Regulations on reimbursement of outpatient services for special diseases in 2022

The regulations are as follows:

Outpatient reimbursement can also be carried out for special diseases, and the reimbursement ratio varies from place to place, and the relevant departments of human resources and social security in various places have also issued relevant regulations to regulate the reimbursement of outpatient services for special diseases.

Under normal circumstances, there is no threshold for outpatient reimbursement for special diseases, and the compensation can generally be calculated according to the proportion of 75% of the actual expenses paid by the patient, and if the annual limit of medical insurance is exceeded, then the reimbursement will not be made.

Legal analysis: The minimum payment standard for outpatient reimbursement for special diseases is 400 yuan. Less than 400 yuan will not be reimbursed.

Special diseases are diseases that have a longer course of illness and cost more, and these conditions will be more covered than ordinary diseases. Patients suffering from these diseases should prepare relevant materials, apply for special disease registration, and obtain approval before obtaining outpatient reimbursement.

The medical expenses incurred in the agreed medical institutions can be reimbursed if they meet the standards of the basic medical insurance drug catalog, diagnosis and treatment items, and medical service facilities, and can be reimbursed by the medical insurance center in the insured place with the settlement bills and daily lists.

The specific process is as follows:

1. The applicant pays the relevant medical expenses in advance.

2. Bring the information required for medical insurance reimbursement to the social security institution or medical institution to go through the reimbursement procedures.

3. After review, if the conditions are met, the relevant medical expenses will be reimbursed.

Some provinces have opened a settlement system for remote medical treatment in the province, and the insured can be directly discharged from the hospital for settlement. The specific reimbursement process is subject to the local medical insurance policy.

Medical insurance generally refers to basic medical insurance, which is a social insurance system established to compensate workers for economic losses caused by the risk of disease. Through the employer and individual payment, the establishment of medical insurance**, after the insured person is sick and incurs medical expenses, the medical insurance institution will give him a certain amount of economic compensation. The establishment and implementation of the basic medical insurance system gathers the economic strength of the unit and the members of the society, coupled with the best funding, which can enable the sick members of the society to obtain the necessary material help from the society, reduce the burden of medical expenses, and prevent the sick members of the society from becoming poor due to illness.

Legal basis: Social Insurance Law of the People's Republic of China

Article 28 In line with the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards and medical expenses, emergency and rescue medical expenses, in accordance with the provisions of the State from the basic medical insurance **.

Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance** shall be directly settled by the social insurance agency and the medical institution and the drug business unit. The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits.

Special Disease Outpatient Reimbursement Regulations 2022:

Materials required for outpatient reimbursement for special diseases:

1. Fill in the "Medical Insurance Employee Medical Expense Declaration Schedule" and sign it;

2. Medical insurance outpatient medical bills and prescriptions;

3. Copies of outpatient medical records, outpatient medical records for special diseases and related records;

4. For reimbursement of medical expenses transferred to non-designated medical institutions and resettled personnel due to emergency or medical insurance center approval, medical expense details, prescriptions, long-term medical orders, and temporary medical orders shall be provided;

5. A copy of the "Approval Form for Special Prescribed Diseases".

Article 26 of the Social Insurance Law of the People's Republic of China.

The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with national regulations.

Article 28.

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards, and emergency and rescue medical expenses shall be paid from the basic medical insurance in accordance with national regulations.

[Legal Analysis].: Reimbursement treatment for special diseases:

1.Reimbursement ratio: The expenses of "special diseases" incurred in outpatient treatment are treated as hospitalization and reimbursed according to the hospitalization ratio, and can accumulate the minimum payment line with the expenses of ordinary hospitalization.

2.The settlement cycle of "special diseases" is 360 days, and the minimum payment line of 1,300 yuan is only charged once within 360 days (here is the Beijing standard), including the general hospitalization in my designated medical institutions, and the maximum reimbursement limit is 300,000 yuan.

[Legal basis].: "Social Insurance Law of the People's Republic of China" Article 28 in line with the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue medical expenses, in accordance with the provisions of the State from the basic medical insurance **.

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1. Reimbursement ratio.

2. Reimbursement formula:

The total amount of outpatient expenses during the treatment period - full self-payment - minimum payment standard - the first part of the individual's out-of-pocket expenses) * compensation ratio.

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Reimbursement procedures for special diseases.

