FAQ

The Chronic Disease Co-Care Pilot Scheme (CDCC Pilot Scheme) provides subsidy for the public to conduct screening for and manage targeted chronic diseases, including diabetes mellitus and hypertension, in the private healthcare sector via a "Family Doctor for All" and multidisciplinary public-private partnership model coordinated by District Health Centres (DHC) / District Health Centre Express (DHCE). The CDCC Pilot Scheme aims to facilitate early detection and timely intervention of such chronic diseases and encourage self-management by Scheme Participants, so as to help them better manage their chronic diseases and prevent complications, as well as reduce the demand for public specialised and hospital services.

The CDCC Pilot Scheme comprises a Screening Phase with or without a Treatment Phase for each Scheme Participant. In the Screening Phase, Scheme Participants will be provided with screening services including medical consultation and assessment by the Family Doctors and laboratory investigation services, followed by the making of diagnosis and selection of an appropriate management plan. In the Treatment Phase, Family Doctors will provide medical consultation and medication, as clinically indicated, for eligible Scheme Participants. Based on the diagnosis and clinical condition of the Scheme Participants, nurse consultation, allied health services and laboratory investigation services will also be provided as appropriate.

To enrol in the CDCC Pilot Scheme as a Scheme Participant, an individual is required to meet the following criteria:
(a) is a holder of a valid Hong Kong Identity Card within the meaning of the Registration of Persons Ordinance (Cap. 177), unless he / she is a holder of the Hong Kong Identity Card by virtue of a previous permission to land or remain in Hong Kong granted to him / her and such permission has expired or ceased to be valid; or a holder of a valid Certificate of Exemption within the meaning of the Immigration Ordinance (Cap.115);
(b) is aged 45 or above;
(c) has no known history of diabetes mellitus or hypertension; and
(d) has registered as a DHC / DHCE member and agrees to share his / her data in the eHRSS with related service providers.

Eligible individuals can enrol in the CDCC Pilot Scheme at DHC / DHCE.

Generally, participation in the CDCC Pilot Scheme will not affect the healthcare services that Scheme Participants are currently receiving from the HA or DH such as emergency services and other specialist services. Individuals who are receiving treatment for diabetes mellitus and / or hypertension from the public healthcare system (such as HA), are not eligible to participate in the CDCC Pilot Scheme. If Scheme Participants elect to use the public healthcare system for treatment of their diabetes mellitus and / or hypertension, they are required to immediately notify DHC / DHCE to arrange withdrawal from the CDCC Pilot Scheme.

As the objective of the CDCC Pilot Scheme is to provide targeted subsidised services through a "Family Doctor for All" and multi-disciplinary public-private partnership model to enable eligible public to receive screening and management of target chronic diseases (including diabetes mellitus and hypertension) in the private healthcare sector, the main target group of the CDCC Pilot Scheme are those with first diagnosis of diabetes mellitus or hypertension, which does not cover those with diabetes mellitus or hypertension currently being treated in the public healthcare system.

Scheme Participants can select a suitable Family Doctor, according to their own choice, by searching the website of CDCC Pilot Scheme, which provides the list of Family Doctors with their essential information including practice district, service charge under the CDCC Pilot Scheme and participation in other Government subsidised primary healthcare programme e.g. Elderly Healthcare Voucher Scheme (EHVS).

If Scheme Participants' attending private doctor has already enrolled in the CDCC Pilot Scheme, they may consider to pair with their private doctor directly. If the private doctor has not yet enrolled in the CDCC Pilot Scheme, the Scheme Participants can contact the DHC / DHCE and the DHC / DHCE will invite that private doctor to join the CDCC Pilot Scheme so that the Scheme Participants can be paired with the named doctor.

Family Doctors under CDCC Pilot Scheme are required to be listed in the Primary Care Directory maintained up by the Government. Apart from treatment and caring of health conditions, the Family Doctor also provide continuous support throughout different stages of life such as vaccination, cancer screening, chronic disease screening and management, life course preventive care and self-management of disease. As the Family Doctors, with good understanding of a patients' health conditions and needs, they can provide the patients with the most suitable care and professional advice in promoting their health. At the same time, Family Doctors under the CDCC Pilot Scheme are required to pursue continuing education and follow treatment guidelines, ensuring service quality. Through the CDCC Pilot Scheme, Scheme Participants can receive consultation and related medical services subsidised by the Government; otherwise they are required to pay at their own expense if they select private doctors who are not participating in the CDCC Pilot Scheme.

