At present, the outpatient co-ordination in China's basic medical insurance is divided into resident medical insurance outpatient co-ordination and employee medical insurance outpatient co-ordination. Staff outpatient co-ordination refers to the medical expenses incurred in the outpatient service of designated medical institutions, which are reimbursed by the outpatient co-ordination fund according to a certain proportion. Overall planning of residents' outpatient service refers to the system of reimbursement of medical expenses incurred by residents' medical insurance insured persons in qualified primary medical institutions.
At present, outpatient co-ordination can be divided into the following three types:
A, outpatient serious illness, chronic disease as a whole, that is, a small number of outpatient diseases will be included in the overall fund for reimbursement, and will be managed according to the fixed cost of diseases. Usually, the scope of serious illness in outpatient service is relatively small;
The second is the overall planning of large outpatient expenses. According to the cost division, outpatient expenses exceeding the higher deductible line can be reimbursed;
Third, general outpatient co-ordination, which is what we usually call outpatient co-ordination, is also divided according to the cost, but the deductible line is relatively low, and residents' medical insurance usually adopts this method.
Generally speaking, there is a time limit for outpatient co-ordination fund payment, which can be understood as that the balance of the general outpatient co-ordination fund account will be cleared. For example, the maximum limit of Guangzhou medical insurance outpatient co-ordination fund is 300 yuan/person/month, and the maximum limit of urban and rural medical insurance outpatient co-ordination fund is 600 yuan/person/year. The limit of outpatient co-ordination fund in different regions and different medical insurance categories is different, which shall be subject to the announcement by the local medical insurance department.
The general outpatient co-ordination fund shall meet the following conditions:
1, the insured person needs to seek medical treatment in a designated medical institution;
2, must comply with the local basic medical insurance drug list, diagnosis and treatment projects, medical service facilities within the scope of outpatient projects.
The general outpatient co-ordination fund is not personal property, and can only be used if the above two conditions are met at the same time.
Legal basis:
Guiding opinions on outpatient co-ordination of basic medical insurance for urban residents
First, to carry out outpatient co-ordination of basic medical insurance for urban residents. On the basis of adhering to basic medical insurance policies and regulations, we should fully consider the characteristics of outpatient medical services and the urgent needs of urban residents for basic outpatient medical insurance, further improve policies such as coverage, financing and payment of basic medical insurance and management measures such as medical treatment, expense settlement and business handling, and share the outpatient medical expenses of insured residents reasonably through co-ordination.
Two, to carry out outpatient co-ordination should adhere to the following principles: based on basic security, starting from a low level, and gradually reducing the burden of outpatient medical expenses; Implement a socialized economy, and improve the ability to guarantee funds by coordinating the use of funds; Mainly rely on community health service centers (stations) and other grassroots medical and health institutions to facilitate people's medical treatment and reduce medical costs.
Three, according to the ability to pay the basic medical insurance fund for urban residents, on the basis of focusing on ensuring the medical expenses of the insured residents' hospitalization and serious illness outpatient service, the outpatient medical expenses will be gradually included in the scope of fund payment. The basic medical insurance fund for urban residents should adhere to the principle of balance of payments, and the expenses required for outpatient co-ordination should be charged in the basic medical insurance fund for urban residents and accounted for separately.