out by the National Medical Insurance Bureau, and formulating the catalogue of pilot varieties of payment standards in the province according to the actual situation of each province to realize the unification of payment standards in the province. The pilot period is generally 2 years.
Legal basis
According to Article 26 of the Interim Measures for the Administration of Medication in Basic Medical Insurance (Order No.1 of the State Medical Insurance Bureau), the payment standard is the benchmark for the basic medical insurance fund to pay the drug expenses when the insured persons of basic medical insurance use the drugs in the medical insurance catalogue. The basic medical insurance fund pays the drug expenses to the designated medical institutions and retail pharmacies according to the payment standards of drugs and medical insurance payment regulations.