Scheme Participants are recommended to visit DHC or DHCE for the pairing process. DHC / DHCE staff will provide a list of eligible doctors for Scheme Participants to select as their Family Doctor, according to their own choice. DHC / DHCE staff will not recommend or assign any Family Doctor to the Scheme Participants. After successful pairing, Scheme Participants will be arranged to receive screening and treatment by the selected Family Doctor.

Family Doctors are the main providers of primary healthcare services. Apart from treatment and caring of health conditions, a Family Doctor also provides continuous support throughout different stages of life such as vaccination, cancer screening, chronic disease screening and management, life course preventive care and self-management of disease. As a Family Doctor, with good understanding of a patient's health conditions and needs, they can provide the patients with the most suitable care and professional advice in promoting their health. Therefore, individuals are recommended to arrange to have a Family Doctor for themselves irrespective of whether they are participating in the CDCC Pilot Scheme.

Scheme Participants may only pair up with one Family Doctor under the CDCC Pilot Scheme at any one time.

Scheme Participants are encouraged to maintain a long term relationship with the paired Family Doctor. In the Screening Phase only, the Scheme Participants cannot change their paired Family Doctor within 180 days from the first attendance date of the subsidised medical consultation visit. However, if they do want to change their paired Family Doctor in the Treatment Phase, they may submit the request to DHC / DHCE for arrangement. The request will be handled on a case-by-case basis.

Scheme Participants who have made an appointment for consultation should bring along their valid Hong Kong Identity Cards or Certificates of Exemption (the meaning of which is the same as that in the Immigration Ordinance (Cap. 115)) and appointment slips when they visit their Family Doctor's clinics to facilitate identity verification and registration by the clinic staff. Scheme Participants are also encouraged to bring along self-monitoring blood pressure / glucose records and past medical history and medication records for reference by Family Doctors.

All Scheme Participants and Family Doctors are required to participate in the eHRSS so as to enable sharing of clinical information between the private and the public sectors. For details, please visit DHC / DHCE, the eHRSS website at https://www.ehealth.gov.hk or contact the eHealth hotline for general public at 3467 6300 for assistance.

In general, the CDCC Pilot Scheme will send the following three types of SMS to the Scheme Participants:

• Type 1: to confirm that the Scheme Participants have successfully enrolled in the CDCC Pilot Scheme.
• Type 2: after each subsidised medical consultation visit undertaken by the Scheme Participants
• Type 3: after each co-payment is made by the Scheme Participants.

The CDCC Pilot Scheme will not make any request for personal data of Scheme Participants via the SMS sent. If Scheme Participants have any enquiries about SMS received, please call our hotline at 2157 0500.

Scheme Participants are required to arrange withdrawal from the CDCC Pilot Scheme at the DHC / DHCE. However, individuals are recommended to pay attention to their own health conditions and consult healthcare professionals for appropriate treatment according to their needs.

The main target group of the CDCC Pilot Scheme are those have not been diagnosed with diabetes mellitus or hypertension, which does not cover those with diabetes mellitus or hypertension currently being treated in the public healthcare system.

Scheme Participants may contact the CDCC Pilot Scheme hotline at 2157 0500 or visit their local DHC / DHCE to make enquiries with responsible staff. The hotline operates from 9:00am to 9:00pm Monday to Saturday. If the line is busy or if the call is made outside of operating hours, Scheme Participants may leave a voicemail and we will respond to the inquiry as soon as possible during our office hours.

Based on the screening results and the clinical conditions of the Scheme Participants, Family Doctors will arrange appropriate follow-up treatment for Scheme Participants in accordance with the established guidelines. The DHC / DHCE will also co-ordinate the services with a view to assist Scheme Participants to maintain their health and reduce risk of related complications in the long term.

