There are three catalogues of social medical insurance in China, namely, the catalogue of basic medical insurance drugs, the catalogue of diagnosis and treatment items and the catalogue of medical service facilities, which are the most basic guidelines for the implementation and reimbursement of medical insurance policies in China. Among the three major catalogues of medical insurance, the catalogue of medical insurance drugs and the catalogue of medical treatment items are divided into "Class A" and "Class B". But what do "Class A" and "Class B" mean, and what is the difference between the reimbursement scope of the corresponding drugs and medical treatment items?
What are the meanings of "Class A" and "Class B" in the medical insurance drug list?
In response to this problem, the staff of the Municipal Medical Security Bureau said that in recent years, especially through the COVID-19 epidemic, people have paid more and more attention to medical security. The three catalogues of social medical insurance in China are the most basic standards for the implementation and reimbursement of medical insurance policies in China. Of course, these three catalogues are not immutable, they are adjusted and improved with the development of society and the improvement of people's living standards. For example, at the end of 20 19, the national medical insurance bureau added 128 drugs to the medical insurance catalogue through negotiations. At that time, it attracted the attention of public opinion and won unanimous applause from the people.
In life, the list of basic medical insurance drugs is the most talked about and concerned. It is the policy basis and standard for medical care, industry and commerce, and maternity insurance to pay for drugs, and it is the choice of cheap and effective drugs necessary for treatment on the basis of national essential drugs.
Drugs included in the scope of basic medical insurance payment are divided into Class A and Class B. Class A drugs refer to drugs that are basically unified in the whole country, necessary for clinical treatment, widely used, with good curative effect, low price among similar drugs, and can ensure the basic needs of clinical treatment. The expenses of such drugs are included in the payment scope of the basic medical insurance fund, and the expenses are paid according to the basic medical insurance payment standard. When the insured uses "Class A" drugs, they can all be included in the scope of reimbursement. The list of Class B drugs is also formulated by the state, which refers to drugs that can be used for clinical treatment and have good curative effect, and the price of similar drugs is higher than that of Class A drugs. When the insured uses "Class B" drugs, if the proportion of personal burden is not indicated, the individual shall bear a certain proportion of drug expenses first (which varies from place to place), and the rest shall be included in the payment scope of medical insurance fund. If the proportion of personal burden has been marked, it shall be borne by the individual according to the marked proportion, and the rest shall be included in the payment scope of medical insurance fund. Provinces and cities can adjust themselves, and the adjustment range cannot exceed 15% stipulated by the state. Generally speaking, the out-of-pocket proportion of Class B drugs is between 10%-30%.
Drugs that are not in the "A" and "B" drug lists are "not in the list", and drugs that are not in the list are self-funded drugs (commonly known as "C"). Of course, with the continuous improvement of medical insurance policy and social welfare, some self-funded drugs will be adjusted to Class A and Class B every year, and new drugs will be listed one after another and enter the self-funded category. June 2020: 65438+1 October1,China implemented the 2020 version of the medical insurance drug list. There are three main changes in this directory adjustment: 1. More good medicines have been included. The new version of the medical insurance catalogue has reached 2535 kinds of drugs. This adjustment has brought out 150 kinds of old drugs (mainly including drugs whose approval numbers have been cancelled, drugs that have been unreasonably used and expired drugs), and added 148 kinds of good drugs, most of which are life-saving drugs, including drugs for serious diseases such as cancer and rare diseases and drugs for chronic diseases such as diabetes. In this way, the catalogue contains more drugs with better efficacy, and the scope of reimbursement for specific serious diseases becomes wider, which naturally reduces the pressure on medical expenses of ordinary people. 2. Make the drug price cheaper. This time, through negotiations, the state allowed pharmaceutical companies to reduce prices and included 128 anticancer drugs in the medical insurance catalogue, which was much cheaper than before, with the highest price being 70% and the lowest price being nearly 40%. Take the treatment of colorectal cancer as an example. From 4232 yuan per bottle to 1.295 yuan, which is the lowest price in the world. After negotiation, the price of oxytinib for lung cancer was also greatly reduced by 7 1%. After the "high-priced anticancer drugs" were included in medical insurance, it did relieve a lot of pressure on patients. I believe that more good drugs will enter the medical insurance in the future. 3. Improve the repayment rate. In this new medical insurance catalogue, 74 kinds of B drugs are all adjusted to Class A, such as Xiaoer Qingre Ganmao Tablet, Shuanghuanglian Oral Liquid, Li Qiang Pipa Dew, etc. This means that taking these drugs, originally 10-30%, can now be reimbursed 100%. So overall, this catalogue adjustment is a good thing for the benefit of the people.
