What is the reimbursement scope of NCMS major illness, and what is included in the reimbursement sco

2017 NCMS reimbursement coverage.

Farmers who participate in NCMS can be reimbursed for outpatient and hospitalization in designated medical institutions, and the scope of reimbursement mainly includes reimbursement of drugs, examination expenses, and bed fees. Taking drug reimbursement as an example, Class A drugs can basically be reimbursed, some Class B drugs can be reimbursed, and Class C drugs cannot be reimbursed; Taking hospitalization reimbursement as an example, the inpatient bed fee or outpatient (emergency) observation bed fee can also be reimbursed.

1.self-purchased drug fees;

2.The cost of drugs that exceeds the "Provincial List of Essential Drugs for New Rural Cooperative Medical Care";

3.** fee, outpatient medical record production cost, house visit fee, Chinese medicine decoction fee, ambulance fee, escort bed fee, bed charter fee, special care fee, consultation fee, air conditioning (including heating) fee, TV fee, ** fee, personal life cooking fee, nursing fee, etc.;

4.Expenses for non-basic medical care (referring to special outpatient clinics, specialist outpatient clinics, bed fees exceeding 35 yuan per day, medical cosmetology, family beds, etc.);

5.Fights, alcoholism, drug abuse, drug rehabilitation, venereal diseases, work-related injuries and injuries suffered in the course of labor, traffic accidents, intentional self-injury, non-productive pesticide poisoning, occupational poisoning, medical accidents, violations of laws and disciplines and medical expenses caused by others;

6.abortion induction;

7.All kinds of plastic surgery, orthopedics, **, correction of physiological defects and various health care, preventive diagnosis and treatment items and drug costs;

8.the cost of purchasing organs or tissues for organ or tissue transplantation or installation of artificial organs;

9.Medical services, examinations, ** items that are not approved by the price and health authorities, as well as all expenses incurred by inflating the fee standard without authorization;

10.There are fraudulent medical expenses such as non-hospitalization or impersonation hospitalization;

11.Those who have received basic medical insurance for urban employees, basic medical insurance compensation for urban residents, and other basic medical insurance compensation;

12.medical expenses incurred abroad;

13.Other provisions of the new type of rural cooperative medical care.

The 20 diseases included in the critical illness benefit are: childhood leukemia, congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, AIDS** infection, hemophilia, chronic myeloid leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, rectal cancer.

As far as serious illness is concerned, because there is also a large gap between the rich and the poor in rural areas, once those poor families get seriously ill, even if they go to the hospital for treatment, they can reimburse part of it, but they are still unable to pay for the remaining part, so these poor families still cannot afford to see a doctor. Of course, for those wealthy families, this is a real discount for them. Therefore, from the perspective of serious diseases, not only does the new cooperative medical care not solve the medical problems of poor families in rural areas, but on the contrary, the gap between them and rich peasant families becomes wider and wider, further aggravating the gap between the rich and the poor in rural areas.

1. It is necessary to obtain the medical record diagnosis certificate issued by the outpatient department, but it should be noted that it must be signed by three deputy chief physicians or above, and the official seal of the diagnostic department must be stamped at the same time.

2. After discharge, bring the diagnosis certificate of the hospital to the NCMS Settlement Department to submit relevant materials for review.

3. The NCMS Settlement Department will review the relevant information provided by the patient, and if it meets the compensation requirements for major diseases, it can be stamped with the special seal for the diagnosis and treatment of major diseases of NCMS, and the compensation for NCMS can be obtained.

4. After the patient receives the reimbursement amount in NCMS, he or she will go to the corresponding insurance company for reimbursement.

Critical illnesses include: congenital heart disease, acute leukemia, and simple cleft lip in rural children aged 0-14 years old are compensated by NCMS at a rate of 70%, and medical assistance is compensated at a rate of 20%. The designated rescue institutions in our city are the First People's Hospital of Jining City and the Affiliated Hospital of Jining Medical College.

In 2011, five major diseases, namely severe mental illness, breast cancer, cervical cancer, end-stage renal disease, and hemophilia, were included in the pilot scope, and the compensation ratio of NCMS was not less than 70%. Participating patients are treated in the corresponding designated medical institutions in the province and enjoy the prescribed compensation. Patients with the above major diseases do not need other procedures except for the need to go through the referral procedures at the NCMS Management Office in the county and urban areas in advance for treatment in medical institutions outside the city.

NCMS reimbursement in this way can save a lot of money. It costs too much to see a doctor in the hospital, and after the NCMS reimbursement is completed once, it can be reimbursed twice.

New Rural Cooperative Medical Reimbursement Model.

NCMS reimbursement coverage.

NCMS reimbursement coverage.

