Article 1 In order to promote the establishment of a fairer and more reasonable basic medical insurance treatment guarantee mechanism, implement a unified outpatient chronic disease and outpatient special disease system in the whole province, and standardize the management of chronic diseases and outpatient special diseases (hereinafter referred to as "outpatient special diseases") in the basic medical insurance of the whole city, according to the Notice of Shaanxi Provincial Health and Wellness Committee, Shaanxi Provincial Department of Finance, Shaanxi Provincial Medical Insurance Bureau on Printing and Distributing the Standardized Management Measures for Outpatient Chronic Special Diseases in Shaanxi Province (for Trial Implementation) (Shaanxi Medical Insurance issued)
Article 2 The term "outpatient chronic diseases and special diseases" as mentioned in the Measures refers to the abbreviation of outpatient chronic diseases and special diseases, and refers to a class of chronic diseases or major diseases with high incidence rate, heavy economic burden or low prevalence rate and high medical expenses, which can be treated in outpatient service without hospitalization. In the original basic medical insurance system, outpatient chronic diseases, outpatient special diseases and other related security policies and contents were all collectively referred to as "outpatient chronic special diseases" policy.
Article 3 These Measures shall apply to the standardized management of chronic diseases and special diseases in outpatient clinics of basic medical insurance for employees and basic medical insurance for urban and rural residents.
Article 4 The municipal medical security administrative department shall be responsible for establishing and improving the management system of chronic diseases and special diseases in outpatient clinics in the whole city, and formulating and publishing the identification standards and treatment standards of chronic diseases and special diseases in outpatient clinics. County (city, district) medical security administrative department is responsible for the organization and implementation of the administrative region. City, county (city, district) medical insurance agencies responsible for disease identification, treatment payment, cost settlement, agreement management and other work. And regularly dispatch the operation of the medical insurance fund to ensure the safety of the regional medical insurance fund. The financial department shall allocate the basic medical insurance working capital according to the regulations to ensure that the insured enjoy the treatment of chronic diseases and special diseases in outpatient clinics on time. The health department urges designated medical institutions to provide necessary, safe, effective and affordable outpatient services for patients with chronic diseases and special diseases in accordance with the diagnosis and treatment norms, and carry out identification work according to regulations.
Chapter II Scope of Diseases
Fifth outpatient chronic diseases shall be classified and managed. * * * It is divided into outpatient chronic diseases of Grade I, II and III.
Outpatient chronic special disease is a kind of outpatient chronic special disease which is guaranteed by the whole province. The city belongs to the insured persons (including insured workers and insured residents) within the scope of chronic diseases and special diseases in class I outpatient clinics, and the city has implemented the unified policies and regulations of the whole province since June 65438+ 10/day, 2023.
Class II outpatient chronic special diseases are diseases that have been carried out in this city before the reunification in the province, but are not within the scope of Class I outpatient chronic special diseases stipulated by the province. The city continues to retain the treatment status of the security objects that have been included in this kind of disease, but no new security objects are added.
Three kinds of chronic diseases and special diseases in outpatient department are new diseases according to the development of medical insurance system. In accordance with the principle of "gradually unifying the stock of diseases and strictly controlling the incremental diseases", the work of adding new diseases will be carried out in due course after the release of the Provincial Medical Insurance Bureau.
Sixth outpatient chronic diseases and special diseases I for the province's unified management standards for the implementation of diseases. The name of the disease, the identification standard, the payment standard, and the time limit for re-inspection are all implemented according to the unified provisions of the Provincial Medical and Social Security Bureau.
