Guiding Opinions of the General Office of the State Council on Improving the Long-term Mechanism for Participation in Basic Medical Insurance

Guiding Opinions of the General Office of the State Council on Improving the Long-term Mechanism for Participation in Basic Medical Insurance

Guo Ban Fa [2024] No. 38

The people's governments of all provinces, autonomous regions, and municipalities directly under the Central Government, and all ministries and commissions of the State Council, and all agencies directly under the State Council:

In order to actively respond to the aging of the population and the diversification of employment forms, adapt to the changes in population flow and insurance needs, continue to consolidate and expand the achievements of national insurance, and consolidate the foundation of the basic medical insurance system, with the consent of the State Council, the following opinions are hereby put forward on improving the long-term mechanism of basic medical insurance.

1. General requirements

Guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 20th National Congress of the Communist Party of China and the 2nd and 3rd Plenary Sessions of the 20th CPC Central Committee, completely, accurately and comprehensively implement the new development concept, accelerate the construction of a new development pattern, strive to promote high-quality development, adhere to the people-centered development philosophy, thoroughly implement the national insurance plan, strengthen departmental linkage, accelerate the completion of shortcomings, implement classified and precise policies, optimize the insurance structure, improve the quality of insurance, safeguard the rights and interests of the masses in accordance with the law, and improve people's livelihood and well-being in high-quality development. Earnestly solve the worries of the masses about seeking medical treatment.

-- Clarify the responsibilities of all parties and implement insurance participation in accordance with the law. Implement the rights and obligations of citizens to participate in basic medical insurance in accordance with the law, guide citizens to enhance their awareness of being the first person responsible for their own health and actively participate in insurance, promote employers to fulfill their payment obligations in accordance with the law, consolidate the responsibilities of governments and departments at all levels, and form a pattern of co-construction, co-governance and sharing led by the government, coordinated by departments, mobilized at the grassroots level, fulfilled by units, and fulfilled by individuals.

-- Improving policies and measures to encourage continuous participation in insurance. Standardize and unify insurance management services, improve incentives and constraints, and categorical subsidies for insurance participation, effectively mobilize the enthusiasm of the grassroots, improve the long-term mechanism of insurance participation, and form a good insurance situation.

——Improve the quality of service and strengthen the feeling of insurance. Comprehensive measures have been taken from various aspects such as insurance registration, declaration and payment, management services, mobilization and publicity, performance appraisal, and treatment guarantees, and we will continue to deepen reforms, improve the convenience and accessibility of medical insurance services, and the service standardization of designated medical institutions, and continuously improve the satisfaction and sense of gain of the insured people.

2. Improve policies and measures

(1) Improve the insurance policy. Further relax and relax the household registration restrictions on participating in basic medical insurance in the place of permanent residence and employment. Megacities and megacities should earnestly implement the policy of holding residence permits to participate in insurance, and promote primary and secondary school students and preschool children with household registration in other places of residence to participate in resident medical insurance. Megacities should abolish the household registration restrictions on flexible employment, migrant workers, and new forms of employment to participate in basic medical insurance at the place of employment, and do a good job in participating in employee medical insurance at the place of employment. Encourage college students to participate in resident medical insurance in their place of residence, implement relevant policies for insurance participation, and do a good job in expanding the coverage of college students' participation in resident medical insurance.

(2) Improve fund-raising policies. Promote the linkage of residents' medical insurance contributions with the level of economic and social development and the per capita disposable income of residents, and maintain a reasonable proportion structure of financial subsidies and individual contributions. Persons in extreme poverty, recipients of minimum livelihood guarantees, and eligible targets for monitoring the prevention of returning to poverty are to be given categorical subsidies in accordance with relevant provisions. Implement the policy of paying the medical insurance (including maternity insurance) premiums for employees who receive unemployment insurance money from the unemployment insurance fund, and ensure that they enjoy the same medical insurance and maternity insurance benefits as insured employees. Support the personal account of employee medical insurance to pay for the personal payment of the close relatives of the insured personnel to participate in the resident medical insurance and the personal medical expenses incurred by the close relatives who have been insured in the designated medical institutions for medical treatment and drug purchase. Adapt to the diversification of employment forms, and study and improve the insurance payment methods for flexibly employed persons.

(3) Improve treatment policies. On the basis of consolidating the level of hospitalization treatment, the level of outpatient protection of basic medical insurance can be steadily improved according to the level of economic and social development and the affordability of the medical insurance fund. Qualified areas can use a certain proportion of the annual new financing of residents' medical insurance to strengthen outpatient protection, and tilt towards grassroots medical institutions to guide the masses to seek medical treatment at the grassroots level.

