In order to further expand the benefits of outpatient medical insurance, reduce the burden of outpatient medical expenses of insured persons, ensure the basic medical needs of insured persons, and ensure the rational use of basic medical insurance funds, it is decided to expand the scope of special outpatient diseases and implement the Interim Measures for the Management of Outpatient Diseases. The relevant matters are hereby notified as follows:
A, outpatient prescribed diseases
Anti-tumor drug therapy for myasthenia gravis, polymyositis and dermatomyositis, systemic lupus erythematosus, psoriasis (pustular psoriasis, arthropathy psoriasis and erythrodermic psoriasis), myelodysplastic syndrome, polycythemia vera, Behcet's disease, aplastic anemia, hemophilia, chronic hepatitis B and its compensatory cirrhosis (antiviral therapy), chronic hepatitis C (antiviral therapy) and malignant tumor.
Second, the overall fund payment scope
Insured persons who meet the criteria for the identification of outpatient diseases will be paid in proportion to the overall fund for the treatment of diseases in medical insurance coverage. There is no pooling fund qifubiaozhun, and the highest payment limit is set. The part exceeding the maximum payment limit shall be borne by the individual.
Three, the overall fund monthly maximum payment limit
Outpatient diseases are paid by the overall fund on a monthly basis. The maximum monthly payment limit of the following disease funds is 350 yuan: myasthenia gravis, polymyositis and dermatomyositis, systemic lupus erythematosus, psoriasis (pustular psoriasis, arthropathy psoriasis and erythrodermic psoriasis), myelodysplastic syndrome, polycythemia vera, Behcet's disease, aplastic anemia, chronic hepatitis B and its compensatory cirrhosis (antiviral therapy), and anti-tumor drug treatment of malignant tumors.
The outpatient service of chronic hepatitis C (antiviral treatment) stipulates that the maximum monthly payment limit of the disease treatment pooling fund is 3000 yuan.
Hemophilia is managed by the annual maximum payment limit of the overall fund, and the annual maximum payment limit is 12000 yuan.
If it is determined that there are two or more outpatient diseases (except hemophilia and chronic hepatitis C), the 50 yuan will be increased monthly on the basis of the maximum payment limit of one of the pooling funds; Those who are identified as suffering from hemophilia or chronic hepatitis C and other outpatient diseases at the same time are given the limit of two diseases; Those who are found to have both hemophilia and chronic hepatitis C, as well as other diseases, will have their 50 yuan increased every month on the basis of the two limits of hemophilia and chronic hepatitis C..
Four, the overall fund payment ratio
The outpatient service stipulates that the proportion of disease pooling fund payment is: 75% for on-the-job employees and 85% for retired employees.
Verb recognition program (abbreviation for verb)
Outpatient service stipulates that diseases should be recognized and certified. The municipal medical insurance management center is responsible for the appraisal work, and the specific appraisal time, appraisal procedures and related matters shall be formulated separately by the municipal medical insurance management center.
To meet the requirements of outpatient diseases, the municipal medical insurance management center issued the certificate of "outpatient diseases of basic medical insurance for urban workers in Shenyang".
VI. Medical Management of the Insured
Outpatient service stipulates that insured persons should seek medical treatment at designated places when they are sick. Insured persons who meet the conditions of outpatient diseases are only allowed to choose one designated medical institution as the designated medical institution for outpatient diseases every year, and the designated medical institutions shall not be changed at will during the period. The insured shall go to the designated medical institution for medical treatment with the medical insurance IC card and the certificate of "diseases specified in the outpatient service of basic medical insurance for urban workers in Shenyang".
The drugs used in outpatient treatment of hemophilia are anti-hemophilia globulin [factor VIII] and recombinant human coagulation factor VIII or IX for injection, and the related treatment should be completed in designated medical institutions.
The outpatient department of chronic hepatitis C (antiviral treatment) stipulates that the payment period of the disease pooling fund is 12 months, and HCV RNA is reviewed at 12, 24 and 36 weeks according to the treatment principle. Those who meet the medication conditions can continue to use drugs, and those who do not meet the medication conditions or do not conduct evaluation should stop using drugs.
