1、为什么要制定《城镇职工基本医疗保险用药范围管理暂行办法》?
1991年5月12日《关于印发<城镇职工基本医疗保险用药范围管理暂行办法>的通知》(劳社部发[1999]15号)中明确指出，“为了贯彻落实《国务院关于建立城镇职工基本医疗保险制度的决定》”(国发[1998]44号)，“制定了《城镇职工基本医疗保险用药范围管理暂行办法》”。
具体来说，目前，我国上市的药品数量大、品种多。截止1997年，我国药品生产企业已达6391家，共生产4000多种西药制剂，8000多种中成药。由于药品流通体制管理不健全，同一药品在不同医疗机构之间、国产药与进口药之间价格差异加大，一些药品的零售价格相差几十倍，再加上上市药品的质量不一、治疗性与一般保健性药品混同管理，各种因素导致了药品使用中的大量浪费。城镇职工基本医疗保险用药范围管理暂行办法的制定，可以保障职工基本医疗用药，合理控制药品费用，规范基本医疗保险用药范围管理。
2、确定《药品目录》品种的原则是什么?
《药品目录》是《基本医疗保险药品目录》的简称，通过对它的制定，实现基本医疗保险用药范围的管理，确定《药品目录》中药品品种的原则是：“考虑临床治疗的基本需要，也要考虑地区间的经济差异和用药习惯，中西药并重。”
3、哪些药品可以纳入《药品目录》的遴选范围?
根据《城镇职工基本医疗保险用药范围管理暂行办法》第3条的规定，纳入《药品目录》的药品，应是临床必需、安全有效、价格合理、使用方便、市场能够保证供应的药品，同时，还必须具备以下条件之一：
(一)符合国家药品监督管理部门颁发标准的药品;
(二)国家药品监督管理部门批准正式进口的药品;
(三)《中华人民共和国药典》(现行版)收载的药品。
4、哪些药品不能纳入《药品目录》的遴选范围?
根据《城镇职工基本医疗保险用药范围管理暂行办法》第4条的规定，下列药品不能纳入《药品目录》的遴选范围：
(一)用中药材和中药饮片泡制的各类酒制剂;
(二)部分可以入药的动物及动物脏器，干(水)果类;
(三)血液制品、蛋白类制品(特殊适应症与急救、抢救除外);
(四)各类药品中的果味制剂、口服泡腾剂;
(五)主要起营养滋补作用的药品;
(六)劳动社会保障部规定基本医疗保险基金不予支付的其他药品。
5、《药品目录》包括哪几类药品?
根据《城镇职工基本医疗保险用药范围管理暂行办法》第5条的规定，《药品目录》所列药品包括西药、中成药(含民族药)、中药饮片(含民族药)。西药和中成药列入基本医疗保险基金准予支付的药品目录，药品名称采用通用名，并标明剂型。中药饮片列入基本医疗保险基金不予支付的药品目录，药品名称采用药典名。
6、西药和中成药为什么要被列入基本医疗保险基金准予支付的药品目录中?
西药和中成药分别被列入基本医疗保险基金准予支付的药品目录，并分为“甲类目录”和“乙类目录”，是由于它们的药用成分和治疗适应症相对明确，药品的剂型、剂量、规格及其价格都有明确的规定，同时，使用广泛，疗效好，是临床治疗必需或可供临床治疗选择使用的药品。
7、中药饮片为什么被列入基本医疗保险基金不予支付的药品目录中?
纳入《药品目录》的药品，必须是临床必需、安全有效的药品，但是，中药饮片的药源广泛、药材品种繁多，没有明确的使用剂量和规格，同时，考虑到我国传统中医在使用中药时配伍的特点，中药饮片不符合上述条件，所以列入不予支付的目录。
8、基本医疗保险不支付哪些生活服务项目和服务设施费用?