No. Scheme Participants are required to go through Screening Phase before proceeding to the Treatment Phase. The Screening Phase is an essential step to ensure a correct diagnosis is made and an appropriate management plan can be arranged for Scheme Participants.

The number of subsidised medical consultation visits to which Scheme Participants are entitled is subject to their admitted management programme for their diagnosis. Scheme Participants diagnosed with diabetes mellitus and/ or hypertension are entitled to a maximum of 6 subsidised medical consultation visits per year, while those diagnosed to have prediabetes with HbA1c 6.0% - 6.4% or FPG 6.1 mmol/L - 6.9 mmol/L having no hypertension are entitled to a maximum of 4 subsidised medical consultation visits per year.

A "Participant Programme Year" is each 12-month period in which a Scheme Participant is enrolled in the CDCC Pilot Scheme, and is counted from the date on which the Scheme Participant is admitted into a management programme of the Treatment Phase based on his / her diagnosis, and recounted on the same date each year (e.g. if a Scheme Participant joined the CDCC Pilot Scheme on 1 November 2023, the next "Participant Programme Year" will be counted from 1 November 2024).

Where a Scheme Participant's clinical condition changes during the Treatment Phase, the Family Doctor will make a new diagnosis. If a Scheme Participant's diagnosis is changed, the start date for his / her "Participant Programme Year" will be reset from the date on which the new diagnosis is made.

As individuals with chronic diseases (such as diabetes mellitus or hypertension) require timely and continuous treatment, Scheme Participants can attend regular follow-up medical consultations and receive treatment from the Family Doctors.
Equipped with a good understanding of the Scheme Participants' health conditions and needs, the Family Doctors will formulate appropriate management plans (including arrangement of next medical consultation date) in accordance with the relevant guidelines having regard to the Scheme Participants' clinical conditions and treatment progress, so as to prevent complications, encourage self-management of chronic disease and promotion of their health.

Scheme Participants can receive diagnosis and treatment for both chronic diseases and general episodic diseases at the same subsidised medical consultation visit, and receive medications under the "Specified Drugs" list and/ or up to 3 days of medications for episodic illnesses with no extra charge. If the medical service and medications provided are not within the scope of the CDCC Pilot Scheme, Scheme Participants should discuss with their Family Doctors and pay for such additional service(s) out-of-pocket according to the costs charged by individual Family Doctors.

During each subsidised medical consultation visit of the Treatment Phase, Scheme Participants will receive management of their chronic illnesses. When receiving treatment for their chronic illnesses, Scheme Participants may also receive diagnosis and treatment for episodic illnesses during the same subisidised medical consultation visit when required. If Scheme Participants receive treatment for episodic illnesses only, such is considered outside the scope of the CDCC Pilot Scheme and Scheme Participants have to pay the full costs specified by the Family Doctors.

Scheme Participants can only use a maximum of one subsidised medical consultation visit quota per day. For multiple medical consultation visits on the same day, Scheme Participants are required to pay for any additional expenses after the first subsidised medical consultation visit on the same day.

To support and empower Family Doctors in long-term management of Scheme Participants, the Government has developed a bi-directional referral mechanism with the Hospital Authority (HA) involving seven HA Clusters under the CDCC Pilot Scheme. Based on the pre-defined criteria, if a Scheme Participant is assessed by a Family Doctor as having clinical needs (such as undesirable disease control or complications), the Family Doctor can arrange for the Scheme Participant to receive a one-off specialist consultation at a designated Medicine Specialist Out-patient Clinic of the HA according to the guidelines. The Scheme Participants can obtain clinical advice on a care plan, which he / she can then continue to follow up with the Family Doctor. This special arrangement is not regarded as a specialist out-patient referral nor follow-up consultation, and each attendance is charged at a standardised fee of $135. The HA in general would not arrange follow-up appointments for Scheme Participants. In the event that drug prescription is required for Scheme Participants, a charge of $15 will be applied per prescribed drug item. Medical fee waiver is not applicable to this arrangement, and same fees apply to Scheme Participants who are HA staff or civil service eligible persons.

