The Medical Insurance Bureau and the Ministry of Finance jointly issued opinions on establishing a medical insurance benefit list system

August 10, the National Medical Insurance Bureau and Ministry of Finance jointly issued the "Opinions on the Establishment of Medicare benefits list system"
.

Reads as follows:
National Insurance Bureau Ministry of Finance
on the establishment of a list of health care treatment system of
health insurance Fa [2021 ] 5 Hao
provinces, autonomous regions and municipalities and Xinjiang Production and Construction Corps Insurance Bureau, Department of Finance (Bureau): basic medical insurance under the new situation Promote the construction of a healthy China and implement the institutional basis for the priority development strategy of people’s health
.
In order to implement the people-centered development idea, continuously improve the level of administration according to law and guarantee performance, and protect the basic medical security rights of the people in a fair and appropriate manner, the following opinions are hereby provided on the establishment of a medical security benefit list system:
1.
General requirements
(1) Guiding ideology
.
Guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 19th National Congress of the Communist Party of China and the 2nd, 3rd, 4th and 5th Plenary Sessions of the 19th National Congress of the Communist Party of China.
China builds an overall strategic layout, firmly grasps the important window period of medical insurance reform, and aims to comprehensively build a multi-level medical security system with clear rights and responsibilities, appropriate security, and sustainability, to meet the needs of building a medical security system with Chinese characteristics, and to determine the basic security content , Clarify the boundary of benefit payment, clarify the policy adjustment authority, standardize the decision-making process, and gradually establish and improve the medical security benefit list system
.
(2) Basic principles
.
Adhere to basic guarantees and fair enjoyment
.
Proceed from the basic national conditions, follow objective laws, do our best, and do what we can, and earnestly safeguard the people's basic medical security needs
.
Persist in stability, sustainability, and balance of responsibilities
.
Keep the boundaries of government responsibility, scientifically determine the level of financing treatment and the burden ratio of all parties, and realize the sustainable development of the medical insurance system
.
Adhere to responsibility sharing and diversified guarantees
.
Adhere to equal rights and obligations, improve the risk sharing mechanism, and encourage the development of a multi-level medical security system
.
Persist in making scientific decisions in accordance with laws and regulations
.
Coordinate system and policy arrangements, clarify decision-making levels and powers, standardize decision-making, and encourage exploration, and promote the legalization, standardization and standardization of medical security system management
.

　　2.
Standardized management
(1) Establish basic systems in accordance with the law
.
The medical security administrative department of the State Council, in conjunction with relevant departments, drafts relevant laws and regulations of the basic system, formulates relevant policies, and organizes implementation in accordance with national laws and regulations and the decisions and arrangements of the Party Central Committee and the State Council
.
Local governments shall not set up other medical security systems beyond the scope of the basic system framework on their own
.
(2) Strict decision-making authority
.
The medical security administrative department of the State Council, in conjunction with relevant departments, formulates, adjusts and releases basic medical security policies
.
All provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps (hereinafter collectively referred to as provinces) can formulate specific financing and treatment policies within the scope of national regulations and adjust them dynamically according to relevant national requirements
.
Each coordinating area shall formulate implementation rules in accordance with relevant regulations and be responsible for organizing implementation
.

