1. Why do you need to issue the "Guiding Opinions on Improving the Long-term Mechanism of Basic Medical Insurance"?
Since the 18th National Congress of the Communist Party of China, the participation rate of basic medical insurance in mainland China has remained stable at 95%, the quality of insurance participation has continued to improve, the insurance structure has been more optimized, and the results of national insurance participation have been further consolidated. Among them, the resident medical insurance is funded by individual contributions and government subsidies, covering more than 900 million insured people, becoming a model for developing countries to solve the problem of medical treatment and medical insurance, and has been highly praised by the international community. The vast majority of the people have been able to participate in the insurance continuously, which has made an important contribution to the sustainable operation of the system.
However, in the process of operating the system, there are still some problems. First, there are still blockages in the insurance in the place of permanent residence. In the context of deepening urbanization, the population flows frequently across regions, and the statistics of the "Seven Censuses" show that the floating population in the country has reached 375 million, of which the inter-provincial floating population is about 125 million. The "Guiding Opinions" actively respond to the demands of the masses and make targeted arrangements for convenient insurance participation in the nearest area.
Second, the financing treatment policy still needs to be improved. Due to the continuous rise in medical expenses and the continuous increase in the individual payment standards of residents' medical insurance, the insured people hope to improve the financing mechanism of residents' medical insurance; Some people lack the sense of mutual aid, and are reluctant to participate in insurance when they are healthy, selectively participate in insurance when they are sick, or young and middle-aged people do not participate in insurance, and only participate in insurance for the elderly and children who spend more money on medical treatment. In addition, the continuous insurance people are eager to get certain incentives, and those who are not sick every year also hope to get certain policy preferences. The "Guiding Opinions" actively respond to the reasonable demands of the masses, improve the financing and treatment policies in a targeted manner, and better safeguard the interests of all insured.
Third, the insurance work mechanism still needs to be improved. With the full completion and use of the national unified medical insurance information platform, the governance of duplicate insurance has been further promoted, and the quality of national insurance data has continued to improve. In view of the problems existing in work coordination, the "Guiding Opinions" strive to strengthen the data sharing mechanism, departmental coordination mechanism, insurance payment service, publicity and mobilization mechanism, and provide solid basic support for achieving more accurate expansion.
2. What are the contents of the "Guiding Opinions on Improving the Long-term Mechanism for Basic Medical Insurance"? What are the features?
The "Guiding Opinions" adhere to the people-centered development philosophy, strengthen departmental linkage, accelerate the completion of shortcomings, classify and implement precise policies, optimize the insurance structure, improve the quality of insurance, improve people's livelihood and well-being in high-quality development, and effectively solve the worries of the masses in seeking medical treatment. Main features: First, focus on the key points. In terms of the insurance system, the focus is on improving the medical insurance for urban and rural residents, innovating and proposing a series of effective and powerful working mechanisms, and relaxing the household registration restrictions for insurance participation. The second is to focus on long-term results. Institutional arrangements have been made for information sharing between departments, coordinating to promote the expansion of insurance coverage, and controlling the unreasonable rise of medical expenses. The third is to pay attention to incentives. There are incentives for continuous insurance, and there are rewards for those who do not see a doctor and do not spend the medical insurance fund, which provides a repair mechanism for the waiting period for change of treatment after the insurance is terminated, expands the scope of mutual aid in the personal account of employees' medical insurance, and encourages qualified areas to strengthen outpatient protection.
The main contents are: First, improve the incentive and restraint mechanism. It is proposed to increase the maximum payment limit of serious illness insurance for those who are continuously insured by resident medical insurance and those who are not reimbursed by the fund, and the waiting period for the treatment of those who have not participated in the insurance or interrupted the payment of the payment during the centralized insurance period of the resident medical insurance has been clarified, and it provides a way to repair the waiting period for changing the treatment, which is an important improvement of the resident medical insurance system. The second is to improve the precise expansion mechanism. Promote the construction of a "one person, one file" national insurance database across the country to help all localities accurately expand their insurance coverage. The third is to improve the publicity and mobilization mechanism. Widely mobilize all units, innovate forms, enrich carriers, and create a good atmosphere for insurance participation. Fourth, strengthen the departmental coordination mechanism. Further clarify the responsibilities of relevant government departments in the work of insurance participation, and strengthen the linkage of work. Fifth, improve the information sharing mechanism. Relying on big data and government service data platforms to promote information sharing, all departments work together to promote the expansion of insurance coverage. Sixth, establish an organizational leadership mechanism. To uphold and strengthen the party's leadership throughout all aspects of insurance, all relevant departments should be in accordance with the division of responsibilities and strengthen the linkage of the system. Seventh, improve the fund guarantee mechanism. All regions shall implement funding guarantee policies in accordance with regulations. Qualified areas can give incentives according to the completion of the insurance plan and the quality of the insurance to fully mobilize the enthusiasm of the grassroots.
