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国家医保局:北京广州异地就医结算,医保按当地标准报销

2019-04-27 佚名 医谷

4月26日,国家医保局发布消息称,全国跨省异地就医住院医疗费用直接结算工作稳步推进,跨省异地就医定点医疗机构数量和备案人数持续增长,跨省异地就医直接结算人次突破200万。

4月26日,国家医保局发布消息称,全国跨省异地就医住院医疗费用直接结算工作稳步推进,跨省异地就医定点医疗机构数量和备案人数持续增长,跨省异地就医直接结算人次突破200万。

国家医保局提示:按政策规定,跨省异地就医直接结算执行就医地基本医疗保险药品目录、诊疗项目和医疗服务设施标准,手工报销仍执行参保地目录范围及有关规定。同时对于提供跨省就医相对集中的北京、广州两地高值医用耗材(即直接作用于人体、对安全性有严格要求、临床使用量大、价格相对较高、群众负担费用重的医用耗材)医保支付有关规定,在这些地区就医的外省参保人员直接结算时适用当地规定。

据统计,截至2019年3月底,跨省异地就医定点医疗机构数量为16230家,二级及以下定点医疗机构13580家,国家平台备案人数385万。自2017年1月启动以来,累计实现跨省异地就医直接结算203万人次,医疗费用485.4亿元,基金支付285.1亿元,基金支付比例58.7%。基金支付超过1万元的76.7万人次,超过5万元的10.0万人次,超过10万元的1.7万人次。

2019年3月,跨省异地就医定点医疗机构数量新增201家;基层医疗机构覆盖范围持续扩大,二级及以下定点医疗机构新增195家。当月跨省异地就医直接结算20.5万人次,环比增长70.8%;医疗费用48.7亿元,环比增长79.0%;基金支付28.3亿元,环比增长75.8%,基金支付比例58.0%;日均直接结算6614人次。职工及城乡居民医保单日结算峰值9857人次(3月18日),当日发生医疗费用2.5亿元,基金支付1.4亿元。

关于异地直接结算适用北京、广州当地的规定如下:

北京市:对单价超过500元的耗材采取个人先行负担一部分后,再纳入报销范围按比例报销的办法。《关于调整基本医疗保险参保人员待遇标准有关问题的通知》(京劳社医发〔2008〕111号)规定,个人先行负担比例为30%。《关于调整基本医疗保险人工器官报销标准有关问题的通知》(京人社医发〔2010〕170号)规定,对于人工关节、人工晶体、心脏瓣膜、心脏起搏器等人工器官,采取最高支付限额纳入报销范围的办法。

广州市:根据《广州市社会医疗保险眼白内障摘除及人工晶体植入术医疗费用结算办法》(穗人社发﹝2014﹞28号)、《广州市人力资源和社会保障局关于将人工耳蜗纳入广州市社会医疗保险统筹基金支付范围的通知》(穗人社发﹝2018)号)等有关规定,广州市医保参保人员进行白内障手术发生的人工晶体材料费用,按不高于1800元/个的标准纳入统筹基金支付范围;参保人员住院治疗发生的符合规定的人工耳蜗费用,按不高于76000元/个的标准纳入统筹基金支付范围。此外,广州市暂未对其他高值耗材制定相关的限价政策或支付标准。

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    2019-12-15 vividelife
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