Outpatient chronic diseases and special diseases *** 5 1 species, including: hypertension; Diabetes; Hyperlipidemia; Outpatient treatment of malignant tumor; Anti-rejection treatment of organ transplantation; Sequela of cerebrovascular disease (sequela of stroke); Active period of tuberculosis (including drug-resistant tuberculosis); Mental illness (including schizophrenia, bipolar disorder, delusional disorder, schizoaffective disorder, epileptic psychosis, mental retardation above severe degree); Dialysis (including hemodialysis and peritoneal dialysis); Skeletal fluorosis; Kaschin-Beck disease; Keshan disease; Phenylketonuria in children; Tetrahydropterin deficiency; Abnormal thyroid function; Hemophilia; Aplastic anemia; Outpatient treatment of leukemia; Chronic myeloid leukemia; Childhood leukemia; Epilepsy; Cerebral palsy; Chronic obstructive pulmonary disease; Bronchial asthma; Idiopathic pulmonary interstitial fibrosis; Coronary heart disease; Pulmonary heart disease; Chronic heart failure; Heart valve disease; Rheumatic heart disease; Cardiomyopathy; Viral hepatitis; Decompensated stage of liver cirrhosis; Decompensation period of chronic renal insufficiency; Nephrotic syndrome; Chronic nephritis; Chronic glomerulonephritis; Immune thrombocytopenia; Growth hormone deficiency; Ankylosing spondylitis; Rheumatoid arthritis; Chronic osteomyelitis; Parkinson's disease; Systemic lupus erythematosus; Psoriasis; Demyelinating diseases of central nervous system; Motor neuron diseases; Necrosis of femoral head; Systemic sclerosis; Hepatolenticular degeneration; myasthenia gravis
Seventh outpatient chronic diseases and special diseases refer to the diseases retained and continued to be guaranteed in this Municipality. The name of the disease, the identification standard, the payment standard and the time limit for re-inspection shall be formulated by the Municipal Medical Insurance Bureau. Applicable to the insured workers and outpatient residents with chronic diseases in this city.
There are 4 kinds of chronic diseases in outpatient service II * * *: vitiligo; Tuberculosis (except active tuberculosis); All kinds of mental diseases (except schizophrenia, bipolar disorder, delusional disorder, schizoaffective disorder, epileptic psychosis, mental retardation above severe degree); Cirrhosis (compensatory period).
Chapter III Treatment and Protection
Eighth urban workers and urban and rural residents outpatient medical insurance benefits for chronic diseases and special diseases are linked to the level of payment, and the medical insurance fund payment is accounted for separately.
Ninth outpatient chronic diseases and special diseases include medical expenses such as examination, inspection, medicine, treatment and special materials. Drugs related to diseases and in line with the basic medical insurance drug list, the scope of diagnosis and treatment projects, the scope of medical service facilities and payment standards. Inspection, inspection, drugs, treatment, special materials and other expenses. Not related to the disease or outside the above catalogue will not be paid. Encourage the combination of traditional Chinese and western medicine to treat chronic diseases and special diseases in outpatient clinics, and support the application of appropriate Chinese medicine technology and Chinese herbal medicines in the treatment of chronic diseases and special diseases in outpatient clinics. The scope of payment for chronic diseases and special diseases in outpatient service does not include drugs for diseases, and all drugs related to diseases (including complications and complications) can be paid. The scope of use is classified according to the drug list of basic medical insurance, work injury insurance and maternity insurance. Special drug protection shall be implemented in accordance with relevant policies.
Tenth outpatient chronic diseases and special diseases diagnosis and treatment settings, in principle, should set the minimum deductible, about 10% of the annual average outpatient expenses of the disease, individual special diseases can not set the minimum deductible. The proportion of medical insurance fund payment within the policy scope of urban and rural residents and urban workers is not less than 70% and 85% respectively. Class B payment items related to chronic diseases and special diseases in the first-class outpatient department shall be paid by 5% first, and then included in the proportional reimbursement. The annual payment limit is included in the management of the annual maximum payment limit of the basic medical insurance fund.
Article 11 When the insured suffers from various diseases covered by outpatient chronic diseases and special diseases, it is allowed to declare two or more outpatient chronic diseases and special diseases at the same time, and the annual minimum compensation limit can be increased according to a certain proportion. The maximum annual payment limit of the second disease, the third disease and the fourth disease shall be accumulated according to the maximum annual payment limit of the first disease in principle. The maximum payment limit for multiple diseases can be determined in the order from high to low according to the payment limit for declared diseases.