1. Submit the above materials to the district medical insurance center where the insured unit is located, and the flexible employment personnel will directly submit the above materials to the medical insurance center of their own insured district. The application time for special diseases is 1-20 days per month.

2. The applicant should dial the medical insurance center** or go directly to the unit or medical insurance center to learn about the address and inspection time of the inspection hospital on the 23rd and 24th of each month (postponed accordingly on holidays), and arrive at the designated hospital on time at 8:30 on the day of the inspection.

3. On the day of the examination, the applicant should bring the original outpatient medical records (medical records within 2 years including 2 years from the date of onset of the disease), a copy of the inpatient medical record (must be stamped by the hospital), the original and original film of the inspection data (such as CT, MRI, coronary angiography), and the original ID card and medical guarantee.

4. Insured persons who apply for diabetes and liver cirrhosis (decompensation) need to go to the hospital for examination on an empty stomach (spare breakfast).

2022 Reimbursement Standard for Outpatient Clinics for Special Diseases. Medical insurance needs to be paid for 6 consecutive months before the insured can enjoy benefits such as medical reimbursement, and it cannot be reimbursed after the payment is stopped. Therefore, it is recommended that you do not easily cut off your medical insurance.

Summary. Hello dear Reimbursement standard for outpatient services for special diseases 1, reimbursement ratio Employee medical insurance: Within a medical insurance year, the starting line for outpatient services for special diseases is 400 yuan, and the reimbursement ratio of medical expenses within the scope of relevant laws and regulations is the same as that of ordinary hospitalization.

Medical insurance for urban and rural residents: In a medical insurance year, the minimum payment line for outpatient services for special diseases is 400 yuan, and the reimbursement ratio of medical expenses within the scope of relevant laws and regulations** is the same as that of ordinary hospitalization. 2. Reimbursement formula:

The total amount of gate expenses in a ** period - full self-pay - minimum payment standard - individual first self-payment part) * compensation ratio....

Where do I go to apply for the special outpatient clinic?

Hello dear The reimbursement standard for outpatient services for special diseases 1, the reimbursement ratio is the same as that of ordinary hospitalization. Medical Insurance for Urban and Rural Residents:

In a medical insurance year, the minimum payment line for outpatient services for special diseases is 400 yuan, and the reimbursement ratio of medical expenses within the scope of relevant laws and regulations is the same as that of ordinary hospitalization. 2. Reimbursement formula: the total amount of gate expenses in a ** period - full self-payment - minimum payment standard - individual first self-payment part) * compensation ratio....

Where is the insurance or where is the household registered?

2. How to handle the reimbursement procedures for outpatient services for special diseases, as long as the applicant applies for certification of special diseases, he can enjoy the above reimbursement ratio. Reimbursement of medical insurance for special diseases can be carried out in accordance with the following process: 1. Required materials:

Basic Medical Care Municipal Co-ordination of Special Disease Declaration Form", two 1-inch recent photos, signed and stamped by the unit or the person will be the declaration form, a copy of the mu cavity ID card and **. 2. Reimbursement process: 1) Submit the above materials to the district medical insurance center where the insured unit is located, and flexibly submit the above information directly to the medical insurance center of the insured district.

Is it in the place where you are insured, or is it where you are registered?

Where you are insured.

You don't need a local household registration to apply, right?

OK.

Special diseases can also be reimbursed at the outpatient department, and the reimbursement ratio also varies from place to place. The relevant departments of human resources and social security have also issued relevant regulations on the reimbursement of outpatient expenses for special diseases. Generally speaking, there is no threshold for reimbursement for specific diseases in outpatient clinics, and the compensation amount can be calculated at a rate of 75% of the actual expenses paid by the patient.

If the annual limit of Medicare is exceeded, it will not be reimbursed.

Notice on Adjusting the Outpatient Policy for Special Diseases of Local Urban Basic Medical Insurance

Article 1 There is no minimum payment line for the compensation for outpatient chronic special diseases of the basic medical insurance for urban and rural residents, and the compensation shall be calculated according to the proportion of 75% of the actual cost of the patient within the annual compensation limit of the corresponding disease, and the medical insurance will not be reimbursed if it exceeds the annual limit.

Social Insurance Law of the People's Republic of China

Article 28 In line with the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards and medical expenses, emergency and rescue medical expenses, in accordance with the provisions of the State from the basic medical insurance **.