What should I do if my chronic disease quota is used up?

Don’t panic. After the chronic disease quota is used up in most areas, the compliant chronic disease expenses incurred in the remaining time period can be reimbursed proportionally by general outpatient services after the local deductible is reached. Those with Huimin Insurance and commercial medical insurance can also apply for a second claim. Some areas also have special chronic disease excess subsidy policies. The cost of additional out-of-pocket payments is actually not as high as expected.

A while ago, I accompanied my aunt at home who suffers from type 2 diabetes to get prescriptions. Her annual employee medical insurance limit for chronic diseases is 7,000 yuan. In early November last year, she spent all of it on insulin and kidney and heart protection drugs for complications. At first, she thought that the remaining two months of prescriptions would be paid for at her own expense. She was so worried that she even wanted to reduce the amount of medicines she took. However, she found out at the checkout window that local chronic diseases The quota has long been established with the general outpatient clinic. After she paid the minimum payment of 400 yuan out of pocket, she could still claim 55% for dispensing medicines. At the end of the year, she applied for a special subsidy of 1,200 yuan from the street for the elderly with chronic diseases based on her chronic disease payment receipts throughout the year. After calculating the excess, she spent less than 300 yuan, which was more than half of what she expected.

However, not all places have such loose policies. I have seen some netizens in medical insurance-related exchange groups say that specific chronic diseases such as malignant tumors and pneumoconiosis in their hometown are calculated separately. After they are used up, they can no longer be reimbursed by basic medical insurance in the same year, and can only be reimbursed by self-pay or supplementary insurance. The differences in local policies are indeed not small, and there is no need to copy the rules of other places.

In fact, there have always been different opinions on the setting of quotas for chronic diseases. Many patients who need long-term use of high-priced targeted drugs and original drugs feel that the current quota is not enough. They often spend it in half a year, and the burden of subsequent treatment is too heavy.； Some practitioners in the medical insurance system also mentioned that the core purpose of setting the quota is to prevent the fund from running out and leaking, and to prevent people from over-prescribing and reselling medical insurance drugs. After all, the medical insurance fund has such a large plate, and it must take into account the medication needs of more people. In fact, many places have been dynamically adjusting their quotas in the past two years. For example, in many places, the quotas for hypertension and diabetes have increased by nearly 30% in three years. The quotas for some special cancer diseases have been liberalized to be combined with the hospitalization quota. They are slowly finding a balance between the two.

By the way, don’t overstock up on medicines just to make up for the current year’s quota. Medical insurance clearly stipulates that chronic disease dispensing can only be prescribed for a maximum of 1-3 months. Not only will over-prescribed medicines not be reimbursed, but it may also trigger risk control warnings from medical insurance, affecting subsequent eligibility for chronic disease benefits, and the gain outweighs the gain. If you feel that the quota is not enough every year, during the annual review of chronic disease qualifications, you can casually ask the local medical insurance agency whether you can apply for a higher level of chronic disease benefits. For example, in many places, chronic diseases such as malignant tumors and uremic dialysis are divided into two levels: ordinary and special needs. As long as you can provide recent treatment records to prove the need for medication, you can apply for a higher reimbursement amount, which can save a lot of money.

If you really encounter the situation of running out of quota, you should first contact the hospital's medical insurance window or call the 12393 medical insurance hotline to find out the local reimbursement rules before paying. Don't just pay all out of pocket.