What is the reimbursement rate for hospitalization for chronic diseases?

At present, there is no uniform fixed reimbursement ratio for hospitalization for chronic diseases in China. The overall reimbursement range is roughly between 50% and 90%. The specific value will be affected by several factors such as the type of insurance, the level of the hospital where you are treated, the local co-ordination regional policy, and whether it falls into the category of special chronic diseases.

The employee medical insurance that we usually have the most contact with has higher payment standards, and the overall reimbursement ratio is better than that of urban and rural residents' medical insurance. In cities with relatively abundant pooling funds, such as the Yangtze River Delta and the Pearl River Delta, the reimbursement ratio for employees hospitalized in secondary hospitals for common chronic diseases such as blood pressure and blood sugar regulation can generally reach more than 85%, and it can be 2-3 percentage points higher for retirees. If they go to a tertiary hospital, the ratio is usually lowered by 5%-10%. This is also to guide ordinary patients with chronic diseases to give priority to primary care.

A while ago, I accompanied a friend to a community health service center in Hangzhou for discharge. He was covered by employee medical insurance due to flexible employment. He was hospitalized for a week due to an acute exacerbation of COPD, and the total cost was more than 3,800. In the end, the medical insurance co-ordinated a reimbursement of 3,200, which is more than 84%. He said that he had been hospitalized in Zhejiang No. 1 Hospital for the same problem before, and the total cost was about the same. He paid almost 1,400, and the reimbursement was just over 60%, which is quite a difference.

If you pay urban and rural residents' medical insurance, the reimbursement ratio for hospitalization for common chronic diseases is generally between 50% and 70%. The upper limit of reimbursement for first-class hospitals can usually reach 70%. Most of the reimbursement for tertiary hospitals is in the range of 50%-55%. However, most areas now cover hypertension, diabetes and so on. High-risk chronic diseases such as cancer, radiotherapy and chemotherapy for malignant tumors, and renal dialysis are included in the list of special chronic diseases. For patients who meet the recognized standards for hospitalization, the reimbursement rate will be 5%-15% higher than that for ordinary diseases. In some areas, the hospitalization deductible for such diseases will be cancelled, which is equivalent to saving an extra amount of money.

Many people will wonder why the reimbursement ratio calculated by themselves is different from what is written in the policy. In fact, it is normal. The policy indicates the reimbursement ratio of compliance expenses. If imported drugs and self-paid consumables outside the medical insurance catalog are used during hospitalization, these expenses are not included in the reimbursement base. The actual reimbursement ratio will naturally be slightly lower than the published value. Before hospitalization, you can also ask the doctor if there are alternative drugs in the medical insurance catalog, which can save a lot of money.

There are also different voices regarding the reimbursement ratio for hospitalization for chronic diseases. Many patients feel that the hierarchical reimbursement setting is unreasonable. If the diagnosis and treatment level of grassroots hospitals cannot keep up, even if the reimbursement ratio of large hospitals is low, they can only go to large hospitals, which will increase the financial burden. The consideration of the medical insurance department is to treat large hospitals The hospital's medical resources are reserved for acute and critical patients, and follow-up and conditioning for common chronic diseases can be completed at the grassroots level. Currently, many regions are piloting the same reimbursement policy for the same disease type. As long as the diagnosis and treatment standards are met, patients will enjoy the same reimbursement ratio regardless of the hospital level they are hospitalized in. This is a compromise solution that takes into account the needs of both parties.

If you want to know the specific reimbursement rules in your area, it is most accurate to directly call the 12393 medical insurance service hotline to ask, and clearly indicate your insurance type and the hospital you plan to visit. The answers given by the staff are much more reliable than the general information searched online. After all, the overall policies vary greatly from place to place. Don’t find out that it is different from what you expected when you are hospitalized.