Direct cross-provincial settlement! 5 types of outpatient chronic and special diseases are included in the pilot program, and these patients will benefit

People's Daily Online, Beijing, September 15 (Reporter Cui Yuanyuan) In order to further solve the "urgent, difficult, and anxious" problems encountered by the people in cross-provincial medical settlement, on the basis of accelerating the cross-provincial direct settlement of ordinary outpatient medical expenses, the National Health Insurance Administration and the Ministry of Finance recently decided to carry out a pilot project for cross-provincial direct settlement of outpatient chronic and special disease-related treatment expenses. Before the end of 2021, each province (autonomous region, municipality directly under the central government, including the Xinjiang Production and Construction Corps, hereinafter referred to as the province) will select at least one coordinated area to carry out a pilot project for cross-provincial direct settlement of outpatient chronic and special disease-related treatment expenses, which can provide cross-provincial direct settlement of five outpatient chronic and special disease-related treatment expenses, including hypertension, diabetes, outpatient radiotherapy and chemotherapy for malignant tumors, dialysis for uremia, and anti-rejection treatment after organ transplantation.

Which outpatient chronic and special diseases can be settled directly across provinces?

According to the National Healthcare Security Administration, this pilot program will include five outpatient chronic and special diseases with great demand from the public and widely provided in various places, including hypertension, diabetes, outpatient radiotherapy and chemotherapy for malignant tumors, dialysis for uremia, and anti-rejection treatment after organ transplantation.

In which regions can insured persons enjoy the benefits?

The National Healthcare Security Administration stated that before the end of 2021, each province (autonomous region, municipality, including the Xinjiang Production and Construction Corps) will select at least one coordinated area to carry out a pilot program for direct cross-provincial settlement of outpatient chronic and special disease treatment expenses. After each pilot area completes the upgrade, transformation, testing, and acceptance of the information system of the medical insurance agency, the insured persons in the area can enjoy direct cross-provincial settlement of outpatient chronic and special disease treatment expenses when they seek medical treatment across provinces.

Insured persons can check the opening status of pilot areas through the National Medical Insurance Service Platform APP or website.

Which insured persons can apply for it?

The National Healthcare Security Administration said that people who have completed the qualification certification for the above five outpatient chronic and special disease treatments in the insured area and have completed the cross-provincial medical treatment registration procedures in accordance with the regulations of the insured area.

Which designated medical institutions can carry out this work?

According to the National Medical Insurance Administration, pilot areas will give priority to designated medical institutions with high diagnosis and treatment level, standardized management, and complete the coding of medical insurance business such as medical insurance disease diagnosis, medical insurance drugs, medical service items, medical consumables, and outpatient chronic and special diseases from designated medical institutions that have opened cross-provincial direct settlement of ordinary outpatient medical expenses to carry out pilot projects. After necessary system transformation and sufficient testing, the information of designated medical institutions and the opened outpatient chronic and special diseases will be uploaded, and insured persons can query it through the National Medical Insurance Service Platform APP or website.

How are expenses reimbursed?

The National Medical Insurance Administration pointed out that in order to take into account the differences in the scope of diseases in various regions, when the treatment costs of outpatient chronic and special diseases are directly settled across provinces, the national unified outpatient chronic and special disease codes and disease names will be used, and settlement will be temporarily made according to the project payment method. When settling, the payment scope and relevant regulations of the place of medical treatment (basic medical insurance drugs, medical service items and medical consumables, etc.) will be implemented, and the relevant regulations such as the medical insurance fund deductible standard, payment ratio, and maximum payment limit of the insured place will be implemented.

If the place of medical treatment has a corresponding outpatient chronic and special disease with a limited payment scope, the payment scope of the place of medical treatment shall be implemented; if there is no corresponding outpatient chronic and special disease, the designated medical institution and the attending physician shall follow the relevant disease diagnosis and treatment standards and medication regulations for reasonable diagnosis and treatment. If the insured person enjoys multiple outpatient chronic and special disease benefits at the same time, the insured place shall determine the benefit calculation rules according to local regulations.

How do designated medical institutions determine patient qualifications?

According to the National Healthcare Security Administration, the agencies in the insured areas must promptly upload the eligibility information for outpatient chronic and special disease treatment for people who have registered for medical treatment in other places to the National Healthcare Security Administration's information platform, so that designated medical institutions in the area of ​​medical treatment can obtain relevant information and carry out corresponding diagnosis and treatment settlement services.

When designated medical institutions at the place of medical treatment provide cross-provincial direct settlement services for outpatient chronic and special disease treatment expenses to insured persons from other places, they can obtain the insured persons' eligibility information for outpatient chronic and special disease treatment through the National Health Insurance Administration information platform.

What settlement rules do designated medical institutions implement?

The National Medical Insurance Administration pointed out that when designated medical institutions provide cross-provincial direct settlement services for non-local insured persons who are eligible for outpatient chronic and special disease treatment, they should treat specific diseases and use drugs reasonably, and settle the treatment costs of outpatient chronic and special diseases separately by disease type. Other medical expenses not related to outpatient chronic and special disease treatment should be settled separately as ordinary outpatient expenses.