The outpatient department of anti-tumor drug treatment for malignant tumor stipulates that the payment period of the disease pooling fund is 60 months after the first diagnosis.
Seven, the management of designated medical institutions
1. Outpatient diseases shall be managed at fixed points. Medical institutions designated by medical insurance in our city (including designated third, second and first-class hospitals and community health service centers) can voluntarily undertake outpatient service. Designated medical institutions that voluntarily undertake outpatient prescribed diseases shall sign a service agreement with the municipal medical insurance management center, accept the management of the municipal medical insurance management center, and assist the medical insurance center to upload outpatient prescribed disease information and manage the insured in accordance with the provisions of the agreement. In view of the small number of patients with hemophilia and chronic hepatitis C, for the convenience of management, the designated medical institution for outpatient diseases is tentatively set as 1 ~ 2.
2. Designated medical institutions undertaking outpatient service for specific diseases should strictly implement the medical insurance policy, and record the outpatient medical treatment in detail. The prescriptions should be bound into volumes and kept separately. The attending doctor should "check reasonably, use drugs rationally and charge reasonably" according to the patient's condition.
3. Patients who enjoy the prescribed disease treatment in the outpatient clinic shall have a prescription for one week. If the elderly over 70 years old are in stable condition and need to take similar drugs for a long time, the outpatient prescription can be relaxed to two weeks.
4 city medical insurance management center should strengthen the agreement management and daily supervision and inspection of designated medical institutions, and organize the identification of outpatient diseases of insured persons.
Eight. Settlement management
Enjoy the treatment of outpatient diseases of the insured, in the designated medical institutions for the treatment of the diseases of the outpatient drug costs, which belongs to the overall fund payment, by the municipal medical insurance management center and the designated medical institutions for outpatient diseases for settlement; Belonging to the personal burden of the insured, it shall be settled by myself and the designated medical institution.
Nine, this notice shall be implemented as of April 1 2009.
Attachment: Identification standard for outpatient diseases of basic medical insurance: Shenyang Municipal Bureau of Labor and Social Security, Shenyang Municipal Finance Bureau, 2009 1 month 10 Attachment: Identification standard for outpatient diseases of basic medical insurance; Diagnostic criteria of myasthenia gravis 1. Muscle weakness, fluctuating symptoms, early light and late heavy; 2. The fatigue test is positive; 3. Neostigmine test is positive; 4. EMG nerve repetitive electrical stimulation examination: the amplitude of low-frequency stimulation action potential decreased 10% or more, which was positive; 5. The titer of serum anti-acetylcholine antibody increased. Polymyositis and dermatomyositis 1. Progressive pain, tenderness and weakness of limb muscles (shoulder girdle and proximal limb muscles), which may be accompanied by dysphagia and dyspnea; 2. Typical rash of dermatomyositis: periorbital edema with purple erythema of eyelid, erythema and papules on the back of knuckles, erythema of upper chest triangle, scaly rash, abnormal discoloration of facial skin; 3. Pathological biopsy: the changes of skin and muscle are consistent with the pathological changes of dermatomyositis; 4. Serum creatine is increased, urine creatine is increased, serum creatine phosphokinase, transaminase, lactate dehydrogenase and aldolase are increased; 5. EMG is a myogenic change. If there are 3 or 4 criteria and rash, a diagnosis can be made. If there is no skin lesion, it can be diagnosed as polymyositis. Systemic lupus erythematosus 1. Buccal erythema; 2. Discoid erythema; 3. Photosensitivity; 4. Oral ulcer: oral