Wai [1] is: the part of the medical insurance reimbursement scope (i.e., effective medical expenses) incurred by the participants in the designated hospital for diagnosis and treatment due to illness during the overall planning period, such as drug expenses, examination fees, laboratory fees, surgery fees, ** fees, nursing fees, etc., which meet the reimbursement scope of urban employee medical insurance.

The new type of rural cooperative medical care** payment establishes a minimum payment standard and a maximum payment limit. Hospitalization expenses below the hospital's annual payment standard shall be paid by the individual. If the minimum payment standard is reached during the same pooling period, the hospitalization expenses incurred by two or more hospitalizations can be reimbursed cumulatively.

Hospitalization expenses exceeding the minimum payment standard shall be calculated in stages and reimbursed cumulatively, with a maximum limit for cumulative reimbursement per person per year.

Case-by-case analysis.

At present, there is no unified provision on the reimbursement scope of major diseases of the new rural cooperative medical insurance in China, and the reimbursement of major diseases is determined by each province according to the actual local situation. For example:

1) Reimbursement scope of critical illness in Zhangjiajie, Hunan Province: If the basic medical insurance for urban and rural residents incurs high medical expenses in the year of serious illness, after the basic medical insurance for urban and rural residents is paid according to the regulations, the compliant medical expenses borne by the individual shall be compensated by the serious illness insurance according to the prescribed proportion. Among them, the high medical expenses are more than 10,000 yuan in the annual cumulative amount of compliant medical expenses borne by individuals.

2) Hubei Province: There is no specific type of disease in the serious illness medical insurance, and all those who participate in the basic medical insurance for urban residents in Hubei Province and the new rural cooperative medical care can be included in the scope of the serious illness insurance system. Conditional Dishan Escort District, urban staff basic medical insurance participants can be included in the scope of the serious illness insurance system, after the insurance, the amount can be verified minus the amount of basic medical reimbursement, more than 10,000 yuan can enjoy serious illness insurance.

1. NCMS Critical Disease Application and Reimbursement Process.

Due to the different policies and standards in different places, as long as the local application and reimbursement standards are met, you can apply for reimbursement for major diseases of NCMS, and the specific reimbursement materials and procedures are as follows:

1.Bring the household registration booklet, ID card, NCMS payment bill, hospitalization invoice, diagnosis certificate, expense list, inpatient medical record, and first reimbursement voucher of joint treatment (other materials required by the local reimbursement) within the specified reimbursement time;

2.Prepare the above materials and submit them to the settlement department of NCMS for review;

3.The NCMS Settlement Department will review the relevant information provided by the patient, and if it meets the compensation requirements for major diseases, it can be stamped with the special seal for the diagnosis and treatment of NCMS major diseases on the diagnosis certificate, and then you can get the compensation of NCMS.

Generally, if you want to have NCMS reimbursement, you must be a participant within the validity period, and you must keep all the original bills and lists for submission for review.

2. Reimbursement standards for major diseases of NCMS.

1.Minimum payment line: The starting line of ordinary farmers' insurance is 10,000 yuan; The minimum payment line for low-income households, five-guarantee households and rural serious illness protection targets is 10,000 yuan.

2.Reimbursement ratio: **50% for expenses of $50,000 or less; 55% for the cost of 5-100,000; 60% for the cost of 10-150,000 yuan; 65% for the cost of 15-200,000 yuan; If the cost exceeds 200,000 yuan, it will be reimbursed at a rate of 70%.

Legal basis

Social Insurance Law of the People's Republic of China

Article 24: The State is to establish and improve a new type of rural cooperative medical system.

The management measures for the new type of rural cooperative medical care shall be stipulated by ***.

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 **.

Legal analysis: the first or main diagnosis of childhood leukemia, childhood congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, multidrug-resistant tuberculosis, AIDS infection, lung cancer, esophageal cancer, gastric cancer, colon cancer, rectal cancer, chronic myeloid leukemia, acute myocardial infarction, cerebral infarction, hemophilia, etc.

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

Article 2: The State shall establish social insurance systems such as basic endowment insurance, basic medical insurance, work-related injury insurance, unemployment insurance, and maternity insurance, to protect citizens' right to receive material assistance from the State and society in accordance with law in the event of old age, illness, work-related injury, unemployment, childbirth, and so forth.

Article 3: The social insurance system adheres to the principles of wide coverage, basic protection, multi-level, and sustainability, and the level of social insurance shall be commensurate with the level of economic and social development.

Article 4 Employers and individuals within the territory of the People's Republic of China who pay social insurance premiums in accordance with the law have the right to inquire about payment records and records of personal rights and interests, and to arbitrarily request social insurance agencies to provide social insurance consultation and other related services.

Individuals enjoy social insurance benefits in accordance with the law, and have the right to supervise their own units' contributions for them.