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 Centre (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-health 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.

To cater to the healthcare needs of the underprivileged groups, the Government piloted preventive screening and care services for the groups in the General Out-patient Clinics (GOPC) of the Hospital Authority (HA). Comprehensive Social Security Assistance (CSSA) Scheme recipients, Old Age Living Allowance (OALA) recipients aged 75 or above, or holders of valid Certificate for Waiver of Medical Charges who are interested in joining the programme, may be arranged to receive the service at designated HA GOPCs via District Health Centres (DHC) / DHC Expresses, with the same service scope as the CDCC Pilot Scheme. For details, please click here to download the service information.

The CDCC Pilot Scheme comprises a Screening Phase followed by, where applicable, a Treatment Phase based on the diagnosis of each Scheme Participant. In the Screening Phase, Scheme Participants will be provided with screening services including medical consultation and assessment by Family Doctors, investigation services, 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 Scheme Participants, nurse consultation, allied health services and investigation services may also be provided as appropriate.

The Government has expanded the CDCC Pilot Scheme to cover blood lipid testing for eligible individuals, allowing for a more comprehensive approach to the assessment and proper management of cardiovascular disease risk factors, including the "three highs" (high blood pressure, high blood sugar and high cholesterol).

Following the expansion of CDCC Pilot Scheme, all eligible individuals can receive blood lipid testing during the Screening Phase. Through blood lipid testing and management, Scheme Participants can better effectively prevent or lower the risk of cardiovascular disease with lifestyle modification and drug treatment.

To enrol in the CDCC Pilot Scheme as a Scheme Participant, an individual is required to meet the following criteria:

1. 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 is a holder of a valid Certificate of Exemption within the meaning of the Immigration Ordinance (Cap.115);
2. is aged 45 years or above;
3. has no known medical history of diabetes mellitus/ hypertension; and
4. has registered as a DHC/ DHCE member and agrees to share his/ her data in the eHRSS with related service providers.

The eligibility criteria of Scheme Participants remains unchanged following the expansion of CDCC Pilot Scheme. For details of the eligibility criteria for Scheme Participants, please refer to Q4.

The eligibility criteria of Scheme Participants remains unchanged following the expansion of CDCC Pilot Scheme. For details of the eligibility criteria for Scheme Participants, please refer to Q4.

Eligible individuals can enrol in the CDCC Pilot Scheme at DHC/ DHCE or at the clinics of Family Doctors who have joined the CDCC Pilot Scheme and support participant enrolment.

For Comprehensive Social Security Assistance (CSSA) Scheme recipients, Old Age Living Allowance (OALA) recipients aged 75 or above, or holders of valid Certificate for Waiver of Medical Charges who are interested in joining the programme, they may be arranged to receive the service at designated HA GOPCs via District Health Centres (DHC) / DHC Expresses, with the same service scope as the CDCC Pilot Scheme.

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.

With clear documentation of the event, the diagnosis of hypertension made by emergency service doctor does not inhibit the individual from enrolling in the CDCC Pilot Scheme if the referral to emergency service is made by Family Doctor or DHC/ DHCE healthcare staff during enrolment.

The individual can participate in the CDCC Pilot Scheme if her blood sugar level returns to non-diabetic range after baby delivery and fulfils other eligibility criteria for the CDCC Pilot Scheme.

Scheme Participants can select a suitable Family Doctor, according to their own choice, by searching the website of the 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.

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 the 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, Family Doctors 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 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.

Pairing may take place at Family Doctor clinics or DHC/ DHCE. Eligible individuals may enrol in the CDCC Pilot Scheme at the Family Doctor clinics which support participant enrolment and directly pair with the Family Doctor visited, provided that the individual Scheme Participants have not been previously paired with any Family Doctor. Scheme Participants may also visit their registered DHC/ DHCE to carry out the pairing process or apply for a change of their paired Family Doctor. 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, if applicable, treatment by their selected Family Doctor.

Family Doctors are the main providers of primary healthcare services. Apart from treatment and caring of health conditions, Family Doctors 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 Family Doctors, 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 their 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.

Scheme Participants may change the appointment themselves by contacting the Family Doctor's clinics/ investigation services providers directly or contact DHC/ DHCE for assistance.

