The Notice will further expand the scope of outpatient payment of Shenzhen Medical Insurance Co-ordination Fund, with the highest payment ratio reaching 90%. Basic medical insurance participants who meet the scope of 52 outpatient specific diseases can enjoy treatment according to the policy.
Who can enjoy the treatment of specific diseases in outpatient department?
Insured persons who normally participate in and pay the basic medical insurance fees in Shenzhen, and patients who meet the scope of 52 outpatient specific diseases stipulated by the policy:
Proportion of reimbursement for outpatient specific diseases
According to the "Notice", outpatient specific diseases are divided into three categories according to the severity of the disease and medical expenses.
The first category is diseases managed according to the outpatient serious illness policy of our city. The diagnosis of serious outpatient diseases in our city is carried out by designated medical institutions, and each type of serious outpatient diseases has corresponding medication scope and diagnosis and treatment items. The outpatient treatment of serious illness of the insured person is linked to the continuous insured time. The continuous insured period is less than 12 months, and the full 12 months is less than 36 months. The outpatient basic medical care and local supplementary medical care expenses are paid by the overall fund for 60%, 75% and 90%. Outpatient serious illness does not set a separate disease payment limit, and the insured person's basic medical insurance fund payment limit is implemented. The insured person's continuous participation time is linked to the payment limit of the basic medical insurance pooling fund, which is up to 6 times of the average salary of employees in the city last year. Anti-rejection therapy, myelofibrosis and myelodysplastic syndrome after lung transplantation also enjoy the treatment of serious diseases in outpatient department of our city.
The second category is diseases implemented according to the "two diseases" policy. Hypertension and diabetes are subject to relevant regulations. The proportion of the "two diseases" drug outpatient medical insurance co-ordination fund issued by contracted family doctors is 80%, and the proportion of the "two diseases" drug medical insurance co-ordination fund issued by non-contracted family doctors in social health is 50%.
According to the "two diseases" policy of hypertension and diabetes, the payment ratio of medical insurance co-ordination fund for drug outpatient expenses issued by contracted family doctors is 80%, and the payment ratio of medical insurance co-ordination fund for drug outpatient expenses issued by social health non-contracted family doctors is 50%. Moreover, these six diseases have set an annual payment limit of 10000 yuan/year/disease.
The third category is the new outpatient specific diseases. In addition to the first and second kinds of diseases, people suffering from other outpatient specific diseases (collectively referred to as "new outpatient special diseases") will pay 70% of the basic medical expenses incurred in the selected treatment medical institutions, and the first-class insured of basic medical insurance will be paid by the basic medical insurance serious illness insurance pooling fund according to the regulations, and the insured will pay 80% over 70 years old; The second and third categories of insured persons in basic medical insurance shall be paid 60% by the basic medical insurance serious illness insurance pooling fund according to regulations. The rest can be paid by his personal account, and the insufficient part of the personal account can be paid by the individual.
Patients who enjoy treatment need to go to designated institutions for diagnosis and medical treatment.
Patients suffering from the second category of six new outpatient-specific diseases and the third category of new outpatient-specific diseases need to go to designated medical institutions with outpatient-specific disease service qualifications for identification. The second-and third-level designated medical institutions in Shenzhen can file with the municipal medical insurance agency according to the scope of diagnosis and treatment subjects licensed by the health administrative department, and provide new outpatient specific disease identification and treatment services for the insured. Patients suffering from specific outpatient diseases of category I (i.e., according to the management of serious outpatient diseases) shall, in accordance with the existing regulations, apply to the designated medical institutions with the qualification for diagnosis of serious outpatient diseases for identification of serious outpatient diseases.
In the designated medical care, except for the first and second kinds of diseases, they are all implemented in accordance with the relevant provisions of the outpatient serious diseases and the "two diseases" policy. Insured persons suffering from third kinds of new outpatient specific diseases must choose designated medical institutions with outpatient specific disease service qualifications as their medical institutions, and the treatment institutions must report the insured information to the municipal medical insurance agency for the record.
How to go through the relevant procedures and enjoy the treatment of special diseases in outpatient department?
You can go to a designated medical institution with accreditation qualifications for accreditation or pre-apply for accreditation through the personal online service system. The identification of outpatient specific diseases requires carrying social security cards/ID cards and medical records stamped with the official seal of the hospital (including disease diagnosis, discharge summary, inspection report, etc.). ) to a qualified medical institution to apply, and fill out the "Shenzhen outpatient specific disease identification application form" on the spot.
You can also use the personal service web page (
Can the selected outpatient treatment institutions for specific diseases be changed?
According to the unified regulations of the whole province, the insured person shall not change the selected treatment institution within one year. If it is really necessary to change the selected treatment institution due to illness, migration of residence and other reasons, the insured person shall apply for change to the designated medical institution to be changed, and the designated medical institution shall submit the change information to the medical insurance agency for the record.
What should I do if I exceed the reimbursement limit for specific diseases in outpatient department?
Outpatient serious illness and "two diseases" apply to the payment limit of the basic medical insurance pooling fund of the insured, and the part exceeding the annual payment limit shall be handled in accordance with the relevant provisions of the Measures of Shenzhen Municipality on Social Medical Insurance; For 2 1 2 new outpatient special diseases, such as chronic obstructive pulmonary disease, coronary heart disease, sequelae of cerebrovascular disease, rheumatoid arthritis, bronchial asthma and chronic hepatitis B, the annual outpatient payment limit is set from 1 10,000 yuan/year to10.9 million yuan/year respectively. For more than the annual outpatient payment limit, according to "Shenzhen society"
How to reimburse the outpatient specific disease expenses incurred in different places?
2 1 For the insured who has been identified as a specific disease in outpatient department, 21The expenses for the specific disease in outpatient department will be paid by the insured in cash in advance, and can apply to the medical insurance handling department for review and reimbursement with relevant documents and materials.
Do you need to be recognized every year to enjoy the treatment?
In case of enjoying the validity period, it will automatically terminate on the natural day from the date when the designated medical institution uploads the identity information to the medical insurance information system for filing. Shenzhen implements the provisions of Guangdong Medical Insurance Bureau on the validity period of outpatient treatment for specific diseases. If the insured enjoys the validity period, he shall re-apply for the corresponding outpatient treatment for specific diseases according to the regulations.