Meanwhile, based on the clinical condition of participants, Family Doctors can also refer patients to receive healthcare services at specialist out-patient clinics under HA following prevailing mechanism.

Upon referral by their Family Doctors, Scheme Participants can receive specified laboratory investigation and / or ECG services at medical laboratories designated by Government. The address(es) of the designated medical laboratory(ies) and the participants' co-payment fee will be displayed on the website of CDCC Pilot Scheme for public information.

Scheme Participants will choose from any of the service points of the medical laboratories assigned to their chosen Family Doctors for receiving laboratory investigation services. The service points and service hours can be found on the referral slip issued by the Family Doctors.

Scheme Participants may choose to use medical laboratories other than the Government designated medical laboratories, however Scheme Participants will have to pay out-of-pocket for the full costs incurred without Government subsidy.

Scheme Participants are required to make their own appointments and visit designated medical laboratories to receive specified laboratory investigation or ECG services using the referral letter issued by the Family Doctors. The Family Doctors will receive the results of the investigations to explain the diagnosis to the Scheme Participants and provide appropriate follow-up and treatment.

Scheme Participants are required to pay the corresponding co-payment directly to the medical laboratories for the relevant investigation service items as specified in the Family Doctor's referral letter.

The Family Doctors may ask the Scheme Participants to repeat the investigation or examination test if they consider that the test results are not satisfactory or have not been completed. In such cases, no additional cost will be incurred by the Scheme Participants.

The Family Doctors will prescribe the appropriate duration of chronic disease drugs according the Scheme Participant's clinical condition and subject to the Scheme Participant's consent.

The Family Doctors will prescribe the appropriate duration of chronic disease drugs according the Scheme Participant's clinical condition and subject to the Scheme Participant's consent. If the duration of drugs prescribed by the Family Doctors is less than three days, no additional cost will be incurred by the Scheme Participants. If the duration of prescribed drugs for episodic illness is beyond 3 days and not within the list of "Specified Drugs", the Scheme Participants have to pay the full costs of such additional service(s) out-of-pocket. Participants are advised to consult their Family Doctors if they have any special needs.

The Family Doctors will charge a one-off co-payment of $120 at the first subsidised visit at the Screening Phase, which covers all medical consultation visit(s), laboratory investigation services, diagnosis and selection of a management plan. Scheme Participants are only required to pay this co-payment for the Screening Phase, and the remaining costs are subsidised by the Government.

During the Treatment Phase, Scheme Participants will receive a specified quota of subsidised medical consultation visit(s) for each "Participant Programme Year" based on the results of his / her screening and the admitted management programme. Each time Scheme Participants utilise a subsidised medical consultation visit quota, they only need to pay the co-payment determined by their family doctors for the consultation, the provision of drugs from "Specified Drug List", and / or provision of drugs for episodic illnesses (e.g. colds, flu and coughs) for a maximum of three days. The remaining costs of the above services are subsidised by the Government.

The co-payment for specified laboratory investigation(s) and examination(s) under the CDCC Pilot Scheme are as follows (for laboratory tests conducted at the designated medical laboratories of the CDCC Pilot Scheme only):

1. Screening Phase: All the specified laboratory investigations and examinations are subsidised by the Government and Scheme Participants are not required to pay any fees.
2. Treatment Phase: The Government will provide partial subsidy for each of the laboratory investigation and examination test, and Scheme Participants are only required to pay the specified co-payment for each of the relevant investigation service item.

The fees incurred for Scheme Participants who choose to receive laboratory investigation(s) and examination(s) from medical laboratories outside the scope of the CDCC Pilot Scheme will be at their own expense and will not be subsidised by the Government.

Family Doctors will prescribe drugs from the list of "Specified Drugs" and / or drugs for episodic illnesses (e.g. colds, flu, or coughs) for up to three days based on Scheme Participant's clinical condition. The fee for medication is included in the co-payment for the subsidised medical consultation visit of the Treatment Phase and Scheme Participants are not required to pay any additional fee. Apart from the abovementioned prescription of medication, Family Doctors may also prescribe other drugs as clinically necessary with the consent of Scheme Participants, and charge the relevant additional costs for which no Government subsidies will be provided.