3. After the issuance of the "Guiding Opinions on Improving the Long-term Mechanism of Basic Medical Insurance", what are the major advantages of participating in basic medical insurance?
In response to the problem, the "Guiding Opinions" clarified the mechanism of strengthening the participation in the insurance in the place of permanent residence, improving the incentive and constraint, improving the financing policy, improving the precise expansion of the coverage, strengthening the publicity and mobilization, strengthening the linkage of departments, and ensuring financial support. It is proposed that megacities should abolish the household registration restrictions on flexible employees, migrant workers, and new forms of employment to participate in employee medical insurance. "Expansion" means expanding the scope of mutual aid in the personal account of employees' medical insurance, from family members to close relatives. "Mention", that is, the continuous participation in the resident medical insurance personnel to increase the maximum payment limit of serious illness insurance. "Award", that is, to establish a reward mechanism for zero reimbursement personnel of the resident medical insurance fund, and increase the maximum payment limit of serious illness insurance in the following year. "Convenience", that is, it is more convenient for the insured to enjoy medical services nearby, promote more village clinics to be included in the medical insurance designated points and direct settlement, and promote the centralized procurement of drugs at the grassroots level.
4. Why does the state encourage residents to participate in basic medical insurance? What are the benefits of participating in basic health insurance?
At present, the mainland has basically achieved universal medical insurance, and the world's largest basic medical security network has been built. The state encourages residents to participate in basic medical insurance in order to safeguard the health rights and interests of all residents. The basic medical insurance provides the masses with basic, reliable and safe medical security regardless of age and medical history, ensuring that the masses can seek medical treatment in a timely manner, the medical expenses can be shared, and they can also get assistance when they are seriously ill.
There are many benefits of medical insurance for residents in the mainland, which are embodied in: first, the cost is low, the payment standard for medical insurance for mainland residents in 2023 is not less than 380 yuan, with an average of more than 1 yuan per day and more than 30 yuan per month, so that the masses can obtain protection for their health at low cost; Second, the subsidy is wide, all the insured people can enjoy the state financial subsidies, insurance is to pay a small head (380 yuan), the state to make up the big head (640 yuan), the annual financial subsidy reaches more than 600 billion yuan, for the people who are in difficulty, the state subsidizes more than 80 million people every year; In 2023, the average hospitalization rate of those participating in resident medical insurance will be 20.7%, while the average hospitalization cost of tertiary hospitals, secondary hospitals, and first-class hospitals in 2023 will be 12,765 yuan, 6,205 yuan, and 2,943 yuan respectively, and the reimbursement amount for third-level hospitals, second-level hospitals, and first-level hospitals will be 6,648 yuan, 3,944 yuan, and 2,172 yuan respectively, and the average reimbursement amount for residents will be 4,437 yuan. The sum of the 10-year resident medical insurance expenses is less than the reimbursement of a hospitalization expense; Fourth, the comprehensive security has advantages, after participating in the resident medical insurance, not only enjoy the basic medical insurance outpatient reimbursement, outpatient chronic disease reimbursement, hospitalization reimbursement, but also enjoy serious illness insurance, many local residents pay more than 15,000 yuan for medical treatment, medical insurance will automatically start the cost sharing of serious illness insurance, because of serious illness hospitalization does not need to apply for automatic reimbursement, so many residents have benefits but do not feel, difficult people can also enjoy medical assistance; Fifth, the medical security service is good, except for special circumstances, the insured no longer need to take a bunch of bills back and forth for manual reimbursement, in the medical institutions can enjoy the convenience of direct settlement, can be remote medical treatment, only need to be online or offline in advance, you can seek medical treatment in other places, you can participate in insurance in other places, more and more places to relax the restrictions on household registration, you can participate in resident medical insurance in the permanent place of residence with a residence permit.
5. Is it correct for some young adults to think that they are in good health and do not need to participate in basic medical insurance?