根据《关于确定城镇职工基本医疗保险医疗服务设施范围和支付标准的意见》，基本医疗保险医疗服务设施是指由定点医疗机构提供的，参保人员在接受诊断、治疗和护理的过程中必需的生活服务设施，主要包括住院床位费及门(急)诊留观床位费。对已包含在住院床位费或门(急)诊留观床位费中的日常生活用品、院内运输用品和水、电等费用，基本医疗保险基金不另行支付，定点医疗机构也不得再向参保人员单独收费。
而基本医疗保险基金不予支付的生活服务项目和服务设施费用，主要包括以下五大类：
(一)陪护费、护工费、洗理费、门诊煎药费;
(二)膳食费;
(三)空调费、电视费、电话费、婴儿保温箱费、食品保温箱费、电炉费、电冰箱费及损坏公物赔偿费;
(四)就(转)诊交通费、急救车费;
(五)文娱活动费以及其他特需生活服务费用。
同时，由于各地生活环境和经济水平的差异，其他医疗服务设施项目(如取暖费等)是否纳入基本医疗保险基金支付范围，由各省(自治区、直辖市)劳动保障行政部门规定。
9、基本医疗保险住院床位费支付标准是什么?如何确定?
基本医疗保险住院床位费支付标准，由各统筹地区劳动保障行政部门按照本省物价部门规定的普通住院病房床位费标准确定。需隔离以及危重病人的住院床位费支付标准，由各统筹地区根据实际情况确定。
这一标准的确立，主要是参考了公费、劳保医疗制度关于按普通病房床位费报销的规定，这一方面与我国社会主义初级阶段的国情相适应，另一方面也与基本医疗保险保障基本医疗的原则相一致。
10、基本医疗保险门(急)诊留观床位费支付标准是什么?
基本医疗保险门(急)诊留观床位费支付标准，按本省物价部门规定的收费标准确定，但不能超过基本医疗保险住院床位费的支付标准。
11、如何保证参保人员就诊时得到适宜的医疗服务设施?
根据《关于确定城镇职工基本医疗保险医疗服务设施范围和支付标准的意见》中的规定，为了保证参保人员在就诊时及时得到适宜的医疗服务设施，定点医疗机构必须公开床位收费标准和基本医疗保险床位费支付标准，在安排病房或门(急)诊留观床位时，应将所安排的床位收费标准告知参保人员或其家属。参保人员可以根据定点医疗机构的建议，自主选择不同档次的病房或门(急)诊留观床位。因床位紧张或其他原因，定点医疗机构必须将参保人员安排在超标准病房时，应当首先征得参保人员其或家属的同意。
12、为什么各种健康体检不列入基本医疗保险诊疗项目的范围?
根据《关于城镇职工基本医疗保险诊疗项目管理的意见》，基本医疗保险诊疗项目是指符合以下条件的各种医疗技术劳务项目和采用医疗仪器、设备与医疗用材料进行的诊断、治疗项目：
(一)由物价部门制定了收费标准的;
(二)临床诊断必需、安全有效、费用适宜的;
(三)由定点医疗机构为参保人员提供的定点医疗服务范围内的。
结合上述条件，在该意见的附件《国家基本医疗保险诊疗项目范围》中，将包括各种健康体检在内的若干非疾病治疗列入基本医疗保险不予支付费用的诊疗项目范围。同时，这一规定，是过去公费、劳保医疗政策的延续。
健康体检分为一般健康查体和特殊目的的健康体检。一般健康查体是为了早期发现、早期治疗疾病，由各用人单位组织的预防性疾病普查措施，其体检经费由各用人单位负担，不在公费、劳保医疗经费中支出;特殊目的的健康体检，就是职工根据一些特定的要求所进行的体检，比如职工在求职、办理出国手续、购买商业医疗保险等活动中按要求进行的体检，其费用一般由个人负担。所以，医疗保险制度改革后，各种健康体检不列入基本医疗保险诊疗项目的范围，而是单位组织的健康检查经费由各用人单位负担;原由个人自付的特殊目的的健康体检的费用仍由个人支付。
1. Why should we formulate the Interim Measures for the administration of the scope of use of basic medical insurance for urban employees?
The notice on printing and distributing the Interim Measures for the administration of the scope of use of basic medical insurance for urban employees (LDF [1999] No. 15) on may12,1991 clearly stated that "in order to implement the decision of the State Council on establishing the basic medical insurance system for urban employees" (GF [1998] No. 44), "The Interim Measures for the administration of the scope of use of basic medical insurance for urban employees" have been formulated.
