Chronic disease medical insurance

The current domestic chronic disease medical insurance (the official name is "Outpatient Chronic Special Disease Protection Policy") is a medical insurance benefit specifically for chronic disease patients who need long-term medication and regular follow-up visits. The average reimbursement ratio for outpatient compliance expenses nationwide is more than 60%, and the reimbursement ratio for special chronic diseases such as dialysis, malignant tumor radiotherapy and chemotherapy, and hemophilia can generally reach 80%. However, the reimbursement catalog and filing requirements vary greatly from place to place, which is the core reason why ordinary users are most likely to get stuck when enjoying benefits.

Speaking of which, I helped my aunt in my hometown register for hypertension and chronic disease last month, and I really realized how practical this policy is. My aunt has been suffering from high blood pressure for almost 12 years. She used to think that she could only be reimbursed by medical insurance if she was hospitalized. She takes antihypertensive drugs every month and does regular liver and kidney function monitoring, which costs more than 300. For an old man with a monthly pension of only more than 2,000, she occasionally secretly reduces the dosage of medicine. This time, the doctor at the community hospital happened to remind her that she could apply for chronic disease registration. She submitted her medical records and diagnosis certificates for the past two years, and she got it done on the same day. Now she only pays just over 50 out-of-pocket for medicine every month, saving almost 85%. She now tells everyone that this policy is good.

Of course, not all chronic diseases can enjoy this treatment. This has been the most controversial area within and outside the industry in the past two years. Many patients with rare diseases have spoken out online, saying that diseases such as ALS and tuberous sclerosis require long-term use of high-priced specific drugs. Many prefectures and cities have not included them in the chronic disease catalogues. The drug expenses of more than 100,000 yuan a year are completely borne by the family, which is too stressful. I have read an open letter written by an ALS patient to the local medical insurance bureau before, saying that it costs more than 4,000 for him to take riluzole every month. If he cannot register for chronic disease, he will not be able to survive. However, some staff in the medical insurance system have privately discussed this issue: There is no unified chronic disease catalog across the country. Each region delimits the scope based on the affordability of its own medical insurance funds. In economically developed provinces such as Jiangsu, Zhejiang and Guangdong, the chronic disease catalog can cover more than 200 diseases, and even includes severe depression and early Alzheimer's disease. However, some cities in the central and western regions with high fund pressure may only have 30 or 40 high-incidence chronic diseases in the catalog. It is really unrealistic to achieve national leveling in one step. However, the good news is that since 2023, 17 provinces have begun piloting a unified provincial chronic disease catalog. This year, many places have gradually added rare diseases such as Gaucher disease and Pompe disease to the list. Although the progress is slow, it is indeed being pushed forward.

In addition to whether the catalog can be entered, many people complain that the filing process is too tortuous. I heard from a colleague that his grandfather had rheumatoid arthritis and had to register for a chronic disease. He had to go to the hospital three times to get a diagnosis certificate, and he also had to go to the medical insurance bureau to submit the documents. It took almost half a month. The old man had bad legs and it was very difficult. But there are also difficulties from the perspective of managers: in the past few years, there have been many cases of fraudulent claims and loans for chronic disease benefits. Some people used their qualifications for high blood pressure and chronic diseases to prescribe antihypertensive drugs to several relatives at home, and robbed tens of thousands of medical insurance funds a year. If the registration threshold is completely relaxed, the fund will not be able to cover it, and in the end it will harm the interests of patients who really need it. Fortunately, many places are simplifying the process. This time, my aunt received medical treatment at a community hospital. The doctor submitted the filing application for her directly in the system without going to the medical insurance bureau. Moreover, more and more places have canceled the requirement of annual review. As long as the payment of medical insurance is not stopped, the benefits will be automatically renewed. This can be said to be a balance between both sides.

By the way, there is another question about reimbursement in other places that everyone asks a lot. I have a netizen who works as an Internet operator in Shanghai. His hometown is in Jingzhou, Hubei Province. He has been diagnosed with diabetes for three years. He used to be unable to reimburse for medicines purchased at pharmacies in Shanghai or for outpatient follow-up visits. Every time, he had to save invoices and send them back to his hometown for reimbursement at the end of the year, which was very troublesome. Last year, the country started piloting the direct settlement of chronic disease expenses across provinces. He told me last month that when people prescribe antidiabetic drugs in community hospitals in Shanghai, they can reimburse 65% of the cost by directly swiping their social security cards, without even having to pay in advance. After checking the data, as of the first half of 2024, more than 70% of the coordinating areas across the country have opened inter-provincial direct settlement for at least 5 or more high-incidence chronic diseases. Of course, if the disease you have is relatively rare, you may still have to pay in advance and then go back for reimbursement. This can only be covered gradually in the future.

To be honest, I used to think that medical insurance policies were far away from me. It wasn’t until I helped my family members apply for them that I discovered that they are really benefits that can be implemented in real terms. If you have an elderly person at home who takes medicine for a long time, or you have a chronic disease, don’t wait for notification from the community or work unit, call the 12393 medical insurance hotline directly and ask: what is your local chronic disease catalog and what materials are required for registration. In many places, you can now submit the materials in the medical insurance mini-programs of Alipay and WeChat, without having to go offline for the whole process. Oh, by the way, a reminder, even if you apply for chronic disease registration, you still need to prescribe drugs in the catalog before you can apply. I have seen people register for hypertension before, but they have to prescribe imported original drugs. The local catalog is not included, and in the end they have to pay for it all at their own expense. If you ask in advance, you will avoid pitfalls.

Anyway, I will talk about this policy when I meet people in need around me. It can save a little bit. After all, for ordinary families, the two or three hundred saved every month may be able to buy two more boxes of milk for their children and two more pounds of meat for the elderly. These are real benefits.