Twelfth outpatient treatment of chronic and special diseases according to the annual insurance payment, annual enjoyment, with natural years as the treatment cycle; The insured person enjoys treatment at the beginning of the next month after obtaining the identity of outpatient chronic special disease, and the annual maximum payment limit when obtaining the identity of outpatient chronic special disease for the first time is determined by multiplying the monthly average of the annual maximum payment limit of the disease by the remaining months.
Thirteenth insured workers (including retirees, the same below) meet the requirements of outpatient chronic diseases and special diseases of medical expenses, the implementation of outpatient chronic diseases and special diseases payment policy, more than the annual limit of the corresponding diseases within the scope of the policy, according to the general outpatient co-ordination policy to pay; Other expenses incurred in outpatient service are paid directly according to the overall policy of general outpatient service. The initial conditions for outpatient treatment of chronic diseases and special diseases are no longer related to the use of personal accounts. After the insured workers use the highest payment limit for chronic diseases and special diseases in the outpatient service in the current year, the outpatient medical expenses within the scope of medical insurance policies in designated medical institutions can enter supplementary medical insurance. If it is indeed difficult and meets the conditions of medical assistance, it shall be included in the scope of medical assistance according to regulations.
After the medical expenses for chronic diseases and special diseases in urban and rural residents' medical insurance clinics are paid by the chronic diseases and special diseases policy, the medical expenses within the policy scope borne by individuals will be gradually included in the scope of serious illness insurance and medical assistance. Residents' medical insurance provides special security treatment for hypertension and diabetes, and if it fails to meet the criteria for identifying chronic diseases and special diseases in outpatient service, it shall be implemented in accordance with the relevant policies and standards of the special security mechanism for hypertension and diabetes in outpatient service. "Two diseases" special protection and outpatient treatment of chronic diseases and special diseases do not accumulate.
Fourteenth outpatient chronic special disease patients medical insurance relationship transfer, applicable to the same disease.
In this case, the identities of chronic diseases and special diseases in outpatient department are transferred synchronously, and the place where the relationship is transferred will not be re-identified or identified. The transfer place is decomposed into months according to the annual quota, and its treatment quota is calculated and the treatment is terminated; Transferred to the city for treatment, the limit to be met in the remaining months of the year shall be calculated on a monthly basis according to the same disease. If there is no same disease in the transfer place, the relationship between outpatient chronic disease and special disease treatment will not be transferred, and the treatment guarantee will naturally terminate.
Chapter IV Disease Identification
Fifteenth in strict accordance with the "Shaanxi basic medical insurance outpatient chronic diseases and special diseases identification general rules" to carry out identification work. Anyone who meets the category I scope of chronic special diseases in outpatient department shall implement the Identification Standard of Chronic Special Diseases in Shaanxi Basic Medical Insurance Outpatient Department and the Treatment Standard of Chronic Special Diseases in Shaanxi Basic Medical Insurance Outpatient Department.
Sixteenth medical insurance agencies can entrust secondary and above designated medical institutions with the ability to identify chronic diseases and special diseases as designated institutions for outpatient identification of chronic diseases and special diseases. According to the discipline construction of the hospital and the strength of doctors, one or more expert groups are set up, which are composed of doctors at or above the level of deputy chief physician. Individual medical institutions can be composed of business presidents and personnel with the title of attending physician or above in related majors under the condition of insufficient deputy chief physician configuration. Outpatient chronic diseases and special diseases identification experts list should be reported to the medical insurance agencies at the same level for the record.
For the same chronic special disease applied by the same insured, the appraisal result shall be signed by at least two experts.
Seventeenth outpatient chronic diseases and special diseases identified by the implementation of one-stop processing. Entrusted designated medical institutions shall be responsible for submitting the appraisal results to the medical insurance agencies at the same level through online or offline methods, and timely and accurately register the information into the medical insurance information system.
