Case analysis | Whether the drugs in the medical insurance directory can be paid by the Medical Insurance Fund

Case

On April 19th and 21st, 2017, Xu Jia (a pseudonym) was clinic at the Wuhan General Hospital of the Guangzhou Military Region. After biochemical testing the white protein was 20.5g/L, diagnosed with liver cirrhosis, in line with diffuse primary liver cell carcinoma, etc. Major diseases. On April 24 of the same year, he was transferred to Wuhan General Hospital of the Guangzhou Military Region to be discharged on April 26 with the consent of the Medical Insurance Department of Ezhou City Hospital. Secondary malignant tumors, schizophrenia and other major illnesses; on April 27th, staying in Hubei Cancer Hospital until June 5th, and the diagnosis conclusion was the same as above; on June 10, the first time I stayed at Ezhou Traditional Chinese Medicine Hospital until October 14 Dis -hospital was discharged from the hospital on October 20th, and was discharged from the hospital for the second time to March 2, 2018. On March 7, 2018, he stayed at Ezhou Traditional Chinese Medicine Hospital for the third time, and died clinically at the Ezhou Traditional Chinese Medicine Hospital on May 1, 2018.

Xu Jia was in four inspections in the Ezhou Traditional Chinese Medicine Hospital from June 11, 2017 to January 14, 2018, in which the white protein content per liter of blood exceeded 30g/L during the two inspections.

Xu Yi's brother Xu Yi (a pseudonym) According to the doctor's order, Xu Jia purchased a total of 235,870 yuan for Xu Jia's purchase of human blood albumin, golden dragon capsule, nourishing accumulation capsule, toluene sulfininic nittyinib, ozine and An Lufan, etc. Except for toluene sulfonic acid Sorafini purchased at the outpatient department of Wuhan Tongji Hospital, other drugs are purchased in pharmacies. The above drugs are during the hospitalization of Xu Jia, and they are purchased according to clinical needs. After Xu Jia's death, there was a controversy on whether these drugs should be included in the scope of payment of basic medical insurance funds. As the only close relative of Xu Jia, Xu Yi filed an administrative lawsuit and asked the medical insurance center to include this in the fund payment.

Trial

The court of first instance believes that according to the "National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog (2017) Year Edition" (hereinafter referred to as the 2017 version of the National Drug Catalog), human hemoglobin injection, restricted rescue of severe illness or cirrhosis, cancer causes breasts to cause chest chest Patients with ascites and albumin below 30g/L shall be included in the scope of basic medical insurance payment according to category B drugs. Human albumin injection is the scope of medical insurance reimbursement. Golden Dragon Capsules, nourishing and eliminating capsules, toluene sulfonic acid Sorafini, ozine and An Lufan's five types of medicines, the defendant shall make specific administrative actions in accordance with the scope of the medical insurance directory and the proportion of reimbursement. The defendant ordered the plaintiff's obligation to reimburse Xu Jia's medical expenses within the scope of medical insurance.

Both Xu Yi and the Medical Insurance Center did not accept it and appealed. The Medical Insurance Center particularly emphasized that Xu Jia had twice inspected albumin exceeding 30g/L, which did not meet the reimbursement conditions.

The court of second instance held that the results of the blood test at a certain time could not fully reflect the true indicators of the albumin of patients with advanced liver cancer, and to deny that Xu Jia could not use human blood albumin basis with a certain time of blood tests. According to the 2017 edition of the National Drug Catalog, Human Resources and Social Security "Notice on the Scope of 36 Drugs into the National Basic Medical Insurance, Work Injury Insurance, and Maternity Insurance Drug Catalogs, and the" Basic Medical Insurance, Work Injury Insurance and Maternity Insurance in Hubei Province Pharmaceutical Catalog (2017 Edition) and other relevant provisions, combined with Article 8 of the "Social Insurance Law" of the "Social Insurance Law", that is, the medical expenses of the insured persons in the agreement of the agreement, in line with the basic medical insurance drug catalog, diagnosis and treatment projects, medical services, medical services If the facility standards are paid from the basic medical insurance fund according to national regulations, the toluene sulfonicic nicotinic nignic nignic nignicic nicheniic nicheniic acid that Xu Jia can be paid from the basic medical insurance fund. In terms of conditions, the medicine is also within the scope of the drug directory, but the cost reimbursement does not meet relevant laws and regulations, and its claims are not supported. The verdict was canceled, requiring the medical insurance center to review and reimburse the toluene sulfonic acid Sarafinii medical expenses.

The Medical Insurance Center refused to accept it. The application for retrial said that although toluene sulfonic acid is a medical insurance reimbursement drug, the case involved in the drug department Xu Jia was purchased at the outpatient department of Tongji Hospital in Wuhan during his lifetime. Pay in the fund.