Basic medical insurance is a kind of social insurance, which first has the attributes of insurance and is used to prevent risks. Although some young adults feel that they are in good health, the occurrence of diseases is often uncertain, and young adults are often the pillars of the family economy, and if they fall due to illness, the family will face great difficulties. According to the data released by the Health Statistical Yearbook, the hospitalization rate of 25-34 year olds in 2018 was 11.1%, about 1 in 9 people were hospitalized within a year, and the average hospitalization cost was more than 7,000 yuan, not to mention serious illness, once sick will bring a heavy economic burden to individuals and families, basic medical insurance can prevent risks and reduce economic pressure. In addition, the basic medical insurance also has the attributes of socialization, the medical insurance system is a manifestation of social mutual assistance, although the current healthy masses temporarily spend less, but can help the people in need, when they are old and sick, they also need social mutual aid, we participate in the operation of the medical insurance system, share the risk, today I am for everyone, tomorrow everyone is for me, to ensure the health of the whole society. Therefore, regardless of whether you are healthy or not, it is wise and necessary to enroll in medical insurance on time.
6. What are the new requirements for insurance in the place of habitual residence and place of employment?
In terms of children's participation in insurance, although the vast majority of regions have now relaxed the restrictions on household registration in other places, and primary and secondary school students and preschool children can participate in the insurance in their usual places of residence, there are still problems such as the poor insurance process, and there are still a very small number of megacities that have not released the household registration restrictions for children to participate in insurance, so the document proposes to promote the participation of primary and secondary school students and preschool children with foreign household registration in their places of permanent residence, so as to ensure that mainland children can participate in insurance in a timely and convenient manner and enjoy medical insurance treatment nearby.
In terms of the participation of flexibly employed persons, the document proposes that the participation of flexibly employed persons in the employee medical insurance work at the place of employment is to better protect the rights and interests of flexibly employed persons to participate in the employee medical insurance in the nearest place by implementing the policy of holding a residence permit to participate in the insurance policy. Under the current policy, flexible employees can participate in employee medical insurance as well as resident medical insurance.
7. Everyone is very concerned about whether the money in the personal account of the employee's medical insurance can be used by the family, what are the new regulations on the family mutual aid of the personal account of the employee's medical insurance after the promulgation of the "Guiding Opinions"?
The money in the personal account of the employee's medical insurance can be used by the family, "the family can participate in the insurance, and help the elderly to help the young". The promulgation of this document not only affirms the practice of mutual aid in the personal account of employees' medical insurance, but also further optimizes the original policy of mutual aid in personal accounts. First, the scope of mutual aid has been further expanded to include close relatives. The document stipulates that the personal account of the employee's medical insurance can be used for the payment of the resident medical insurance by his close relatives. According to the provisions of the Civil Code, close relatives include spouses, parents, children, siblings, grandparents, grandchildren, and grandchildren. Not only that, but if these close relatives are insured, they can also use the funds in the personal account of the associated employee medical insurance insuree when reimbursing medical expenses. The second is to further expand the mutual aid area, and by the end of this year, we will strive to realize the mutual aid of personal accounts in all provinces and provinces, and will accelerate the exploration and promotion of cross-provincial personal account mutual aid next year. It should be noted that the money in the personal account of the employee's medical insurance can be shared, but the card (code) cannot be shared.
8. What are the policies of the "Guiding Opinions" for people in need?
The "Guiding Opinions" attach great importance to the assistance of the people in difficulty, and propose that the people in difficulty such as those in extreme poverty, those who are eligible for the minimum livelihood guarantee, and those who meet the requirements for monitoring the prevention of returning to poverty will be given classified subsidies in accordance with relevant regulations. In the past three years, the number of people insured by the national medical assistance subsidy has been stable at more than 80 million, and if the number of insured people funded by other departments is added, there are nearly 100 million people who have enjoyed all kinds of insurance subsidies. The state has effectively guaranteed the participation of people in difficulty through the policy of supporting medical assistance.
9. How does the "Guiding Opinions" strengthen the outpatient protection of residents who are insured by medical insurance?
The basic medical insurance in mainland China has generally established outpatient co-ordination, including two aspects: one is outpatient chronic disease protection, such as common hypertension, diabetes and tumor outpatient radiotherapy, chemotherapy, dialysis, etc., the insured only need to follow the regulations of the insurance place to carry out outpatient chronic disease qualification certification can be enjoyed, reimbursement generally refers to hospitalization; The second is the general outpatient co-ordination, the general outpatient co-ordination guarantees the outpatient medical expenses according to the cost rather than the type of disease, and the resident medical insurance mainly relies on the primary medical institutions to carry out services, and the reimbursement ratio starts from 50%. In 2023, 340 million people will be treated for outpatient chronic diseases and 2.08 billion people will be treated for outpatient and emergency treatment. After the policy is promulgated, we encourage qualified areas to use a certain proportion of the new annual financing of residents' medical insurance to strengthen outpatient protection, improve residents' outpatient treatment, and improve the public's sense of access to medical insurance, so as to further realize the "unique guarantee of slow door, and more peace of mind for outpatient treatment".