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.
• Type 4: on the day when Scheme Participants who are eligible for Incentive Mechanism enter their second "Participant Programme Year".

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 who 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.

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.

If Scheme Participants were not diagnosed with diabetes mellitus and/ or hypertension in previous screening(s) conducted prior to the expansion of the CDCC Pilot Scheme to include blood lipid testing, and is currently being followed up by DHC/ DHCE, the Scheme Participants shall be arranged to undergo blood lipid testing together with rescreening of diabetes mellitus and hypertension. The paired Family Doctors of Scheme Participants may also arrange for them to undergo blood lipid testing as clinically indicated.

If Scheme Participants have been diagnosed with prediabetes/ diabetes mellitus and/ or hypertension, and is under the Treatment Phase, the paired Family Doctors of Scheme Participants would refer them for blood lipid testing and any other applicable investigation as part of the laboratory investigations conducted annually or more frequently as clinically indicated.

The number of subsidised medical consultation visits to which Scheme Participants are entitled is subject to 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.

Scheme Participants diagnosed with specified condition of dyslipidaemia without prediabetes, diabetes mellitus or hypertension are entitled to a maximum of 4 subsidised medical consultation visits in the first year and 2 subsidised visits for each subsequent year while those who are diagnosed with specified condition of dyslipidaemia as well as with prediabetes or diabetes mellitus/ hypertension are entitled to a maximum of 4 or 6 subsidised medical consultation visits per year respectively.

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 enters the Treatment Phase 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 and change to the respective management programme. If a Scheme Participant's diagnosis is changed during a "Participant Programme Year", the start date for his/ her current "Participant Programme Year" will be reset from the date on which the new diagnosis is made, the subsidised medical consultation visit quotas of the Scheme Participant is entitled to each "Participant Programme Year" and all subsequent incentive targets will also be reset and re-calculated according to the updated diagnosis.

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 their Family Doctor.

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 Doctor 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 subsidised 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.

The CDCC Pilot Scheme comprises a Screening Phase followed by, where applicable, a Treatment Phase based on the diagnosis of each Scheme Participant. For services rendered within the scope of the CDCC Pilot Scheme, Scheme Participants are only required to pay the co-payment fee.

Having regard to clinical need and subject to mutual agreement between the Family Doctor and Scheme Participant, services outside the scope of the CDCC Pilot Scheme may be provided. Family Doctors should explain to Scheme Participants that such medical services and medications fall outside the scope of the CDCC Pilot Scheme, inform Scheme Participants of any fees arising from such items and obtain agreement and consent from Scheme Participants to receive and pay for those services and/ or medications.

Upon referral by their Family Doctors, Scheme Participants can receive specified investigation services (lab tests, ECGs) at investigation services providers, which are designated by Government. The addresses of the designated investigation services providers and the participants' co-payment fee will be displayed on the website of the CDCC Pilot Scheme for public information.

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

Subject to the mutual agreement between Scheme Participants and Family Doctors, Scheme Participants may pay out-of-pocket to choose to receive investigation services from service providers other than the Government designated investigation services providers. Scheme Participants will have to pay for the full costs of investigation services incurred without Government subsidy.

Scheme Participants are required to make their own appointments and visit designated investigation services providers to receive specified investigation 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 investigation services providers 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 services 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.

Subject to Scheme Participant' clinical needs and the mutual agreement with Family Doctors, Scheme Participants may receive investigation services for items outside the investigation list of the CDCC Pilot Scheme. The fees incurred for Scheme Participants who choose to receive investigation services outside the scope of the CDCC Pilot Scheme will be at their own expense.

After Family Doctor receives the investigation report(s), he/ she will arrange a face-to-face consultation or a phone consultation with Scheme Participant for explanation of the investigation result(s) and the diagnosis as well as selection of an appropriate management plan. On the other hand, Scheme Participants can review the investigation report(s) by themselves via the eHealth App "Investigation". Generally, the investigation report(s) will be viewable in eHealth App in a few weeks after conducting the investigation(s).

If necessary, Scheme Participants may request to receive a copy of the investigation report and pay at their own expense any costs charged by individual Family Doctors.

