Chronic disease cancer reimbursement ratio

The employee medical insurance reimbursement ratio for outpatient chronic diseases is generally 70%-90%, and the inpatient reimbursement ratio is 85%-99%； The urban and rural residents' medical insurance (including the new rural cooperative medical insurance) reimburses 50%-70% of outpatient chronic diseases and 60%-80% of inpatient hospitalization. The specific value is affected by many factors such as the policy of the insured area, the location of medical treatment, whether the medication/treatment item is in the medical insurance catalog, whether the identification of chronic diseases has been completed, and whether the registration for medical treatment in another place has been completed. The fluctuation range can be up to 40%.

To tell the truth, last year I accompanied my aunt from my hometown in Hebei to get a chronic disease certification for lung cancer. She didn’t know about this policy before. The first two chemotherapy treatments were in general outpatient clinics. I spent a total of 12,000 and only reported 2,800. After the certification, I used the same osimertinib (a third-generation targeted drug already included in the medical insurance) for the third chemotherapy, and I directly quoted 7,800, which is almost three times the difference. Do you think this procedure is important?

Many people think that the reimbursement ratio is a fixed number printed in the document. Only after going through the procedures do they realize that there is more floating space than they imagined. First, let’s talk about the most easily overlooked geographical differences - I asked a friend in Shanghai before that the employee medical insurance he paid directly reimbursed 90% for the targeted drug outpatient service after bowel cancer surgery, and the out-of-pocket cost was less than 20,000 yuan a year. But for the same medicine, which was prescribed by my aunt in the county hospital last year, the resident medical insurance could only reimburse 55%, which is almost double the difference. This is not someone’s preference, but the thickness of the pools of medical insurance funds in different regions is different, and the overall policies are also different. The reimbursement ratio will generally be higher in economically developed areas. In sinking districts and counties, the ratio will naturally be adjusted downward due to fund size restrictions.

By the way, there are still pitfalls that many people can easily step into: failing to register for medical treatment in another place. I have a child who works in Beijing and is covered by medical insurance. He was diagnosed with gastric cancer when he returned to his hometown in Wuhan last year. He was in a hurry to have an operation and did not register in advance. Originally, the employee medical insurance could reimburse 90% of hospitalization, but in the end he only reported 55%, which cost him nearly 60,000 yuan more. It was useless to make additional registrations afterward, because many places require that the registration procedures must be completed three days before hospitalization, otherwise the reimbursement can only be reduced at a reduced rate for abnormal referrals.

Don't listen to people who say that you should believe whatever the report says. You have to first check whether the medicine you are taking is Category A or Category B. For example, some new targeted drugs are Category B. You have to pay 10%-20% of the "deductible" out of pocket first, and then reimburse the rest on a pro-rata basis. The actual reimbursement ratio you get will definitely be a little lower than the official figure. This is normal, and it is not a scam by the medical insurance center. If you use new ADC drugs or overseas specialty drugs that have not been covered by medical insurance, you will basically have to pay for them all out of pocket, and it has nothing to do with the reimbursement ratio. In the past two years, immunotherapy drugs that required hospitalization were now covered by outpatient reimbursement for chronic diseases in my home (Hangzhou). Many patients do not have to go to the hospital to occupy beds for reimbursement, which saves trouble for both patients and the hospital.

There is actually a lot of controversy about the cancer reimbursement ratio. On one side are the patients’ families. They are looking forward to more new drugs being added to the medical insurance every day. It is best to have 100% reimbursement. After all, there is a cancer patient in the family, and the expenses of hundreds of thousands a year are really unbearable.； On the other side, I know friends in the medical insurance system who will complain in private that new cancer drugs are entering medical insurance too quickly, and the medical insurance funds in many places are under great pressure. Last year, the medical insurance fund in a central province even exceeded 12% of its cancer reimbursement expenses, and finally had to temporarily adjust the reimbursement amount for common chronic diseases. Both sides have difficulties. There is really no perfect solution to this matter.

In the past two years, I have helped three or four people go through the cancer reimbursement procedures. My biggest feeling is, don’t focus on the reimbursement ratio figures mentioned on the Internet. It is really your turn. Go to the local medical insurance bureau to ask how to identify chronic diseases and what materials are needed. If you want to seek medical treatment in another place, please contact the national hospital in advance. Register on the insurance service platform APP. When choosing a treatment plan, ask the doctor, "Can this drug/item be reimbursed for chronic diseases?" If you really need to use self-paid drugs, you can also look at the local Huimin Insurance and the charitable drug donation policy of pharmaceutical companies. If you look for more ways, you can always spend less money.