1. The expenses incurred by insured patients using drugs in the medical insurance drug list must meet the legal indications of drugs and the limited payment scope of medical insurance before they can be reimbursed according to regulations;
2. When an insured patient visits a doctor in a different place, he/she needs to file a medical record at the medical insurance department of the insured place. The expenses incurred in hospitalization in the designated medical institution where the medical record is filed can be included in the direct settlement scope of medical insurance;
3. The reimbursement of medical expenses that are not directly settled by the insured patients who seek medical treatment in different places must conform to the policies of the insured places;
4. For the specific reimbursement policy, please consult the medical insurance department of the insured place.
The reimbursement rate of targeted drugs is 8% in Beijing, 5% in Shandong and 3% in Shenyang. The proportion of medical insurance reimbursement for targeted drugs varies greatly from region to region, and it is not unified throughout the country. Targeted drugs are managed separately by the outpatient department of designated medical institutions. After the targeted drug treatment is reviewed and filed, all targeted drug patients treated in designated hospitals can be reimbursed in the inpatient outpatient department.
outpatient service includes general outpatient service and special outpatient service. Special outpatient service is chronic disease, and cancer can apply for reimbursement of chronic disease. Targeted drugs in the catalogue are all Class B drugs, which belong to anticancer drugs. As long as patients with chronic cancer are used, they can be reimbursed according to the reimbursement ratio of chronic disease. Ordinary outpatient clinics in many places can also be reimbursed. Some dual-channel drugs can be reimbursed according to the proportion of dual-channel reimbursement. Dual-channel reimbursement needs to meet the restrictions on drug use. Fill in the application and approval form for dual-channel drug use, and those who pass the examination and approval can also directly settle the reimbursement when purchasing drugs in the hospital.
Legal basis:
Social Insurance Law
Article 26
The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.
article 29
the part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be directly settled by the social insurance agency, medical institutions and pharmaceutical trading units.
the social insurance administrative department and the health administrative department should establish a settlement system for medical expenses in different places, so as to facilitate the insured to enjoy the basic medical insurance benefits.
Article 3
The following medical expenses are not included in the payment scope of the basic medical insurance fund:
(1) Those that should be paid from the industrial injury insurance fund;
(2) It shall be borne by a third party;
(3) It shall be borne by public health;
(4) seeking medical treatment abroad.
the medical expenses shall be borne by the third party according to law. if the third party fails to pay or cannot determine the third party, the basic medical insurance fund shall pay in advance. After the basic medical insurance fund has paid in advance, it has the right to recover from the third party.