10. Why should we set up an incentive policy for continuous participation in residents' medical insurance?
Compared with employee medical insurance, resident medical insurance is not compulsory to participate in insurance, and the incentive mechanism has been relatively lacking since its establishment. There is a lack of incentive policies for the masses who are continuously insured, have not been sick, and have not been reimbursed by medical insurance. The document proposes to establish an incentive policy for residents' medical insurance, implement classified policies, encourage self-health management of insured personnel, and encourage continuous insurance. It should be noted that the continuous insurance incentive and the zero reimbursement incentive of the fund can reward at least 1,000 yuan per year for the maximum payment limit of critical illness insurance, and the cumulative increase can reach at least 2,000 yuan per year. It can be said that "there are rewards for continuous insurance, more than 2,000 awards a year, don't miss the centralized insurance, miss the reward, and then the insurance can not be renewed, and the arrears are still waiting." ”
11. The zero reimbursement incentive of the fund, is it that the medical insurance fund has not been used in the current year or has it not been used for serious illness reimbursement?
The guiding opinions put forward that the fund has zero reimbursement incentives, and the rewards are for the residents who have not used the medical insurance fund in the current year, that is, they have not used the medical insurance fund for reimbursement, and all medical expenses, including outpatient and hospitalization, can enjoy the reimbursement incentive in the next year. The zero reimbursement incentive of the fund can enjoy a critical illness insurance reward amount of not less than 1,000 yuan per year, and all localities can appropriately increase the reward amount according to local conditions.
12. Why is the continuous insurance incentive and the zero reimbursement incentive rewarded by the fund the maximum payment limit of critical illness insurance?
Because for the insured people, serious illness is the most likely to lead to poverty due to illness and return to poverty due to illness. As long as you continue to participate in the insurance and the fund has zero reimbursement, you can enjoy the new amount of critical illness insurance after the increase every year, which is equivalent to an additional amount of more than 2,000 yuan of critical illness insurance protection every year. After the reward amount of critical illness insurance is used, the zero reimbursement incentive amount will be cleared and recalculated.
13. When the reward amount is cleared, is it for all the reward amounts?
After using the incentive amount of critical illness insurance, only the zero reimbursement incentive amount is cleared, and it is not for continuous insurance incentive, as long as you have continuously participated in the insurance and participated in the resident medical insurance for 4 years, you can always enjoy the incentive of continuous insurance. If the insurance is interrupted, the number of years accumulated in the previous continuous insurance will be automatically cleared, and the number of years will need to be recalculated when participating in the resident medical insurance. The reward amount accumulated in the previous period will continue to be retained.
According to the spirit of the Guiding Opinions, if a serious illness occurs in the current year and the reward amount is reimbursed and used, the zero reimbursement reward amount accumulated in the previous period will be cleared, and the zero reimbursement reward amount will be calculated again in the second year.
14. Why is there a waiting period for those who pay and stop paying during the non-centralized collection period of resident medical insurance?
The medical insurance system sets up a waiting period for treatment to meet the needs of the mainland's national conditions. Unlike many countries, which adopt compulsory participation in social insurance, mainland residents' medical insurance is not currently compulsory, and the setting of a waiting period is actually a protection for all insured persons. If the necessary protective measures are not taken, there may be some people who selectively participate in insurance and pay, do not participate in insurance and do not pay when they are healthy, and do not contribute when they are healthy, and participate in insurance and pay to enjoy the contributions of others when they are sick, which is extremely unfair to other insured people. If you feel sick and then participate in the insurance, you will be reimbursed an average of 4,437 yuan with a payment of a few hundred yuan, which means that one person will take advantage of more than 10 other people in one hospitalization, which will seriously damage the rights and interests of all the insured. Therefore, focusing on the long-term sustainability of the system, it is necessary to set a waiting period for those who have stopped paying and those who have not enrolled in insurance on time, and the medical expenses incurred during the waiting period will not be reimbursed by the medical insurance. Moreover, this provision has a broad practical basis, and most of the medical insurance co-ordination areas have set up a waiting period for those who have stopped paying and those who have not paid during the centralized insurance period.
15. Why is it not allowed to re-enroll in insurance after the insurance is terminated to restore the waiting period for fixed benefits?
If the waiting period for fixed benefits can be repaired, it is equivalent to allowing the payment after illness, and you can enjoy the treatment immediately after payment, which will increase the risk of selective insurance, so that the people who choose to participate in the insurance can use the information advantage of their own health status to enjoy the contribution of others to themselves, which is very unfair to the vast majority of people who comply with the regulations and participate in the insurance normally and continuously. If it is allowed to continue to buy this lottery ticket after the lottery is drawn, turning an uncertain thing into a deterministic event, then the first buyers have become the givers, and then the buyers are all beneficiaries, obviously this model is impossible to operate. If everyone buys lottery tickets after the lottery is drawn, the winning amount is bound to be significantly lower than the investment amount, which is an ironclad loss.