Although self-funded drugs may be adjusted to the medical insurance catalogue, the following self-funded drugs are at least temporarily excluded from the coverage of the "Basic Medical Insurance Fund", including: drugs that mainly play a nourishing role, some animals and animal organs that can be used as medicines, some dried fruits and fruits that can be used as medicines, various wine preparations brewed with traditional Chinese medicines and Chinese herbal pieces, fruity preparations in various medicines, oral effervescent agents, blood products except first aid and rescue, and protein.
What are the meanings of "Class A" and "Class B" marked in the catalogue of diagnosis and treatment items?
The so-called catalogue of diagnosis and treatment items refers to the clinical treatment and examination items used in hospital treatment, such as treatment fees, examination fees, operation fees, etc. Generally speaking, the basic medical insurance treatment project should meet the following three standards: First, clinical treatment is necessary, safe and effective, and the cost is appropriate; Second, it is necessary for the price department to formulate relevant charging standards; Three, the need for designated medical institutions to provide designated medical services for the insured.
The diagnosis and treatment projects are also divided into "Class A projects" and "Class B projects". The diagnosis and treatment items in Class A Catalogue are necessary, safe, effective and affordable for clinical diagnosis and treatment. The diagnosis and treatment items in Class B Catalogue can be used for clinical diagnosis and treatment, and the curative effect is exact, but it needs to be properly controlled. Some items in the "Class B Catalogue" are limited according to clinical indications, hospital level and specialty characteristics, and qualifications of medical technicians. Similarly, all Class A projects are included in the scope of reimbursement, while Class B projects require individuals to bear part of the expenses first and the rest are included in the scope of reimbursement.
In addition, the diagnosis and treatment projects are divided into overall planning projects, that is, all of them are included in the overall payment; For some overall planning projects, individuals have to bear a certain proportion before they are included in the overall planning scope. For example, in some provinces and cities, individuals have to bear 20% of the cost of CT examination first, and the rest are included in the scope of overall payment; Items out of scope must be paid by individuals. The catalogue of diagnosis and treatment items, like the catalogue of drugs, is not static. It will definitely be adjusted in a direction that is more and more beneficial to the people. Now it is not within the scope, and it may be transferred to the scope of local overall planning. At present, it is a partial overall planning, and it may be adjusted to the scope of complete overall planning in the future.
At present, among the out-of-scope items, the following items are explicitly excluded from the payment scope of the basic medical insurance fund, such as: computer appointment registration fee, initial diagnosis and case establishment fee and case manual fee under the "registration fee" item; The expenses for imaging, laboratory tests and special inspections under "medical examination fees"; One-time supplies under "bed fee"; "Drugs, special consumables and special instruments" under the subject of "nursing expenses"; Monitoring instrument fees under "monitoring fees"; Laboratory tests, special examinations, treatment, drugs, blood transfusion expenses, etc. Under "first aid expenses".
Social medical insurance in China is the "most basic" medical security.
In addition to the above two catalogues, the third catalogue is the Catalogue of Medical Service Facilities, which refers to the catalogue of necessary and suitable medical service facilities and environmental standards selected in the treatment process. The specific contents of medical service facilities cost insurance coverage are provided by designated hospitals, mainly including inpatient bed fees and outpatient and emergency observation bed fees. Different provinces and cities have different payment ranges. Within the scope of reimbursement according to the standard; Out-of-pocket expenses exceeding the standard. At present, it is clear that the expenses of medical service facilities that are not covered by the "basic medical insurance fund" mainly include: one-time outpatient (transfer) transportation expenses and emergency transportation expenses; Air conditioning fee, TV fee, telephone fee, baby incubator fee, food incubator fee, electric stove fee, refrigerator fee and compensation for public property damage; Escort fee, nursing fee, washing fee and outpatient decocting fee; Meal expenses; Entertainment expenses, other special life service expenses, etc.
legal ground
Notice of the Ministry of Labor and Social Security, the State Planning Commission, the State Economic and Trade Commission and other departments. Notice on Printing and Distributing the Interim Measures for the Administration of the Drug Use Scope of the Basic Medical Insurance for Urban Employees Article 8 The expenses incurred by the insured persons of basic medical insurance in using the Drug List shall be paid according to the following principles. The expenses incurred in using Class A drugs shall be paid in accordance with the provisions of the basic medical insurance. The expenses incurred in the use of "Category B drugs" shall be paid by the insured according to a certain proportion, and then according to the provisions of the basic medical insurance. The specific proportion of individual pays shall be stipulated by the overall planning area and reported to the administrative departments of labor security of provinces, autonomous regions and municipalities directly under the Central Government for the record. The expenses incurred in the use of Chinese herbal pieces shall be paid in accordance with the provisions of the basic medical insurance, except for drugs that are not paid by the basic medical insurance fund.