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

When Family Doctors prescribe any chronic diseases medications listed under the basic tier of the "Specified Drugs" list, no extra charge shall be incurred to Scheme Participants.

When clinically indicated, Family Doctors may also prescribe and charge for any chronic disease medications outside the aforementioned situations, or any treatment involving the use of medications at the clinic (e.g. injection for acute pain relief). The charging for these circumstances shall be made under mutual agreement with Scheme Participants.

The Family Doctors will prescribe the appropriate duration of medications for episodic illnesses according to the Scheme Participant's clinical condition and subject to the Scheme Participant's consent.

When Family Doctors prescribe any episodic illnesses medication listed under the basic tier of the "Specified Drugs" list, or up to 3 days of episodic illnesses medications outside the "Specified Drugs" list, no extra charge shall be incurred to Scheme Participants.

When clinically indicated, Family Doctors may also prescribe and charge for any episodic illnesses medications prescribed outside the aforementioned situations, or any treatment involving the use of medications at the clinic (e.g. injection for acute pain relief). The charging for these circumstances shall be made under mutual agreement with Scheme Participants.

Scheme 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 or less at the first subsidised visit at the Screening Phase, which covers all medical consultation visit(s), 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.

If DHC/ DHCE has contacted Scheme Participant for blood lipid testing at his/ her paired Family Doctor, the Scheme Participant would need to pay a one-off co-payment fee of $120 or less to the Family Doctor, which would include medical consultation visit(s) and related laboratory investigation services. The co-payment amount to be paid by Scheme Participants for the Screening Phase remains the same following the expansion of the CDCC Pilot Scheme to include blood lipid testing.

If a Scheme Participant is under the Treatment Phase, the Scheme Participant only has to pay the co-payment fee to the investigation services provider for each investigation item requested and the Government will provide a partial subsidy to investigation services provider.

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 Doctor for the consultation at that service location, the provision of medications from "Specified Drug List", and/ or provision of medications 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 fees for specified investigation services under the CDCC Pilot Scheme are as follows (for investigation services conducted at the designated investigation services providers of the CDCC Pilot Scheme only):

1. Screening Phase: All the specified investigations services 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 item of investigation services, 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 investigation services from investigation services providers 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 medications from the list of "Specified Drugs" for treating chronic diseases (e.g. anti-diabetic drugs, anti-hypertensive drugs, supplementary drugs to anti-hypertensive and lipid-regulating drugs) and/ or medications for episodic illnesses (e.g. colds, flu, or coughs) for up to three days based on Scheme Participants' screening result and clinical conditions. 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. The Government will, from time to time, review the medications included under the list of “Specified Drugs” to better meet the clinical needs of Scheme Participants.

Apart from the abovementioned prescription of medication, Family Doctors may also prescribe other medications as clinically necessary with the consent of Scheme Participants, and charge the relevant additional costs for which no Government subsidies will be provided.

Based on Scheme Participant's clinical conditions, the paired Family Doctor can, with Scheme Participant's consent, refer him/ her to receive Dedicated Nurse Clinic and Allied Health Services under District Health Network, with corresponding arrangements made through DHC/ DHCE. Scheme Participants will receive partial subsidy from the Government and are required to pay a designated co-payment fee for the service each time.

Scheme Participants may use vouchers from the Elderly Healthcare Voucher Scheme towards payment of co-payment charged by Family Doctors or other service providers that are also enrolled in the Government's Elderly Healthcare Voucher Scheme. If the Scheme Participants are Comprehensive Social Security Assistance (CSSA) Scheme recipients, Old Age Living Allowance (OALA) recipients aged 75 or above, or holders of valid Certificate for Waiver of Medical Charges, they may be arranged to receive the service at designated HA GOPCs via District Health Centres (DHC) / DHC Expresses, with the same service scope as the CDCC Pilot Scheme. The fees for using the preventive care services for eligible persons will be fully or partially waived according to their eligibility within one year from the date of receiving their first service. Participants' eligibility will be verified again after the one-year service period. For details, please click here to download the service information.

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 at the Family Doctors, DHC/ DHCE or nurse clinic/ allied health service providers, as well as via the eHealth App.