The retrial court believes that according to the "Administrative Measures for Basic Medical Insurance Payment of Special Drugs in Hubei Province (Trial)", toluene sulfonic acid Sorafiniin cannot be used for hospital outpatient treatment or purchased in outpatient clinics, and cannot be purchased in pharmacies. In this case, the medicine does not meet the conditions of special drug payment, and cannot be reimbursed according to medical insurance payment procedures. Regarding whether five types of drugs such as human hemoglobin, golden dragon capsules, nourishment of positive accumulation capsules, nitrogen, and anchidazole should be paid from the basic medical insurance funds, the court of second instance has fully discussed and the court recognizes it. The judgment was canceled the second trial judgment and rejected all Xu Yi requests.

Evaluate

The judgment of the third -level court in this case is different. Whether the drugs within the scope of the medical insurance directory shall be paid by the medical insurance fund, which will have a great impact on the insured's rights and interests of the insured and the risk of medical insurance funds. It involves the understanding and application of the "Social Insurance Law" and other laws and regulations such as the "Social Insurance Law" and is worth exploring.

1. The scope of the directory of the drug is the necessary, not sufficient conditions for the medical insurance fund to pay

Article 28 of the Social Insurance Law stipulates that: "It meets the basic medical insurance drug directory, diagnosis and treatment items, medical service facilities standards, and medical expenses for emergency and rescue, and pay from the basic medical insurance funds in accordance with national regulations." Medical expenses that meet the pharmaceutical catalogs must still be "paid from basic medical insurance funds in accordance with national regulations", not directly paid by the medical insurance fund. Article 8 of the "Implementation of the Social Insurance Law" stipulates that the medical expenses incurred by insured persons in the agreement medical institution meet the standards of basic medical insurance drugs, diagnosis and treatment items, and medical service facilities, shall be shared in accordance with national regulations from basic medical insurance funds Payment; those who need to be emergency and rescue can seek medical treatment in non -agreement medical institutions; the drugs that must be used for rescue can be appropriately relaxed. Therefore, the requirements for the scope of the drug directory are only necessary conditions for medical insurance funds to pay the drug cost rather than sufficient conditions. Article 23 of the "Interim Measures for the Management of Basic Medical Insurance Drugs" stipulates that the expenses of the use of drugs in the drug catalog in the drug catalog are complied with "provided by the designated pharmaceutical institutions that meet the requirements, except for emergency, rescue" and other conditions. Can be paid by basic medical insurance funds. The "designated pharmaceutical institution" here does not refer to any designated pharmaceutical institution. If the insured person goes to the PR medical institution or a fixed -point retail pharmacy to purchase the catalog scope in the scope of the catalog in the A fixed -point hospital, in principle, it does not meet the condition that "provided by the designated pharmaceutical institutions that meets the requirements" shall not be shared by the medical insurance fund shall not be shared by the medical insurance fund Payment, otherwise it will affect the efficiency of the medical insurance fund, and violate the purpose of implementing the management of designated medical institutions.

2. Restrictions on the medical insurance directory and its applications

Among the six drugs involved in this case, toluene sulfonic acid, sulfenin, human leukin, golden dragon capsules, and nourishment capsules are restricted in the medical insurance directory. For example, the positive and eliminated capsules "restricted liver cancer with auxiliary treatment after hepatic artery intervention therapy", Xu Jia's use of the drug does not meet this restriction. Article 23 of the Interim Measures for the Management of Basic Medical Insurance Drugs also stipulates that the cost of drugs paid by basic medical insurance funds shall be "diagnosed, treatment matching the condition of the legal indications and medical insurance limited payment of medical insurance." Therefore, even if it belongs to the medical insurance catalog, if it does not meet the scope of medical insurance limited payment, it cannot be included in the medical insurance fund payment.

In this case, the court's interpretation of restrictions on drug directory must be paid attention to. The use condition for the use of human hemelin in the drug catalog is that the albumin is less than 30g/L. So is it unavailable if the test results show that the albumin is higher than 30g/L? In other words, in multiple tests, if there are both the standard and lower than the standard, can the drug be included in the medical insurance fund payment scope after testing the standard? The answer of the medical insurance institution is not possible, and the court believes that the results of the blood test at a certain time cannot completely reflect the true indicators of the albumin of patients with advanced liver cancer, and only to negate Xu Jia's insufficient basis. This explanation has reference value for the application of similar limited conditions. Unless the restrictions of the directory are particularly clear and specific, and completely eliminate ambiguity understanding, the processing characteristics of medical treatment and the protection of the insured's rights may need to be explained by the insurer.

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