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Original title: Beijing Medical Insurance issued a new policy: 6 kinds of diseases included in special outpatient diseases, reimbursed according to hospitalization standards
Beijing News Express (Reporter Wu Wei) On September 18, the reporter learned from the Beijing Municipal Medical Security Bureau that Beijing will include 6 illnesses, including serious mental illnesses, in the field of special illnesses in health insurance clinics from Beijing.
After including the special diseases, these 6 diseases can be run according to the hospitalization expense reimbursement rate and the reimbursement limit line in a settlement cycle (360 days), and the burden will be greatly reduced by the patient of personal medical expenses.
Since then, there have been 17 kinds of special illnesses in Beijing Health Insurance Outpatient Clinics. At the same time, Beijing will also increase reimbursement rates for outpatient treatment of malignant tumors and kidney dialysis for special diseases. Outpatient payment for 9 types of expensive drugs, including Roxastat capsules, is based on a fixed ratio.
The new policy will be formally implemented on October 1, 2020 and will apply to urban employees, urban and rural residents, and other insured persons in Beijing.
Aspect 1
What’s Good About the New Outpatient Special Illness Policy?
—— “Patients who spent 80,000 yuan on drugs in the past can be reduced to about 10,000 yuan”
Recently, the Beijing Municipal Medical Security Bureau issued the “Notice on Incorporation of Outpatient Treatment of Serious Mental Illness in the Scope of Special Illnesses in Beijing Basic Health Insurance Outpatient Clinics,” clarifying that it will be suitable for treatment long-term outpatient care and the higher cost of severe mental illness and pulmonary hypertension. To treat, multidrug-resistant tuberculosis, Niemann-Pick type C disease, biological treatment of moderate to severe allergic asthma and anti-fibrosis treatment of idiopathic pulmonary fibrosis have been added to the scope of special diseases at the Beijing Health Insurance Clinic .
After the above 6 diseases are included in the scope of special diseases in outpatient clinics, patients who need to undergo examinations, outpatient treatments and use more than 200 related drugs due to their conditions can be reimbursed according to the standard of hospitalization expenses.
What are the advantages of the outpatient reimbursement policy for special illnesses? According to the competent person in charge of the Beijing Municipal Medical Security Bureau, the current maximum limits for outpatient clinics for employees and urban and rural residents in Beijing are 20,000 yuan and 4,000 yuan respectively. Once the disease is included in the scope of special diseases in the outpatient department, the insured personnel will undergo inspection, treatment and related outpatient services. The cost of drugs can be implemented according to the rate of reimbursement of hospital expenses and the reimbursement limit line. A 360-day settlement cycle will greatly reduce the burden of medical expenses for patients.
The person in charge gave an example. For example, for the treatment of idiopathic pulmonary fibrosis “pirfenidone oral regular-release dosage form”, the annual cost of the drug to the patient is about 80,000 yuan. Once the outpatient special sickness reimbursement is included, the annual personal burden of retired employees will be reduced to about 10,000 yuan.
Participants who qualify for the newly added Special Illness Outpatient Illnesses will enjoy Special Illness Reimbursement for Outpatient Illness upon submission and review by their selected Special Illness Designated Medical Institutions. Failure to submit review or incur no medical expenses at designated medical institutions for special illnesses selected by me will not be included in the scope of reimbursement for medical expenses for special illnesses at outpatient clinics.
Previously, Beijing has provided outpatient treatment for malignant tumors, kidney dialysis, anti-rejection treatment after kidney transplantation, hemophilia, aplastic anemia, anti-rejection treatment after liver transplant, and anti-rejection treatment after liver and kidney transplantation. . Eleven diseases, including treatment, treatment for rejection after heart transplantation, treatment for rejection after lung transplantation, multiple sclerosis, and treatment with intraocular injection for fundus disease, are included in the scope of special diseases in the health insurance clinic.
After the six illnesses, including serious mental illness, were included in the outpatient special illnesses, the number of special illnesses in the Beijing Health Insurance Outpatient Clinic was expanded to 17.
Aspect 2
Is there a good drug that needs to be reimbursed or the reimbursement rate increased?