Establish an incentive mechanism for serious illness insurance benefits for those who are continuously insured by residents' medical insurance and those who have zero reimbursement. From 2025 onwards, the maximum payment limit of critical illness insurance can be reduced for those who have re-enrolled in insurance; For those who have participated in the resident medical insurance for 4 consecutive years, the maximum payment limit of the critical illness insurance can be appropriately increased for each consecutive year after that. For those who have zero reimbursement from the fund in the current year, the maximum payment limit of critical illness insurance can be increased in the following year. In principle, the limit of continuous insurance participation and zero reimbursement incentive shall not be less than 1,000 yuan each time, and the cumulative total increase shall not exceed 20% of the original cap line of critical illness insurance in the overall planning area. After the resident is reimbursed for serious illness and the reward amount is used, the zero reimbursement incentive amount accumulated in the previous period will be cleared. If the insurance is re-insured after the insurance is terminated, the number of consecutive years of insurance shall be recalculated. The specific policy standards shall be determined by each province according to the actual situation such as the affordability of the medical insurance fund.

From 2025 onwards, except for special groups such as newborns, for those who have not participated in the insurance or have not been continuously insured during the centralized enrollment period of resident medical insurance, a waiting period of 3 months will be set for fixed treatment after enrollment; Among them, if the insurance is not continuously insured, for every additional 1 year, in principle, the waiting period for change of treatment will be increased by 1 month on the basis of the fixed treatment waiting period, and the insured person can repair the waiting period for change of treatment by paying premiums, and the waiting period for change of treatment can be reduced by 1 month for every additional year, and if the payment is interrupted for 4 years or more, the sum of the waiting period for fixed treatment and the waiting period for change of treatment after repair shall not be less than 6 months in principle. The payment shall refer to the individual payment standard of the insured place in the current year. The specific standard of the waiting period is determined by each province according to its own situation.

3. Optimize management services

(4) Accurately grasp the insurance situation. The National Health Insurance Administration has established a national insurance database to achieve "one person, one file" management, and regularly pushes the information of uninsured persons to the provincial medical insurance department. Provincial-level medical insurance departments should timely grasp the information of the permanent resident population, registered population, insured persons, and uninsured persons in the region, and regularly update the national insurance database. Give full play to the advantages of grid management at the grassroots level in various localities, and strengthen cooperation between the place of household registration and the place of permanent residence for those who should be insured and uninsured who are separated from households, and jointly implement the responsibility of expanding the scope of insurance. Continue to do a good job in the governance of duplicate insurance participation, optimize the registration of new insurance participation, and improve the quality of insurance participation.

(5) Coordinate the mobilization of insurance participation. In September every year, we carry out centralized publicity activities for universal participation in basic medical insurance. Widely mobilize medical insurance departments at all levels, handling service agencies, designated medical institutions, relevant government departments, enterprises and institutions to carry out publicity and mobilization, give full play to the role of traditional media and new media, innovate publicity forms, enrich publicity carriers, tell good medical insurance stories, respond to social concerns, let the masses fully understand the government's investment and the positive role of basic medical insurance in resisting disease risks and reducing the burden of medical expenses, popularize the concept of mutual assistance, shared responsibility, and joint construction and sharing of medical insurance, and create a good atmosphere for participating in insurance. Encourage areas with the capacity to explore the use of families as a unit to organize and mobilize to participate in insurance. Actively rely on social forces, give play to the role of volunteer speakers, image ambassadors, etc., and cultivate a team of insurance publicity and mobilization who understand medical insurance, have enthusiasm, and are willing to contribute.

(6) Vigorously improve service capabilities. Promote the implementation of the integrated handling of "one thing at birth" such as birth medical certificates, household registration, medical insurance participation, and social security card applications, simplify procedures, optimize processes, and promote guardians to participate in insurance for newborns in the year of birth. The medical insurance department and the tax department should enrich the payment methods for insurance, expand the inquiry channels for individual payment and medical expenses included in the medical insurance settlement, and provide diversified and convenient online and offline insurance payment services for the insured. It will take three years to gradually unify the centralized collection period of national residents' medical insurance. Give full play to the role of commercial banks, commercial insurance institutions and other outlets, and extend medical insurance public services. Complete and improve mechanisms for authorizing inquiries and uses of personal information, and help insured persons obtain convenient services in areas such as purchasing commercial health insurance.