Eighteenth disease identification materials include four categories: basic materials, including medical insurance electronic certificate, social security cards, identity cards and other identity certificates; Application materials, including the application form for outpatient service of chronic diseases and special diseases; Medical records, including medical records, diagnosis certificates, copies of relevant inspections and laboratory reports; Other necessary certification materials in the identification of individual diseases, including materials that need to be explained by other departments and other types of insurance.
Chapter V Service Management
Article 19 Open online and offline service channels, provide services such as outpatient chronic disease and special disease application acceptance and policy consultation by entrusting designated medical institutions to directly accept, medical insurance agencies to accept service windows, medical insurance service stations (rooms), and insured units to act as agents, and actively explore online declaration. The medical insurance agency in the form of centralized declaration accepts the declaration of chronic diseases and special diseases in outpatient department for no less than 6 times every year, and gradually realizes the declaration and handling at any time according to the progress of medical insurance informatization construction, and finally realizes the direct acceptance and recognition of medical institutions with the recognition conditions. After the patient is discharged from the hospital, the identification is completed within 10 working days and reported to the medical insurance agency for filing and information confirmation, which provides direct settlement for patients with chronic diseases to seek medical treatment and purchase medicines in designated medical institutions.
Twentieth outpatient chronic diseases and special diseases drugs to implement the "dual channel" guarantee, all eligible designated medical institutions and designated pharmacies can carry out outpatient chronic diseases and special diseases drug security services. Designated medical institutions can determine the types and doses of drugs for patients according to the needs of disease treatment, and standardize the management of prescription drugs. Long-term prescription drug dosage is up to three months.
Article 21 For the insured who cannot reach the appraisal institution or do not have the online declaration conditions due to mobility difficulties, old age, bedridden disability and other reasons, the qualified medical insurance handling institutions and designated outpatient institutions for chronic diseases and special diseases can organize the handling personnel and experts to provide on-site service or complete the appraisal through remote intelligence.
Chapter VI Supervision and Administration
Article 22 Medical insurance agencies at all levels should include the management of chronic diseases and special diseases in outpatient clinics into the scope of management agreed between designated medical institutions and medical insurance physicians, and strengthen the identification of chronic diseases and special diseases in outpatient clinics and the daily management, supervision and inspection of medical services.
Twenty-third designated medical institutions should improve the internal management system, medical insurance doctors should strictly identify, reasonable diagnosis and treatment, scientific treatment, it is strictly prohibited to overdose, prescription and other illegal acts. Upload the information of qualification identification and expense settlement in time, and shall not settle the expenses unrelated to the disease. Outpatient designated institutions for the identification of chronic diseases and special diseases, designated medical institutions and medical insurance agencies shall do a good job in filing and keeping the identification data, prescriptions, invoices and settlement documents for medical treatment and drug purchase.
Twenty-fourth outpatient patients with chronic diseases and special diseases must strictly abide by the principle of rational drug use and treatment due to illness, so as to achieve the five consistency of "people and disease, disease and disease, medicine and quantity, quantity and price" and ensure the scientific, reasonable and safe drug use of outpatients with chronic diseases and special diseases.
Twenty-fifth designated medical institutions and members of the expert group shall strictly implement the requirements of the relevant norms for the identification of chronic diseases and special diseases in outpatient clinics, and prohibit the expansion of the scope of identification of diseases, and prohibit artificial identification or refusal to identify without justifiable reasons. Medical insurance agencies found relevant violations in the inspection and review, and handled them according to the management requirements of medical insurance fixed-point agreement. If the circumstances are serious, doctors and institutions should be included in the scope of medical insurance agreement, and suspected fraud or insurance fraud should be dealt with according to relevant regulations.
Article 26 Once the insured, medical personnel, medical institutions and handling personnel suspected of defrauding medical insurance funds are verified, they shall be executed in accordance with the relevant provisions of the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds.
Chapter VII Supplementary Provisions
Article 27 These Measures shall come into force on June 65438+1 October1day, 2023, with a validity period of 2 years. If the relevant provisions previously issued by this Municipality are inconsistent with these Measures, these Measures shall prevail. If the policy of China medical insurance system changes, make adjustments.