　　3.
List of benefits The list
of benefits includes basic systems, basic policies, as well as the items and standards paid by the medical insurance fund, and the scope of non-payment.
It will be adjusted dynamically according to the decisions and deployment of the Party Central Committee and the State Council, and will be released in due course
.
(1) Basic system
.
Established in accordance with the "Social Insurance Law" and "Interim Measures for Social Assistance" and other national laws and regulations, as well as the Party Central Committee and the State Council's decision-making and deployment requirements, the institutional arrangements to protect the basic medical needs of the people, including basic medical insurance, supplementary medical insurance and medical assistance
.
Localities are not allowed to establish new systems outside the basic institutional framework, and other existing institutional arrangements in the localities should be gradually cleaned up and transitioned to the basic institutional framework
.
Basic medical insurance covers all employed and non-employed people in both urban and rural areas, and provides fair and universal protection for the basic medical needs of the people
.
Supplementary medical insurance guarantees medical expenses borne by individuals other than the basic medical insurance for the insured that meet the relevant provisions of social insurance
.
Medical assistance helps people in need obtain basic medical insurance services and reduces their burden of medical expenses
.
(2) Basic policies
.
Ensure compliance and basis for the operation of basic systems and norms
.
Including insurance policies, funding policy, the treatment of payments policy
.
Insurance policy including the scope of the insured population, funded insurance policy
.
The main sources of financing, including financing policy, base pay, base rate (standard) and so on
.
Benefit payment policies include basic medical insurance, supplementary medical insurance included in the list management, and medical assistance payment policies
.
The basic medical insurance benefit payment policy is divided into hospitalization, general outpatient, outpatient chronic and special disease payment policies, which mainly include basic treatment standards such as the minimum payment standard, payment ratio and maximum payment limit of medical expenses within the policy scope
.
On the basis of the basic medical security system, the state uniformly formulates special population security policies
.
The introduction of new places not their own special treatment policies based on occupation, age, identity and so on
.
(3) Scope of fund payment
.
Including the list of medicines and medical consumables and the scope of payment for medical service items determined by the access method and the exclusion method
.
The state uniformly formulates the national basic medical insurance drug catalog, and all localities strictly follow the national basic medical insurance drug catalog.
Except for clear regulations of the state, it is not allowed to formulate the catalog by itself or use alternative methods to add drugs in the catalog
.
The state establishes and improves medical consumables and medical insurance access and management policies for medical service items, and clearly determines the procedures and rules for the scope of medical insurance payment for medical consumables
.
Local implementation in accordance with national policies
.
(4) The scope of the fund's non-payment
.
National laws and regulations, the Party Central Committee, and the State Council have stipulated that basic medical insurance and supplementary medical insurance are not paid, or medical services and projects that have other guarantee systems and funding channels are arranged to solve the problem
.

　　4.
Organize and implement
(1) Consciously improve the position and coordinate the promotion of related work
.
All localities must thoroughly implement the decisions and deployments of the Party Central Committee and the State Council, deeply understand the importance of establishing a medical security benefit list system, consolidate main responsibilities, improve working mechanisms, and implement solid implementation, and gradually realize the vertical unification of policies and horizontal balance of benefits to ensure that all areas are coordinated.
The safe operation of the fund and the sustainable development of the medical security system
.
It is necessary to strengthen policy interpretation, guide expectations, ensure a smooth transition of policies, and maintain social harmony and stability
.
(2) Do a good job in transition and properly handle relevant policies
.
In accordance with the requirements of eliminating increments and standardizing stocks, in principle, all localities shall not issue policies beyond the scope of authorization of the list
.
For policies and measures that are not in conformity with the list, the policy-promulgating department will take the lead.
In principle, the clean-up and regulations will be completed within three years, and they will be in line with national policies
.
Accelerate the implementation and application of a unified national medical insurance information platform to ensure that the information system is compatible with the benefit list system, and the cleaning specifications are completed on the information system at the same time.
The information system will not support the information system that exceeds the authorized scope of the list
.
Establish and improve the central government’s accountability mechanism for the provinces and the provinces to the coordinated areas, rewards and punishments, etc.
that meet the needs of the operation of the inventory system, and urge corrections and hold accountable if the implementation is not resolute, incomplete, or in place
.
(3) Strengthen communication and coordination, and establish a major decision-making request and report system
.
It is necessary to establish and improve a system for requesting instructions and reporting on major decisions, major issues, and important matters
.
For new situations and new problems in the process of economic and social development, as well as new mechanisms and new methods that are in line with the reform direction of the central government and localities need to explore in accordance with local conditions, all provinces are encouraged to explore after requesting the report in accordance with the procedures.

.
In order to deal with sudden major situations, etc.
, it is really necessary to break through the limits of the national list, it is necessary to report to the medical security administrative department and the financial department of the State Council in a timely manner
.
Special policy measures such as the inclusion of national drugs in the medical insurance drug catalogue as prescribed by the state, as well as major policy adjustments such as basic medical insurance provincial-level overall planning, must be reported to the medical security administrative department and the financial department of the State Council, and then promoted and filed in accordance with the regulations
.
The opinions shall be implemented from the date of issuance
.
Anything that is inconsistent with the provisions of this opinion shall be implemented in accordance with this opinion
.