(7) Effectively improve the medical experience. Strengthen the management of designated medical institutions and enhance the accessibility of medical services. Actively create conditions to include voluntary applications and eligible village clinics into the scope of medical insurance settlement, and promote real-time settlement. Promote the rational allocation of national centralized procurement of drugs in village clinics, facilitate rural residents to seek medical treatment nearby, and better promote hierarchical diagnosis and treatment. Strengthen the supervision of designated medical institutions, increase the rectification of fraud and insurance fraud and other violations of laws and regulations, make good use of medical insurance funds, and reduce the burden of medical expenses on the masses. Vigorously promote the application of digital medical insurance services such as medical insurance codes (medical insurance electronic vouchers), social security cards (including electronic social security cards), and mobile payments.

Fourth, strengthen departmental coordination

(8) Clarify the responsibilities of the department. The medical insurance department will coordinate and do a good job in insurance mobilization, budget preparation, fund revenue and expenditure, transfer and continuation, publicity and interpretation, etc., and strengthen the management and supervision of medical insurance funds. The departments of human resources and social security and the medical insurance department shall coordinate the registration of insurance. The tax department should do a good job in collection and payment services, timely return payment information, strengthen data comparison with the medical insurance department, and assist in the mobilization of insurance participation. The financial department shall supervise the income and expenditure and management of the basic medical insurance fund according to its duties, review and summarize the draft budget and final accounts of the basic medical insurance fund, and implement financial subsidies at all levels in a timely manner. The education department actively cooperates with the medical insurance department, strengthens work coordination and data sharing, continuously improves the level of students' basic medical insurance participation, and shall not force students to purchase commercial insurance products in any form or in disguise.

(9) Strengthen departmental linkage. The medical insurance department and the public security department have strengthened cooperation, and done a good job of comparing the information of insured persons with the population information data. The medical insurance department and the human resources and social security department jointly support the coordination and linkage of social insurance business, and assist in the payment of employee medical insurance (including maternity insurance) premiums by those receiving unemployment insurance benefits. Public security, health, medical insurance, and human resources and social security departments at all levels have actively cooperated to do a good job in providing "one thing at birth" for newborns. The health department should rationally formulate regional health plans, optimize the allocation of medical resources, and strengthen the supervision of the behavior of medical institutions. The medical insurance department has strengthened the linkage with the health department to promote the reasonable and moderate growth of medical expenses, which is compatible with the level of economic and social development, the level of medical insurance financing and the affordability of the masses. The medical insurance department has strengthened linkage with civil affairs, health and other departments, mobilizing and guiding social forces to participate in medical assistance activities in accordance with the law. The medical insurance department, in conjunction with relevant departments, will promote the coordinated development of basic medical insurance and commercial insurance, and strengthen the connection of multi-level medical security.

(10) Promote information sharing. The medical insurance department should timely grasp the information on the changes in the insured personnel, and provide data support for expanding the coverage of the insurance and governing the duplication of insurance. On the premise of complying with the relevant provisions on national data security management and personal information protection, all relevant departments and medical insurance departments are to rely on channels such as local big data platforms to promptly share information on citizens' births, deaths, household registration, relocation, and cancellation, as well as information on medical assistance recipients, school students, employed persons, changes and cancellations of enterprise establishments, basic endowment insurance, medical insurance, and so forth. The specific form of sharing is to be determined through consultation with the relevant departments in each region.

5. Safeguard measures

(11) Strengthen organizational leadership. Adhere to and strengthen the party's leadership throughout all aspects and the whole process of basic medical insurance participation. All relevant departments should strengthen the linkage of the system in accordance with the division of responsibilities, make efforts in the same direction, and jointly promote the expansion of insurance coverage. Local people's governments at all levels should attach great importance to it, adopt effective measures, strengthen guidance and supervision, and do a solid job in expanding the coverage of insurance. Medical insurance departments at all levels should make every effort to do a good job in insurance participation, so as to achieve a steady increase in the scale of insurance participation and continuous improvement in the quality of insurance participation. The overall planning area should consider the current and long-term, insist on doing its best and doing what it can, focus on the implementation of insurance policies, incentives and constraints, organization and mobilization, departmental coordination, etc., gradually standardize and reasonably adjust relevant policies, strengthen accurate measurement, ensure the smooth implementation of various measures, and ensure the safe, stable and sustainable operation of the fund. Timely request for instructions and report on major matters.

(12) Strengthen comprehensive evaluation. Establish and improve a comprehensive evaluation system for insurance participation to ensure that responsibilities are compacted. In the implementation of target responsibilities, all localities should prevent "one-size-fits-all" and layer upon layer, so as to avoid increasing the burden on the grassroots.

(13) Guarantee financial support. 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. The Ministry of Finance and the National Health Insurance Administration will take the performance of local insurance participation as the adjustment coefficient for the allocation of subsidy funds for the improvement of medical services and security capacity of the central government (the part of medical security service capacity building).

General Office of the State Council

July 26, 2024

(This article has been abridged)

Source: Chinese government website