Family Doctors can refer Scheme Participants to receive relevant allied health services based on his / her clinical condition. Scheme Participants are required to pay a specified co-payment, with the co-payment amount to be confirmed.

No medical fee waiver is available to Scheme Participants, but Scheme Participants may use health care vouchers towards payment of co-payment to Family Doctors that are also enrolled in the Government's EHVS.

Generally speaking, a quota of 4 to 6 subsidised medical consultation visits is sufficient. If Scheme Participants have used up all of their quotas for subsidised medical consultation visits within 12 months, they may seek medical consultation from the same Family Doctor or other healthcare providers at their own expense, but will not receive Government subsidy. Scheme Participants are encouraged to receive medical services from the same Family Doctor in order to establish a long-term doctor-patient relationship.
Prior to exhausting the subsidised medical consultation visit quotas, Scheme Participants are recommended to maintain close communication with his / her Family Doctors to ensure proper management and monitoring of his / her chronic illnesses. In addition, Scheme Participants may take note of his / her remaining quota of subsidised medical consultation visits so that they can receive appropriate medical support when necessary.

Scheme Participants can check his / her relevant records via the eHealth App.

The objective of the incentive mechanism is to encourage Scheme Participants' active engagement in the treatment process to achieve the health incentive targets based on the recommendations of their Family Doctors, so as to reduce the risk of related complications and maintain their health. All Scheme Participants who are diagnosed with diabetes mellitus and / or hypertension, including prediabetes, have the opportunity to receive incentive bonuses during the Treatment Phase.

The incentive mechanism will begin counting from the second "Participant Programme Year" of Scheme Participants. If Scheme Participants meet the health incentive targets, they will be granted a deduction of up to $150 of the co-payment fee (which is equivalent to the Government's recommended co-payment fee) for their first subsidised medical consultation visit in the following "Participant Programme Year" (i.e. from the start of the third "Participant Programme Year").

The health incentive targets of the incentive mechanism are determined based on the diagnosis and treatment needs of Scheme Participants. The health incentive targets may include the following:

1. Self-monitoring of health parameters and reporting to eHealth App;
2. Attending follow-up consultations;
3. Participation in self-health management courses; and
4. Receiving specified investigations.

Scheme Participants who have achieved the various specified targets in a "Participant Programme Year" will be granted additional Government subsidy up to a maximum amount of $150, which will be deducted from the co-payment of the first subsidised medical consultation visit in the following "Participant Programme Year". For details, please refer to the "Incentive - Notice to Patients" provided by Family Doctors to Scheme Participants.

The Government encourages the public to register to a DHC / DHCE which is convenient to them to maintain a long term and stable care. Address of the DHC / DHCE is available on the DHC website.

Healthcare professionals will refer Scheme Participants, with his / her consent, to receive relevant allied health services according to his / her clinical needs and arrangements will be made by the DHC / DHCE as appropriate.

Scheme Participants may attend group classes or activities and receive allied health services under the CDCC Pilot Scheme at his / her respective registered DHC / DHCE or from participating private service providers.

Scheme Participants may attend group classes or activities at DHC / DHCE free of charge.

The "Nurse Clinics" under the CDCC Pilot Scheme are staffed by nurse practitioners who will follow with individual Scheme Participants and coordinate his / her individual health plans and goals based on his / her screening results, the doctor assessment, clinical conditions as well as physical and mental health needs. The nurses also coordinate the multi-disciplinary services under the CDCC Pilot Scheme (including doctor consultation, allied health services, etc.) and arrange the Scheme Participants to participate in appropriate primary healthcare services (e.g. Patient Empowerment Program), with the long-term goal of helping the Scheme Participants to maintain their health, build up a healthy lifestyle, and reduce the risk of developing related complications.

Continuation of care is important to help maintain good health. Members of DHC / DHCE are advised to visit their respective registered DHC / DHCE if they are interested in joining the CDCC Pilot Scheme.

Scheme Participants may contact the staff of their registered DHC / DHCE concerned for arrangement.

Scheme Participants may contact the staff of their registered DHC / DHCE to request to update their information.