In order to strengthen and standardize the management of chronic and special diseases in outpatient clinics for insured employees and residents in our city, expand the channels for guaranteed medication for chronic special diseases, and promote "Internet +" medical insurance services, the Municipal Medical Insurance Bureau recently issued the "On Strengthening the Standardization of Outpatient Chronic and Special Disease Management and Specialty Diseases"

Notice on Online Settlement" (Linyibaofa [2022] No. 14), which will be implemented from July 1, 2022.

First, implement outpatient designated management of chronic and special diseases.

Insured persons who have passed the outpatient chronic disease treatment qualifications are diagnosed and treated within the city. For one certified disease, they can choose one designated medical institution in the city as their outpatient chronic disease designated medical institution (hereinafter referred to as the designated chronic disease institution).

The total number of designated institutions for chronic and special diseases independently selected by the insured for each disease type shall not exceed 2, and the designated institution for chronic and special diseases can be changed voluntarily once per disease type within a calendar year.

When insured persons who have previously been identified as eligible for treatment for chronic special diseases go to a designated chronic disease institution for treatment, the designated chronic disease institution will remind the insured person to choose a designated chronic disease institution.

If the insured person independently determines or changes the designated institution for chronic special diseases, he can do so through the Linyi Medical Insurance APP, Linyi Convenient Medical Insurance Mini Program, Linyi Medical Insurance One Window Online Service Hall (Personal Service) and medical insurance service sites.

The second is to unify the catalog scope and treatment standards for outpatient chronic and special diseases.

The names and disease codes of outpatient chronic and special diseases in the national medical security service platform information business coding standard are unified and standardized. After sorting, standardizing and adding new diseases to the original diseases, the city's current outpatient chronic and special diseases are unified as follows:

There are 75 categories, including 51 outpatient chronic diseases and 24 outpatient special diseases.

The payment ratio for resident medical insurance outpatient chronic diseases exceeding 500 yuan is 60%, and the maximum payment limit per person per year is 8,000 yuan; the payment ratio for special outpatient outpatient compliance fees exceeding 500 yuan is 70%, and the maximum payment limit is the same as for hospitalization.

The maximum payment limit is calculated jointly, and the total amount does not exceed 150,000 yuan.

The third is to standardize the online settlement of outpatient chronic disease expenses.

The insured person goes to the designated chronic disease institution selected by him to seek medical treatment and purchase medicines. The medical expenses related to the recognized outpatient chronic disease diseases will be directly settled online in accordance with regulations. At the same time, other medical expenses that have nothing to do with the outpatient chronic disease treatment will be settled directly.

The fees are settled separately according to ordinary outpatient fees.

The diagnosis and treatment expenses related to the recognized outpatient chronic diseases will be settled separately for each disease category, that is, each outpatient chronic disease category will be settled separately.

Insured persons cannot enjoy outpatient chronic disease treatment while being hospitalized in designated medical institutions.

The fourth is to expand outpatient medication guarantee channels for chronic and special diseases.

Outpatient prescriptions for chronic special diseases issued by designated institutions for chronic special diseases are supported to be dispensed and settled at designated retail pharmacies. The designated institutions for chronic special diseases can upload external prescriptions. The insured can choose to go to the designated place within 3 days with the electronic medical insurance voucher or social security card.

Any medical insurance designated retail pharmacy with electronic prescription circulation function can dispense prescriptions, and the cost of drugs in the medical insurance catalog will be settled online and directly in accordance with regulations.

Electronic prescriptions for external dispensing of chronic special diseases can be transferred to any designated pharmacy for chronic special diseases, and insured persons can purchase and settle medicines nearby.

The fifth is to strengthen drug management and medical insurance services in designated retail pharmacies for outpatient chronic and special diseases.

After qualified designated retail pharmacies transform and connect to the settlement system, they should sign a service agreement with the local county and district medical insurance agency, and the municipal agency will announce to the public the information of designated retail pharmacies for outpatient chronic and special diseases.

Designated retail pharmacies for chronic and special diseases must strengthen the management of medical insurance drugs in accordance with relevant regulations, implement clearly marked prices, and manage by division and classification. The price of drugs should not be higher than the price of drugs in designated medical institutions to ensure drug quality and drug safety.

The drug purchase, sale and inventory system of designated retail pharmacies must be fully connected with the medical insurance information system, and real-time information can be shared to ensure smooth drug purchase and settlement for insured persons with electronic medical insurance vouchers or social security cards.

Anyone who fails to achieve direct online settlement will have their qualifications as a designated retail pharmacy for chronic and special diseases cancelled.

The sixth is to strictly control outpatient chronic disease medical insurance fund expenditures.

Designated medical institutions and treating physicians must strictly abide by relevant disease diagnosis and treatment specifications and medication regulations, conduct scientific diagnosis and treatment, disease-specific treatment, and rational use of medication; they must effectively connect the hospital information system with the municipal medical insurance outpatient chronic disease information platform and information

Upload, and corresponding disease codes.

Medical insurance agencies must determine the management scope of outpatient services for chronic and special diseases based on the qualifications of designated medical institutions, sign annual medical service agreements for medical institutions, and strengthen the assessment and evaluation of the performance of agreements by designated medical institutions.

Medical insurance agencies should issue early warnings through the medical insurance information system on the number of outpatient diagnosis and treatment of chronic special disease patients or other abnormalities, and auditing and regulatory agencies should regularly extract abnormal diagnosis and treatment data information, conduct key investigations and verifications, and severely deal with violations.

The medical insurance departments in all counties and districts must establish long-term supervision and management mechanisms, severely crack down on and resolutely investigate and deal with fraudulent insurance practices by designated medical institutions and insured individuals, and effectively maintain the safety of funds.