How much can be reimbursed for a chronic disease and malignant tumor outpatient clinic in a year?

At present, there is no unified standard for the annual reimbursement amount for chronic diseases in malignant tumor outpatient clinics across the country. Employee medical insurance generally ranges from 150,000 to 500,000, and residents' medical insurance mostly ranges from 80,000 to 300,000. Shanghai, Shenzhen, and some cities in Guangdong currently do not have separate reimbursement limits for malignant tumor outpatients. They are used in conjunction with the hospitalization pool. The maximum reimbursable amount can reach more than 500,000, and in some areas it can be even higher after adding critical illness insurance.

I just sorted out the reimbursement bills for my distant cousin in Wuhan two months ago. He is covered by the employee medical insurance. After being diagnosed with lung cancer, he immediately filed for chronic disease registration for radiotherapy and chemotherapy for malignant tumors. For outpatient prescriptions of targeted drugs and regular reviews, 85% of the expenses exceeding the annual deductible of 1,200 yuan can be reimbursed. Local employees The annual cap of medical insurance is 300,000. Last year, he spent 208,000 on outpatient expenses. In the end, the medical insurance reimbursed 167,000, and he only paid a little over 40,000. If he didn't go for general outpatient reimbursement for chronic diseases, he could only reimburse 4,000 a year at most, which is not even half a star.

Of course, this number is extremely flexible. After all, the "money bags" of medical insurance funds vary from place to place. For example, many economically developed cities along the eastern coast have gradually eliminated the separate cap line for outpatient chronic diseases in the past two years. I know that the annual cap line for employee medical insurance in Shanghai this year is 590,000. This amount is shared regardless of whether it is inpatient or outpatient malignant tumor treatment. The maximum reimbursement for the part exceeding the threshold is 92%. For patients who require long-term outpatient treatment, it really saves a lot of expenses.

However, there are now different voices in this area. Many insured persons in less developed areas have reported that the local residents’ medical insurance reimbursement limit for malignant tumor outpatient clinics is only 60,000-80,000. When it comes to long-term use of imported targeted drugs and immunotherapy drugs that have not been included in centralized procurement, this quota will be used up in less than half a year. There are also medical insurance systems Practitioners mentioned that blindly increasing the amount without considering the local fund's affordability is likely to overdraw the entire pool, which will instead affect the normal benefits of all insured persons. Currently, most regions across the country are also gradually adjusting. In the past three years, more than 20 provinces have raised the cap for malignant tumor outpatient clinics and chronic diseases by more than 20%.

If you or a family member have just been diagnosed and need to apply for reimbursement, don’t be too busy calculating the amount. Call the hotline of the local medical insurance bureau as soon as possible to ask two core questions: first, whether the medicine you are taking is included in the local reimbursement catalog for malignant tumors and chronic diseases, and second, whether the annual cap is calculated separately or shared with hospitalization, so as not to panic if the expectations are wrong. By the way, there is another benefit that many people don’t know about. If the out-of-pocket part exceeds the threshold of the local critical illness insurance, the remaining money can be reimbursed by the critical illness insurance. Last year, I met a resident medical insurance patient in Heze, Shandong. The local cancer clinic’s cap was 150,000. He superimposed the 80,000 reimbursement from the critical illness insurance, and finally claimed a total of 230,000, which was almost half the amount he originally thought.