Specifically, at present, the number of drugs listed in China is large and there are many varieties. As of 1997, there have been 6391 pharmaceutical manufacturers in China, with a total of 4000 Western pharmaceutical preparations and more than 8000 Chinese patent medicines. Due to the imperfect management of drug circulation system, the price difference between different medical institutions, domestic and imported drugs of the same drug is increasing, and the retail price of some drugs is dozens of times different. In addition, the quality of listed drugs is different, the management of therapeutic and general health care drugs is mixed, which leads to a large amount of waste in the use of drugs. The formulation of the Interim Measures for the administration of the scope of use of basic medical insurance for urban employees can guarantee the basic medical use of the workers, reasonably control the drug costs and standardize the management of the scope of use of basic medical insurance.
2. What are the principles for determining the variety of the drug catalog?
The drug catalogue is the abbreviation of the catalogue of basic medical insurance drugs. Through the formulation of the catalogue, the management of the scope of the basic medical insurance drug use is realized. The principle of determining the varieties of traditional Chinese medicine in the drug catalogue is: "considering the basic needs of clinical treatment, we should also consider the economic differences and drug habits between regions, and attach equal importance to Chinese and Western medicines."
3. What drugs can be included in the selection scope of the drug catalogue?
According to the provisions of Article 3 of the Interim Measures for the administration of the scope of use of basic medical insurance for urban workers, the drugs included in the drug catalogue shall be the drugs necessary for clinical use, safe and effective, reasonable price, convenient to use and can be guaranteed by the market. At the same time, one of the following conditions must be met:
（1） Drugs that meet the standards issued by the State Drug Administration Department;
（2） The state drug regulatory department approves the officially imported drugs;
（3） The drugs contained in the Pharmacopoeia of the people's Republic of China (current edition).
4. What drugs can't be included in the selection scope of the drug catalogue?
According to Article 4 of the Interim Measures for the administration of the scope of use of basic medical insurance for urban workers, the following drugs cannot be included in the scope of selection of the drug catalogue:
（1） Various liquor preparations made from Chinese medicine and Chinese herbal pieces;
（2） Some of the organs of animals and animals that can be used as medicine, dry (water) fruits;
（3） Blood products and protein products (except for special indications, first aid and rescue);
（4） Fruit preparation and oral effervescent agent in various drugs;
（5） The main drugs that play the role of nutrition and nourishing;
（6） Other drugs that the Ministry of labor and Social Security stipulates that the basic medical insurance fund will not pay.
5. What types of drugs does the drug catalog include?
According to the provisions of Article 5 of the Interim Measures for the administration of the scope of use of basic medical insurance for urban workers, the drugs listed in the drug catalogue include western medicine, Chinese traditional medicine (including national medicine), and Chinese herbal medicine Pieces (including national medicine). Western medicine and Chinese patent medicine are listed in the list of drugs approved to be paid by the basic medical insurance fund. The name of the drug is general name and the dosage form is indicated. The Chinese herbal pieces are listed in the list of drugs that are not paid by the basic medical insurance fund, and the name of the drug is Pharmacopoeia.
6. Why should Western medicine and Chinese patent medicine be listed in the list of drugs approved to be paid by basic medical insurance fund?
Western medicine and Chinese patent medicine are listed in the list of drugs approved to be paid by basic medical insurance fund, and are classified into "category a catalogue" and "category B catalogue". Because their pharmaceutical components and treatment indications are relatively clear, the dosage form, dosage, specification and price of the drugs are clearly defined. At the same time, they are widely used and have good curative effect, It is necessary or available for clinical treatment.
7. Why is Chinese herbal medicine slices listed in the list of drugs that the basic medical insurance fund does not pay?
The drugs included in the "drug catalogue" must be necessary, safe and effective drugs in clinical practice. However, the source of Chinese herbal pieces is wide, the variety of medicines is various, and there is no clear dosage and specification. At the same time, considering the compatibility characteristics of traditional Chinese medicine in China, the Chinese herbal pieces do not meet the above conditions, so they are listed in the list that cannot be paid.
8. What living services and facilities are not covered by basic medical insurance?
According to the opinions on determining the scope and payment standard of basic medical insurance medical service facilities for urban employees, the basic medical insurance medical service facilities refer to the living service facilities provided by designated medical institutions. The life service facilities necessary for the insured personnel in the process of receiving diagnosis, treatment and nursing, mainly include the hospitalization bed fee and the door (emergency) diagnosis and retention bed fee. For the expenses of daily necessities, transportation supplies in hospital, water and electricity that have been included in the bed fee or door (emergency) room fee, the basic medical insurance fund shall not pay separately, and the designated medical institutions shall not charge the insured personnel separately.