The objective of the incentive mechanism is to empower Scheme Participants to manage their own health. Scheme Participants with diabetes mellitus and/ or hypertension, having been admitted into the Treatment Phase are eligible and will be automatically enrolled for incentive calculation starting from their second "Participant Programme Year" onwards.

Each eligible Scheme Participant will have 3 or 4 applicable targets according to his/ her diagnosis and respective management programme.

Starting from his/ her second "Participant Programme Year" onwards, if he/ she has achieved 2 or 3 of the targets (depending on his/ her diagnosis and respective management programme) by the end of that "Participant Programme Year", he/ she can enjoy a reduction of Medical Consultation Co-Payment fee up to the Government's recommended Co-Payment amount (currently $150) for the first subsidised medical consultation visit in the following "Participant Programme Year".


(For definition of eligible Scheme Participants, please refer to Q57.)
(For details on how to achieve each target, please refer to Q60-Q64.)

Depending on his/ her diagnosis and respective management programme, each Scheme Participant will have 3 or 4 applicable targets. The targets may include the followings:

• Conduct home blood pressure monitoring and report the results in the eHealth App at least once per month;
• Attend at least 4 subsidised medical consultation visits with attendance at least once per quarter within the 12-month "Participant Programme Year", out of a maximum of 6 subsidised medical consultation visits within each 12-month "Participant Programme Year";
• Complete the Patient Empowerment Programme including post-assessment as arranged by DHC/ DHCE within the 12-month "Participant Programme Year"; and
• Complete retinal photography examination as arranged by DHC/ DHCE within the 12-month "Participant Programme Year".

(For details of the parameters for achieving targets, please refer to Q58.)
(For details on how to achieve each target, please refer to Q60-Q64.)

To establish the habit of regular self-monitoring of blood pressure, Scheme Participants are advised to measure their blood pressure and blood pressure results in the eHealth App as least once per calendar month.

To achieve this target, the eligible Scheme Participant is required to measure his/ her blood pressure and upload the results in the eHealth App at least once per calendar month within that "Participant Programme Year".

For example, if the Scheme Participant's second "Participant Programme Year" is from 22 November 2024 to 21 November 2025, the first calendar month for measuring and uploading blood pressure result will be 1-30 November 2024, and the last calendar month will be 1-31 October 2025.

Scheme Participants are encouraged to make use of the built-in reminder function in the eHealth App (settings in "Health Management" > "Blood Pressure Buddy" > "Reminder"), to remind themselves to upload blood pressure measurement results in eHealth App.

(For details of the parameters for achieving targets, please refer to Q58.)

To establish the habit of regular self-monitoring of blood pressure, only blood pressure that is measured and uploaded to eHealth App within the same calendar month will be counted in incentive calculation, all late entries of blood pressure records (i.e. not uploaded within the same calendar month of blood pressure measurement) will not be counted.

If Scheme Participant cannot achieve this target, he/ she can pursue the other targets that are applicable to his/ her diagnosis and respective management programme in order to be entitled to incentive.

(For details of the parameters for achieving targets, please refer to Q58.)

Scheme Participants are encouraged to consult their paired Family Doctors regularly for managing their health conditions, and to plan ahead how to effectively use their subsidised medical consultation visits quota across the "Participant Programme Year" in order to meet the parameter.

Each Scheme Participant diagnosed with diabetes mellitus and/ or hypertension is entitled to a maximum of 6 subsidised medical consultation visits in each "Participant Programme Year".

To meet this parameter, Scheme Participants need to attend at least 4 subsidised medical consultation visits with attendance at least once per quarter* (i.e. at least once in every three months) within the "Participant Programme Year". Only subsidised medical consultation visits will be counted towards incentive calculation.

*Note: "Quarter" refers to each 3-month period of "Participant Programme Year": the day when a Scheme Participant receives a new diagnosis and change to the respective management programme from his/ her Family Doctor, until at the end of the day before corresponding date in the "Participant Programme Year" quarter end (i.e. end of 3^rd month) (where there is no corresponding date in the 3^rd month, at the end of the day before last day of the 3^rd month.

