Outpatient-specific diseases (referred to as "special diseases" for short) refer to diseases with definite outpatient diagnosis, relatively stable condition, long-term treatment or clear diagnosis and treatment plan. Outpatient medical expenses are paid by the medical insurance fund according to the regulations.

2. Who can apply for outpatient service for specific diseases?

If the insured persons of the basic medical insurance for urban workers and the basic medical insurance for urban and rural residents in our city meet the relevant conditions such as special disease access standards, they may apply for the identification of outpatient specific diseases, and enjoy relevant treatment according to regulations after identification.

3. What are the coverage of outpatient specific diseases?

The coverage of outpatient specific diseases includes 56 diseases such as chronic obstructive pulmonary disease, hypertension and diabetes. (See the annex for the standard of treatment and the maximum payment limit. )

4. What is the reimbursement limit for outpatient specific diseases?

According to the policy, "quota management" is implemented for specific outpatient diseases. According to the disease type, set "quarterly quota" or "annual quota" respectively. The special reimbursement limit is the actual payment limit of the fund, and the maximum payment limit is valid in the current period, and it is not rolled over or accumulated. The payment amount of the overall fund is included in the maximum payment limit of the insured's annual basic medical insurance.

5. What is the process of applying for outpatient specific diseases?

(a) the insured with my original social security card or valid ID card to the city with the corresponding outpatient specific disease identification qualification of designated medical institutions to apply for identification and audit. (The list of designated medical institutions that carry out the identification of outpatient specific diseases can be obtained from official website of Meizhou Medical Security Bureau).

(two) the insured who has handled the resettlement and retirement in different places, long-term residence in different places, and permanent work in different places may provide the following materials to the medical insurance handling department of the insured place for application:

1. Original social security card or valid ID card;

2. An application form for the identification of outpatient treatment of specific diseases issued by designated medical institutions of medical insurance at or above the second level;

3. Relevant medical records, inspection reports and diagnosis certificates issued by designated medical institutions for medical insurance above Grade II (including Grade II), and stamped with the seal of the medical institution.

6. What does "dual channel" mean?

The "dual-channel" management pilot of national medical insurance negotiation drugs refers to extending the drug protection for insured patients to designated medical insurance retail pharmacies, realizing "one-stop" settlement of some inpatient drugs and outpatient prescriptions for specific diseases, and paying for medical services through medical insurance internet to meet the needs of insured people for medical treatment and drug purchase, such as taking drugs inside and outside the hospital and delivering them to their homes.

Seven, "dual channel" pilot medical insurance designated medical institutions?

(1) Dual-channel pilot medical institutions: Meizhou People's Hospital, Meizhou Traditional Chinese Medicine Hospital, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, and Meizhou Second Hospital of Traditional Chinese Medicine.

(II) Dual-channel pilot retail pharmacies: Meizhou Pharmacy of Sinopharm Holdings Guangzhou Co., Ltd., Tanghuang Branch of Meizhou Dashenlin Pharmacy Co., Ltd., Tanghuang Road Store of Guangdong Shenhua Pharmacy Chain Co., Ltd., and Haloxylon Bridge Store of Guangdong Nanshoufeng Health Pharmacy Chain Co., Ltd.

8. What are the "dual-channel" management drugs?

According to the Emergency Notice on 20021Accelerating the National Medical Insurance Negotiation by the Office of Guangdong Medical Insurance Bureau (Guangdong Medical Insurance Office Letter [202 1]136), our city implements the unified "dual-channel" drug management scope in the whole province (see the annex for details).

Nine, how to reimburse outpatient medical expenses for specific diseases?

(1) Direct settlement by designated medical institutions. The insured shall directly settle the outpatient medical expenses related to the applied diseases when handling the filing procedures for medical treatment in different places in the designated medical institutions and "dual-channel" pilot medical institutions in the city, and when choosing medical treatment in different places. When the insured handles the settlement, he should provide the original social security card (ID card) to the outpatient charge office for medical insurance bookkeeping.

(2) Manual reimbursement. When the insured person falls ill and goes to a designated medical institution without online settlement for medical treatment, the medical expenses shall be paid in advance by the individual, and the medical insurance agency in the insured place shall apply for reimbursement.

Step 1: Apply for reimbursement. The insured shall apply to the medical insurance agency of the insured place for reimbursement of outpatient medical expenses for specific diseases. The following original materials shall be provided: social security card (original ID card and personal bank account information for those who have not received social security card), original invoice for outpatient medical expenses, and detailed list of expenses (stamped with special seal of medical institution).

Step 2: Review the payment. The medical insurance agency shall review the accepted materials and pay the reimbursement amount to the financial account or bank account of the social security card of the insured within 20 working days.

Note: When handling the manual reimbursement of medical expenses, except for special circumstances such as force majeure or legal disputes, the insured shall go through the manual reimbursement procedures at the medical security agency in the insured place within 1 year from the deadline of diagnosis and treatment shown on the medical expenses document.

10. How long is the validity period of outpatient specific diseases?

According to the provincial policy, the effective period of treatment is set according to the type of disease, the shortest is 6 months, and the longest is long-term effective. Enjoy regular and effective diseases and need to continue to enjoy special treatment before the end of the treatment period. The insured shall apply for renewal or reapplication in time.

Eleven, the insured door fee can be included in the scope of serious illness insurance and medical assistance?

According to the policy, after the medical expenses of the insured are paid by the basic medical insurance,

Personal compliance medical expenses are included in the scope of serious illness insurance and medical assistance in our city according to regulations. (Note: Pay according to regulations after reaching the critical illness insurance deductible line and medical assistance deductible line)

Twelve. What medical expenses can be included in the scope of reimbursement for special care recipients?

After the insured handles the identification of special care, the medical expenses within the scope of the basic medical insurance drug list, diagnosis and treatment list and medical service facilities in designated medical institutions will be included in the payment scope of the special care fund. The outpatient expenses of the insured outside the scope of Mente are not included in the payment scope.