The expenses of living services and service facilities that the basic medical insurance fund does not pay include the following five categories:
（1） The expenses of accompanying, labor, cleaning and treatment, and decocting medicine in outpatient department;
（2） Meal expenses;
（3） Air conditioning, TV, telephone, baby incubator, food, electric stove, refrigerator and damages to public property;
（4） Transportation and first aid vehicle fee for referral;
（5） Entertainment and other special living services.
Meanwhile, due to the differences in living environment and economic level of different regions, whether other medical service facilities (such as heating fees, etc.) are included in the payment scope of basic medical insurance fund shall be stipulated by the labor security administrative departments of each province (autonomous region and municipality directly under the central government).
9. What is the standard of bed fee payment in basic medical insurance? How to determine?
The standard for payment of bed fee for basic medical insurance in hospital shall be determined by the labor security administrative department of all regions in accordance with the standard of bed fee of general inpatient ward stipulated by the provincial price department. The standard for the payment of bed fee for the patients in need of isolation and critical care shall be determined by the overall planning area according to the actual situation.
The establishment of this standard mainly refers to the provisions of the public and labor insurance medical system on reimbursement of bed expenses in general ward. On the one hand, it is suitable for the conditions of the primary stage of socialism in China, and on the other hand, it is consistent with the basic medical insurance principle.
10. What is the standard of payment for the basic medical insurance door (emergency) diagnosis and retention bed fee?
The payment standard of the basic medical insurance door (emergency) outpatient and observation bed fee shall be determined according to the charging standard stipulated by the provincial price department, but it cannot exceed the payment standard of the bed fee of the basic medical insurance inpatient.
11. How to ensure that the insured get the appropriate medical service facilities when they visit the hospital?
According to the opinions on determining the scope and payment standard of basic medical insurance medical service facilities for urban employees, in order to ensure that the insured personnel get the appropriate medical service facilities in time, designated medical institutions must disclose the bed charge standard and the basic medical insurance bed fee payment standard. When arranging the ward or door (emergency) diagnosis and leaving the observation bed, the designated medical institutions must disclose the bed charge standard and the basic medical insurance bed fee payment standard, The insured or their family members shall be informed of the rate of bed charges arranged. The insured can choose different ward or door (emergency) room to stay at the hospital room according to the suggestion of designated medical institution. For the reasons of tight bed or other reasons, when the designated medical institution must arrange the insured in the super standard ward, the consent of the insured or his or her family members shall be obtained first.
12. Why are various health examination not included in the scope of basic medical insurance diagnosis and treatment items?
According to the opinions on the management of basic medical insurance diagnosis and treatment project of urban employees, the basic medical insurance diagnosis and treatment project refers to various medical technical labor projects that meet the following conditions and the diagnosis and treatment items carried out by using medical instruments, equipment and medical materials:
（1） The price department has formulated the charging standards;
（2） The clinical diagnosis is necessary, safe and effective, and the cost is appropriate;
（3） Within the scope of designated medical services provided by designated medical institutions for the insured.
Combined with the above conditions, in the appendix of the opinion "scope of national basic medical insurance diagnosis and treatment project", several non disease treatment including various health examination shall be included in the scope of the diagnosis and treatment items that are not paid by the basic medical insurance. At the same time, this provision is the continuation of the public fee and labor insurance medical policy in the past.
The physical examination is divided into general health examination and special purpose physical examination. General health examination is a general survey measure for preventive diseases organized by each employer for early detection and early treatment of diseases. The medical examination funds are borne by all employers and not paid in public expenses and labor insurance medical expenses; Special purpose health examination is the physical examination conducted by employees according to certain requirements, such as the physical examination conducted by employees in job hunting, going abroad, purchasing commercial medical insurance and other activities. The expenses are generally borne by individuals. Therefore, after the reform of medical insurance system, various health examination items are not included in the scope of basic medical insurance diagnosis and treatment, but the expenses for health examination organized by the units are borne by the employer; The cost of special purpose physical examination originally paid by the individual shall still be paid by the individual.