——Increase reimbursement for two types of special illnesses in outpatient clinics and pay for 9 types of expensive drugs in a fixed proportion
Medicines related to medical insurance reimbursement for special illnesses have also increased in outpatient clinics.
In this new policy, the Beijing Municipal Medical Security Bureau clarified that outpatient treatment for malignant tumors and kidney dialysis have been included in the scope of special diseases in Beijing health insurance outpatient clinics, and their outpatient examinations, Treatments and related medications may be reimbursed in accordance with the outpatient special illness policy.
The relevant person in charge explained that for the two previous outpatient special diseases, the reimbursement of medicines will be further increased, mainly based on changes in the national health insurance medicine catalog, negotiated varieties of medicines, and combined with the real needs of clinical medication, for the treatment of cancer bone metastases and enteral nutrition, etc. More than 70 types of drugs are included in the scope of reimbursement for special diseases in outpatient treatment of malignant tumors; More than 50 types of drugs, including dialysis replacement fluid, are included in the scope of reimbursement for special illnesses at kidney dialysis clinics.
In addition, according to the Beijing Municipal Medical Security Bureau, with the implementation of the national health insurance drug catalog and dynamic drug negotiation mechanism, the number of valuable drugs included in the scope of health insurance reimbursement continues to increase, some of which are suitable for long-term outpatient treatment and higher cost drugs, and are also suitable for Treatment of various diseases. In order to further reduce the burden of medical expenses for the masses and facilitate the outpatient treatment and medication of the masses, the Beijing Municipality refers to the level of reimbursement of special diseases for urban employees and urban and rural residents in health insurance outpatient clinics, and trial outpatient treatment drugs are reimbursed in an appropriate proportion.
For outpatient treatment of policyholders using “Rosastat capsules” and 9 other drugs, the basic medical insurance fund for urban employees will pay 80%, the basic medical insurance fund for urban and rural residents will pay 70% and the part from the health insurance fund will count as hospital admission expenses. , The capping line implements hospitalization standards.
“After the implementation of the new related drug reimbursement policy, the burden of outpatient treatment drugs will also be greatly reduced,” said the relevant official, such as the “Rosastat capsule” for the treatment of anemia due to disease. chronic kidney disease. After the reimbursement limit is 4,000 yuan, the average annual personal burden will be about 18,000 yuan. After reimbursement according to the new policy, the annual personal burden will be reduced to about 6,600 yuan.
Aspect 3
What medications can no longer be reimbursed by health insurance?
——Beijing announced the first batch of drug varieties not on the National Health Insurance Drug List and 224 drugs were removed
Recently, the Municipal Office of Medical Security and the Municipal Office of Human Resources and Social Security jointly issued the “Notice on the announcement of the first batch of drugs from the Beijing non-national medical insurance drug list,” clarifying that as of October 1 this year, phenformin Other 224 kinds of non-domestic health insurance drug catalogs are transferred from the Beijing health insurance drug catalog, and the expenses incurred after the transfer are no longer included in the payment scope of Beijing Basic Medical Insurance, Work Accident Insurance and Maternity Insurance.
It is a national uniform requirement to gradually digest non-national health insurance drugs in the health insurance catalogs of various regions in 3 years. According to the head of the Beijing Municipal Medical Security Bureau, the drugs transferred by Beijing this time are mainly drugs whose registration numbers have been revoked by the State Drug Administration and drugs that have less clinical use and better alternatives. To protect people’s demand for drugs, the notice requires designated medical institutions to timely adjust the list of commonly used drugs to ensure that the transfer of relevant drugs does not affect the clinical use of insured personnel.
In addition, after the publication of this new policy, after the new reimbursement policy for related drugs is implemented, the Beijing health insurance department requires all designated medical institutions to conduct reasonable inspections, reasonable treatments and rational use of medications based on clinical treatment needs. At the same time, they will make full use of the health insurance big data. Real-time monitoring, statistics and analysis of relevant drug costs not only guarantee the reasonable medical needs of the insured persons, but also prevent fraud and unreasonable use of insurance, and ensure the safety of funds health insurance.
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Editor in charge: Xue Yongwei