For example: When a Scheme Participants starts his/ her 2^nd "Participant Programme Year" on 31 January 2025, his/ her 1^st quarter will be from 31 January 2025 to 29 April 2025. If necessary, His/ her 2^nd "Participant Programme Year" will be reset on 1 May 2025, the date on which he/ she being assigned a respective management programme by Family Doctor based on his/ her latest diagnosis, his/ her 1^st quarter will also be reset from 1 May 2025 to 31 July 2025.

(For details of the parameters for achieving targets, please refer to Q58.)

To encourage Scheme Participants' self-management of their own health condition, DHC/ DHCE will arrange for Scheme Participants to complete the Patient Empowerment Progamme. Incentive calculation will be based on the completion date of the Patient Empowerment Programme recorded in the CDCC IT Platform in the second or subsequent "Participant Programme Year".

(For details of the parameters for achieving targets, please refer to Q58.)

DHC/ DHCE will arrange retinal photography examination for Scheme Participants who are diagnosed with diabetes mellitus to monitor any ocular complication of diabetes mellitus. Incentive calculation will be based on the date of assessment completion by Optometrist recorded in the CDCC IT Platform.

(For details of the parameters for achieving targets, please refer to Q58.)

Eligible Scheme Participants who have achieved the required number of incentive targets within the "Participant Programme Year" enjoy a reduction of co-payment fee up to the Government recommended co-payment amount (currently at $150) for the first subsidised medical consultation visit in the following "Participant Programme Year". If the co-payment declared by his/ her paired Family Doctor for the subsidised medical consultation is the same or lower than the Government recommended co-payment amount, then no co-payment is required for that subsidised medical consultation visit. If the co-payment declared by his/ her paired Family Doctor is higher than the Government recommended co-payment amount, then co-payment after deducting the Government recommended co-payment amount of $150 is required for that subsidised medical consultation visit.

(For details of the parameters for achieving targets, please refer to Q58.)

Where a Scheme Participant's clinical condition changes during the Treatment Phase, the Family Doctor may make a new diagnosis and change to the respective management programme. If a Scheme Participant's diagnosis is changed and management plan is changed during a "Participant Programme Year", the start date for his/ her current "Participant Programme Year" will be reset from the date on which the new diagnosis and management programme are adopted, and the subsidised medical consultation visit quotas of the Scheme Participant being entitled to each "Participant Programme Year" and all subsequent targets will also be reset and re-calculated according to the updated diagnosis.

(For details of the parameters for achieving targets, please refer to Q58.)

Should the newly paired Family Doctor continue to follow up the Scheme Participant with the current management programme, the calculation of incentive will not be affected. However, if the newly paired Family Doctor decides to make a new diagnosis based on the change of the Scheme Participant's clinical condition, then the calculation of incentive will be affected. For details, please refer to Q66.

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 Dedicated Nurse Clinic and Allied Health Services under District Health Network 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 Dedicated Nurse Clinic and Allied Health Services under District Health Network under the CDCC Pilot Scheme at his/ her respective registered DHC/ DHCE or from designated service providers.

If Scheme Participants would like to change their chosen service providers of Dedicated Nurse Clinic and Allied Health Services under District Health Network, they may contact their DHC/ DHCE for arrangement. The request will be handled on a case-by-case basis.

If Scheme Participants have used up all of their quotas for subsidised visits of Dedicated Nurse Clinic and Allied Health Services under District Health Network within 12 months, they may seek services from the same or other nurse clinic/ allied health service providers at their own expense, but will not receive Government subsidy.

Scheme Participants are recommended to maintain close communication with their Family Doctors and DHC/DHCE to ensure proper management and monitoring of their chronic illnesses. In addition, Scheme Participants may take note of their remaining quota of subsidised visits so that they can receive appropriate medical support when necessary.

Scheme Participants may choose to use nurse clinic/ allied health services other than the Government designated service providers, however Scheme Participants have to pay out-of-pocket for the full costs incurred without Government subsidy.

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

The Dedicated Nurse Clinics under District Health Network of 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 Programme), 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 or at the clinics of Family Doctors who have joined the CDCC Pilot Scheme and support participant enrolment 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.