or nasopharyngeal ulcer; 5. Arthritis: involving two or more peripheral joints, with tenderness, swelling or exudation; 6. Serositis: pleurisy or pericarditis; 7. Renal lesions: urinary protein is greater than 0.5g/24h or++or cast; 8. Neuropathy: epilepsy or psychosis; 9. Blood diseases: hemolytic anemia, or leukopenia, or lymphopenia, or thrombocytopenia; 10. Immunological abnormality: anti-ds-DNA antibody or anti-Sm antibody or anticardiolipin antibody is positive; 1 1. Abnormal antinuclear antibody titer. More than four can be identified. Psoriasis pustular psoriasis 1. There are miliary yellow superficial pustules on erythema. In severe cases, pustules are dense and spread all over the body, which can be fused into pus. Psoriasis vulgaris lesions can often appear at the same time; 2. Extensive hair is often accompanied by systemic symptoms such as high fever, joint pain and leukocytosis; 3. Localized skin lesions mainly occur in palms and soles, with recurrent attacks. The item 1 can be used for diagnosis, and items 2 and 3 can assist diagnosis. Psoriasis arthropathy psoriasis 1. The joints such as hands, feet, wrists, ankles, elbows and knees are swollen and painful, and in severe cases, they can be stiff and deformed; 2. It often occurs simultaneously with psoriasis vulgaris or pustular psoriasis, and the severity of joint symptoms often changes with the severity of skin lesions. It has items 1 and 2 for diagnosis. Erythrodermic psoriasis 1. Have a history of psoriasis; 2. Skin lesions diffuse flush or dark red, with a lot of desquamation, and sometimes normal skin islands can be seen; 3. It may be accompanied by fever, chills, headache, joint pain and other discomforts, and superficial lymphadenopathy; 4. The course of disease is long, and typical psoriasis damage often appears after regression. Items 1 and 2 can be used for diagnosis, and items 3 and 4 can assist diagnosis. Myelodysplastic syndrome 1. Clinical manifestations: anemia is the main symptom, and fever or bleeding may occur simultaneously; 2. Hemogram: pancytopenia, or any one or two lines of cytopenia, may have pathological hematopoietic manifestations such as giant red blood cells, giant platelets and nucleated red blood cells; 3. Bone marrow image: pathological hematopoiesis of three or two lines or any line of blood cells; 4. Exclude other diseases associated with pathological hematopoiesis, such as chronic myeloid leukemia, myelofibrosis, erythroleukemia, primary thrombocytosis, acute non-lymphocytic leukemia (type M2b), non-hematopoietic tissue tumors, etc. Exclude other erythroproliferative diseases, such as hemolytic anemia and megaloblastic anemia; Except other pancytopenia, such as aplastic anemia, PNH, etc. Polycythemia vera 1. Clinical manifestations of polycythemia: the skin and mucosa are crimson, especially the cheeks, lips, conjunctiva and palms; Spleen enlargement, hypertension or thrombosis in the course of the disease; 2. Laboratory examination (1) showed that hemoglobin determination and red blood cell count increased significantly; Before treatment, hemoglobin ≥ 180g/L (male), or ≥ 170g/L (female), red blood cell count ≥6.5× 10 12/L (male), or ≥ 6.0×/kloc. (2) The volume of red blood cells increased; (3) Increased hematocrit: male ≥0.54, female ≥ 0.50; (4) No infection or other reasons lead to the white blood cell count more than once >11×109/l; (5) The platelet count is more than 300×109/L for many times; (6) The alkaline phosphatase score of neutrophils in peripheral blood >; 100; (7) The myelogram showed that bone marrow hyperplasia was obviously active or active, and all three lines proliferated, especially the red line. 3. Except for secondary polycythemia and relative polycythemia. Behcet's disease 1. Recurrent oral ulcer three times a year; 2. Recurrent genital ulcer; 3. Eye lesions: anterior and posterior uveitis, vitreous opacity or retinal vasculitis; 4. Skin lesions: erythema nodosum, pseudofolliculitis, purulent papules, acne-like rash; 5. The acupuncture test was positive. Aplastic anemia 1. Whole blood cells decreased, and the percentage of reticulocyte was less than 0.5%.
2. Generally no splenomegaly;
3. Decreased bone marrow hyperplasia (