How is reimbursement for outpatient chronic diseases calculated?

I've learned a lot about outpatient chronic disease reimbursement policies, but how are they actually calculated? There are still many participants who have questions about this. In response to this question, the reporter interviewed the person in charge of the Xi'an Municipal Medical Security Bureau, focusing on examples and explanations.

First of all, participants should understand the scope of reimbursement, and the expenses that are included in the scope of medical insurance reimbursement can be reimbursed according to the regulations. The reimbursement scope of medical insurance = the total amount of current expenses-items outside the scope of medical insurance-first out-of-pocket items.

Out-of-coverage items refer to: fully self-pay items, such as self-pay drugs, or items that exceed the medical insurance payment limit, e.g. Dagliflozin for diabetic patients has a price limit, so if the price exceeds the limit, it is self-pay.

Advance out-of-pocket items refer to: Medicare drugs are divided into categories An and B. All Category A drugs are included in the reimbursement, while Category B drugs require 4% out-of-pocket for employees and 5% for residents before being included in the reimbursement.

Then, the reimbursement method for outpatient chronic diseases is calculated as follows.

First, individuals first accumulate the starting line and can choose their own payment method, such as payment by medical insurance card.

Example: Master Li is a chronically ill entitled employee and goes to a designated hospital or pharmacy for the first time this year to purchase medicine. The total cost is 350 yuan, of which 200 yuan is for Class A drugs, 100 yuan is for Class B drugs and 50 yuan is for self-financed drugs outside the scope of medical insurance. Then the amount included in the reimbursement is 350yuan-50 yuan for out-of-pocket items-100x0.04for out-of-pocket items first = 296yuan. The starting line for employees is 700 yuan, which is not enough for the starting line, so all 296 yuan is accumulated into the starting line and the cost is paid by individuals, and the payment method can be freely chosen.

Secondly, after the starting line is exceeded, the reimbursement will be made according to the regulations, and the individual will only pay the personal burden part and can choose the payment method by himself.

Example: Master Li purchased medicine for the second time and spent a total of 800 yuan, including 500 yuan for Class A drugs, 100 yuan for Class B drugs and 100 yuan for drugs outside the scope of medical insurance. Then the amount included in the reimbursement is the total amount of 800yuan-self-pay items 100yuan-first out-of-pocket items 100x0.04 = 696yuan. The first purchase of drugs moncler outlet Li has accumulated a starting payment of 296 yuan, and then accumulated 700-296 0404 yuan to start reimbursement. The remaining 696-404-292 yuan can be reimbursed proportionally. The employee medical insurance reimbursement rate is 70%, so this time the purchase of drugs can be reimbursed 292 × 70% = 204.4 yuan.

Master Li's third purchase of drugs, the total cost of 500 yuan, of which 200 yuan of class A drugs, 300 yuan of class B drugs. Then the amount included in the reimbursement is = total amount of 500yuan-out-of-pocket items 0 yuan-first out-of-pocket items 300x0.04488yuan. Master Li has accumulated enough for the starting line, this time directly reimbursed according to the proportion i.e. 488 × 70% yuan.

Third, no more reimbursement after exceeding the upper limit. The total monthly limit will not exceed three times the total monthly limit for the year, and the maximum annual limit for the year will not exceed the maximum annual limit for the disease type identified by me.

Source: Xi'an Evening News