　　Attachment: National Medical Insurance Benefit List (2020 Edition)
National Medical Security Administration Ministry of Finance January 19, 2021
　　Attachment:
　　National Medical Insurance Benefit List (2020 Edition)
　　1.
Basic System
　　(1) Basic Medical Insurance System
1.
Basic Medical Care Insurance (hereinafter referred to as "employee medical insurance"): An institutional arrangement that provides basic medical insurance for employees
.
2.
Basic medical insurance for urban and rural residents (hereinafter referred to as "resident medical insurance"): An institutional arrangement that provides basic medical insurance for all urban and rural residents who have not participated in employee medical insurance or other medical insurance systems
.

　　(2) Supplementary medical insurance system
1.
Urban and rural residents' serious illness insurance (hereinafter referred to as "serious illness insurance"): to provide further protection for the high medical expenses incurred by resident medical insurance patients who meet the requirements
.
2.
Large amount of medical expenses subsidy for employees (including serious illness insurance for employees in some provinces): Provide further protection for the high medical expenses incurred by insured employees
.
3.
Reference list management of medical subsidies for civil servants
.
enterpriseSupplementary medical insurance, etc.
, funded by institutions themselves will not be included in the list management for the time being
.

　　(3) Medical assistance system
1.
Participate in the personal payment of resident medical insurance for assistance recipients
.
2.
Provide assistance to the recipients of self-paid medical expenses that are unbearable for individuals and their families after being paid by basic medical insurance and supplementary medical insurance
.

　　2.
Basic policy framework
　　(1) Basic insurance policy
1.
Scope of insurance participation
.
1.
1 Employee Medical Insurance: Covers all employees of employers, self-employed industrial and commercial households without employees, part-time employees who are not participating in employee medical insurance in the employer, and other flexible employees can participate in employee medical insurance
.
1.
2 Resident medical insurance: Covers all urban and rural residents except those who should be covered by employee medical insurance or those who are entitled to other protections as required
.
2.
The scope of medical assistance to subsidize the insured persons
.
2.
1 The scope of the full subsidy: the extremely poor
.
2.
2 Scope of fixed-rate subsidies: people in need, such as those who are eligible for subsistence allowances and those who have returned to poverty
.
The fixed funding standards are determined by the people's governments at the provincial level based on actual conditions
.

　　(2) Basic financing policy
1.
Fund-raising channels
.
1.
1 Employee Medical Insurance: The employer and the employee shall jointly pay basic medical insurance premiums for employees in accordance with national regulations
.
Individual industrial and commercial households without employees, part-time employees who are not participating in employee medical insurance and other flexible employees who are not employed by employers shall pay their basic medical insurance premiums in accordance with national regulations
.
1.
2 Resident medical insurance: a combination of personal payment and government subsidies
.
1.
3 Medical assistance: through various channels such as financial subsidies at all levels, lottery public welfare funds, and social donations
.
With the improvement of the system, the overall level of basic medical insurance will be gradually improved
.
Promote coordination between the overall level of medical assistance and the overall level of basic medical insurance
.
2.
The payment base
.
The payment base of employee medical insurance employers is the total wages of employees, and the base of individual payment is my salary income
.
Gradually standardize the payment base
.
3.
Basic criteria for fund-raising
.
3.
1 The unit contribution rate of employee medical insurance: about 6% of the total wages of employees
.
3.
2 Staff contribution rate: 2% of my salary income
.
3.
3 Resident medical insurance financing standards: The state sets minimum standards, and each province determines its own standards in accordance with the requirements of not lower than the national standards
.