If there is no waiting period for treatment, more and more people will choose to participate in the insurance after illness, spend hundreds of yuan, and reimburse tens of thousands or even hundreds of thousands of yuan of medical insurance funds, which will ultimately damage the interests of all the insured.
16. After the introduction of the policy of waiting period for residents' medical insurance benefits, will the people who have not participated in the insurance before 2025 be affected?
It will not be affected, the treatment waiting period policy will be implemented from the 2024 payment to participate in the 2025 basic medical insurance, even if you have not participated in the insurance before, as long as you participate in the resident medical insurance during the centralized collection period every year from the end of 2024, there will be no waiting period for treatment. If you have been insured normally, but you have not participated in the insurance payment during the centralized collection period at the end of 2024, there will be a waiting period for treatment in 2025. Therefore, I hope that everyone will still participate in the insurance on time and according to the regulations.
17. How to determine the payment standard that the masses are concerned about?
Improving the financing policy of residents' medical insurance is an important task of the reform and development of medical insurance, the National Health Insurance Administration and the Ministry of Finance are stepping up the study of relevant policies, and we will issue special documents in a timely manner after the policy is determined. The direction of improving the financing mechanism is determined, that is, to promote the linkage of residents' medical insurance contributions with the level of social and economic development and the per capita disposable income of residents, and to maintain a reasonable proportion structure of financial subsidies and individual contributions.
It should be noted that since the establishment of the resident medical insurance system, financial subsidies have always been an important source of funds, and last year, the subsidy funds for residents' medical insurance at all levels reached 600 billion yuan, and the per capita financial subsidy standard reached 640 yuan. As the country's financial resources increase, the subsidy standard will be increased. It can be said that "individuals have one piece a day, and enjoy six hundred and seven financial institutions", and resident medical insurance is a very cost-effective system for individuals.
18. How will the state promote insurance publicity?
According to the "Guiding Opinions", in September every year, we will carry out centralized publicity activities for basic medical insurance participation, widely mobilize medical insurance departments at all levels, designated medical institutions, etc., innovate publicity forms, tell good stories about medical insurance, and do a good job in insurance publicity and mobilization. At the same time, we actively rely on social forces to cultivate a group of enthusiastic speakers and ambassadors who understand medical insurance.
19. What are the new measures to promote the participation of newborns in insurance?
The "Guiding Opinions" put forward that medical insurance departments at all levels will cooperate with the public security, health, and human resources and social security departments to promote the implementation of birth medical certificates, household registration, medical insurance participation and other "birth events", so that newborns can be born to apply for medical insurance participation, simplifying the process, and many places have realized the local medical insurance participation in hospitals.
20. How to improve the medical experience and increase the sense of access to insurance?
Improving the medical experience of the insured people is an important support for improving the sense of access to insurance. The "Guiding Opinions" have made a series of arrangements to upgrade the "two systems" and strengthen the "one management".
The first is to improve the medical and health service system. At present, the service network of tertiary medical institutions is generally relatively sound, and the focus is on improving the service capacity of the grassroots level. In the next step, it is necessary to include the voluntary application and eligible village clinics into the scope of medical insurance settlement in a timely manner, and at the same time promote the reasonable allocation of drugs in village clinics, so that the masses can conveniently seek medical treatment and purchase drugs at their doorsteps.
The second is to improve the medical insurance management service system. Improve the five-level handling service system at the provincial, municipal, county, township (street) and village (community) levels, and vigorously promote the efficient completion of one thing in the field of medical insurance. Actively promote online services such as medical insurance codes and mobile payments. It is necessary to enrich the way of insurance payment, expand the inquiry channels for individual payment and medical expenses included in the settlement of medical insurance, and provide diversified and convenient online and offline insurance payment and other services for the insured. Encourage the establishment of medical insurance service outlets in commercial banks and commercial insurance institutions to extend the medical insurance public service network.
The third is to strengthen the management of designated medical institutions, reasonably control the growth rate of medical expenses, and reduce the burden of the masses in seeking medical treatment. Intensify efforts to crack down on fraud and insurance fraud, help the masses manage and make good use of the medical insurance fund, so that the medical insurance fund can really be used by the masses to see a doctor and buy medicine.
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Source: National Health Insurance Administration
First instance: Shen Shigang
Second trial: Zheng Tianjun
Third trial: Chen Anbang