　　(3) The basic treatment payment policy All
localities shall adapt to local conditions, and formulate the minimum payment standard, payment ratio and maximum payment limit for inpatient and outpatient services within the scope of national regulations
.
Don’t make your own personal or family account policies
.
Gradually standardize the payment period policy
.
1.
Hospitalization treatment payment policy
.
1.
1 Minimum payment standard: In principle, the minimum payment standard for employee medical insurance should not be higher than 10% of the average annual salary of employees in the overall planning area.
The specific standard is determined by each locality based on local actual conditions
.
Different levels of medical institutions appropriately widen the gap
.
In principle, the critical illness insurance threshold shall not be higher than 50% of the per capita disposable income of residents in the overall planning area in the previous year
.
In principle, the relief thresholds for the subsistence allowance recipients and extremely poor people will be completely cancelled.
For regions that do not meet the conditions for the time being, the annual minimum payment standard shall not be higher than 5% of the per capita disposable income of residents in the overall planning area in the previous year, and gradually explore the cancellation.
The payment standard is determined by about 10% for low-income family members, and about 25% for severely ill patients in poor families due to illness
.
1.
2 Payment ratio: For expenses above the threshold and below the maximum payment limit, the overall payment ratio of basic medical insurance is about 75%.
There is a reasonable gap between employee medical insurance and urban and rural residents' medical insurance, and medical institutions of different levels appropriately widen the gap
.
The proportion of critical illness insurance payment shall not be less than 60%
.
Medical assistance can provide assistance to the minimum living standard and extremely poor people at a rate of no less than 70%.
The level of assistance for other aid targets is in principle slightly lower than that of the minimum living standard, and the specific ratio is determined by the overall planning area according to the actual situation
.
1.
3 The maximum payment limit of the fund: The maximum payment limit of the employee medical insurance and the large-scale medical expense subsidy for the employees and the resident medical insurance and the serious illness insurance shall in principle reach about 6 times the average annual salary of the local employees and the per capita disposable income of the residents
.
The annual maximum limit of medical assistance is set reasonably according to economic and social development, people's health needs, and fund support capabilities
.
2.
Outpatient treatment payment policy
.
2.
1 general outpatient: from to pay for the standard above, the cost of a policy context below the maximum payment, the proportion of outpatient co-ordinate the payment of not less than 50% of the Medicare population
.
2.
2 Outpatient chronic disease: Include outpatient medication such as hypertension and diabetes in medical insurance reimbursement
.
Outpatient radiotherapy and chemotherapy for malignant tumors, uremic dialysis, anti-rejection therapy after organ transplantation, maintenance therapy for severe mental patients, insulin therapy for diabetes, tuberculosis, day surgery, etc.
, can refer to hospitalization management and payment
.
Provide outpatient assistance to eligible subjects who suffer from chronic diseases and require long-term medication or suffer from serious and serious diseases that require long-term outpatient treatment, resulting in higher self-paying expenses
.
The annual aid limit for outpatient clinics is determined by the people's government at or above the county level based on the needs of local aid recipients and the situation of aid fund raising
.
3.
Inclined policies
.
3.
1 Critical illness insurance: For subsistence allowance recipients, extremely poor people, and those who have returned to poverty, the threshold for critical illness insurance will be reduced by 50%, the payment ratio will be increased by 5 percentage points, and the maximum payment limit will be cancelled
.
3.
2 Medical assistance: Provide assistance to eligible assistance objects such as subsistence allowances and extremely poor people in accordance with regulations
.
For the recipients of standardized referral and medical treatment in the province, if the personal burden is still heavy within the scope of the policy after the guarantee of the triple system, preferential assistance will be given, and the specific assistance ratio will be determined by the overall planning area according to the actual situation
.

　　3.
Scope of fund payment The
basic medical insurance is paid in accordance with the prescribed scope of payment for drugs , medical consumables and medical services
.
Supplementary medical insurance and medical assistance shall be implemented with reference to the scope of expenses within the policy scope
.

　　4.
Other non-payment scope
1.
Should be paid from the work-related injury insurance fund
.
2.
Should be borne by a third person
.
3.
Should be borne by public health
.
4.
Seeking medical treatment abroad
.
5.
Sports fitness, health care consumption, health checkup
.
6.
Other expenses not paid by the basic medical insurance fund stipulated by the state
.
In case of a major impact on economic and social development, temporary adjustments may be made after legal procedures
.