Medical insurance reimbursement will usher in major changes

  The scope of use will be extended to family members, and outpatient expenses will be included in reimbursement

  On August 26, the National Medical Security Administration issued the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Assistance Mechanism (Consultation Draft)" (hereinafter referred to as the "Consultation Draft") on its official website to solicit opinions from the whole society .

  The key word of the consultation draft is outpatient mutual aid. According to the consultation draft, my country’s employee medical insurance will usher in at least three major changes:

  ● The use of personal accounts is planned to be extended to family members

  ● General outpatient expenses can also be reimbursed

  ● Unit payment plans no longer enter the personal account

  If you use a scene in your life to introduce this change, that is, in the future, parents will be able to swipe my health insurance card to see minor illnesses in the outpatient clinic, and they can enjoy better treatment without paying more.

  One-person medical insurance, for the whole family: Individual medical insurance accounts can pay for medical expenses such as spouses, parents and children

  According to the 2019 National Medical Security Development Statistical Bulletin issued by the National Medical Security Administration, 329.25 million people participated in employee medical insurance in 2019.

  But this time, the benefits brought about by the new reform will not only benefit the more than 300 million employees' medical insurance participants, but also their families.

  Before the reform, the funds in the insured’s personal account could only be used to pay for out-of-pocket expenses incurred by the insured in designated medical institutions and retail pharmacies.

  After the reform, the scope of payment will be extended to the expenses of the insured’s spouse, parents and children.

  Regarding the scope of use of personal accounts according to the draft for comments:

  Personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured employees in designated medical institutions or designated retail pharmacies.

It can be used to pay for the medical expenses incurred by the employees themselves, their spouses, parents, and children in medical insurance designated medical institutions, and the expenses incurred by individuals for purchasing drugs and medical consumables in designated retail pharmacies.

Explore personal accounts for personal payment for spouses, parents, and children participating in basic medical insurance for urban and rural residents.

  In fact, the concept and practice of "health insurance shared by the whole family" is not new.

  As early as 11 years ago, during the two sessions in 2009, Yu Guangyan, a member of the National Committee of the Chinese People's Political Consultative Conference and Dean of Peking University School of Stomatology, said that personal accounts can only be used for their own use, lacking a taste of "together in the same boat" and cannot be used without hospitalization. The limitation of the personal account has caused the balance of the personal account to accumulate greatly, and it does not really play its role. "Especially among family members, some people often get sick and the money is not enough, while some people have accumulated a lot of money but can’t use it. Looking at the money in the account, I can't save it if I want to save it!"

  For a long time, the efficiency of the use of funds in individual medical insurance accounts for employees in my country has been low, resulting in a waste of funds.

The Medical Insurance Statistics Bulletin shows that in 2019, the accumulated balance of personal accounts of basic medical insurance for employees has reached 842.6 billion yuan.

  After the reform, the expansion of the scope of payment will alleviate the cash-out problem of medical insurance caused by the precipitation of funds.

  At the time, Yu Guangyan suggested that basic medical insurance can establish a "family account", and the money in the basic medical personal account can be shared between the family's immediate family members.

  Practical experience has also proved the feasibility of the program.

  Also in 2009, Jiangsu began to pilot the "medical insurance family account" to expand the functions of personal accounts and expand the scope of medical insurance.

In addition, Yancheng introduced personal accounts in 2008 to provide medical insurance to relatives; Guangdong introduced personal accounts in 2009 to provide medical insurance to immediate family members; Suzhou introduced personal accounts in 2016 that can be transferred to "fitness cards"; Ningbo started in 2016, The balance of individual medical insurance accounts over the years can be used by close relatives.

  The most important thing is that they will not pay more.

  Fan Weidong, deputy director of the Treatment Security Department of the National Medical Security Administration, said that the accumulated part of the personal account still belongs to the individual and will not be affected.

After the reform, not only the medical insurance benefits will not be reduced, but also personal contributions will not be increased.

  Minor illnesses and chronic diseases can be reported, outpatient expenses are planned to be included in the reimbursement, and the reimbursement ratio starts at 50%

  In addition to the expansion of the range of people who can use medical insurance to pay to family members, the scope of diagnosis and treatment items that can be paid by medical insurance has also been greatly expanded.

  Since the establishment of the employee medical insurance system in my country, it has focused on insuring hospitalization and serious illness, and providing relatively high treatment guarantee for hospitalization and serious illness.

However, the outpatient insurance for "small come and go" in daily life is relatively weak.

  Taking the data of 2019 as an example, that year, the medical expense reimbursement rate within the hospitalization policy of the employee medical insurance reached more than 80%.

  After the reform, it shifted to the feature of focusing on both hospitalization and outpatient care, with major and minor illnesses covered.

The basic medical insurance has been transformed from a single insurance model of "insurance for serious illness and hospitalization" to a comprehensive insurance model of "outpatient and hospitalization insurance".

  The draft for comments stated:

  Enhance the mutual aid guarantee function in outpatient clinics.

Establish and improve the general outpatient medical expenses overall guarantee mechanism, start with the outpatient chronic diseases with heavy burdens such as hypertension and diabetes, and gradually include the general outpatient medical expenses of frequently-occurring and common diseases into the scope of the overall plan fund.

General outpatient clinics cover all employees’ medical insurance insured persons, and the payment ratio starts from 50%. As the affordability of the fund increases, the level of protection is gradually increased, and treatment payments can be appropriately tilted to retirees.

According to the characteristics of outpatient medical services, scientifically calculate the minimum payment standard and maximum payment limit, and do a good job of linking up with the hospitalization payment policy.

  The keyword "outpatient mutual aid" appeared.

  The draft for comments gives a specific plan:

  According to the fund's affordability, all localities can explore to gradually expand the scope of outpatient chronic diseases and special diseases that are paid by the overall planning fund, and include some outpatient chronic diseases and special diseases that have long treatment cycles, great health damage, and heavy economic burdens into the scope of payment of the overall planning fund .

Some special treatments that need to be carried out in outpatient clinics and are more economical and convenient than hospitalization can be managed with reference to hospitalization benefits.

With the gradual improvement of the outpatient mutual aid protection mechanism, the transition from disease protection to cost protection is explored.

  What are the benefits of outpatient mutual aid protection?

  Wang Zongfan, a researcher at the Chinese Academy of Labor and Social Sciences, said that outpatient clinics are usually common and frequently-occurring diseases. In the past, these diseases were considered to be small and affordable for individuals. However, this is not the case in reality, such as cancer radiotherapy and chemotherapy, organ transplantation outpatient The cost of treatment of heterogeneous and leukemia is often higher than that of hospitalization, and the burden is heavier.

  Moreover, in life, there are often embarrassing situations where the outpatient medical insurance card is not enough to be used, and minor illnesses are hospitalized for major treatment. Some patients even go to the hospital for reimbursement, in fact, to take medicine.

  According to the current rules, the outpatient deductible line is 1,800 yuan, and employees can only be reimbursed if they spend more than 1,800 yuan in outpatient clinics each year. After the reform, not only this part of the expenses can be reimbursed, but common minor diseases in outpatient clinics can also be included in the scope of the medical insurance overall fund payment.

  The relevant person in charge of the National Medical Insurance Bureau said that general outpatient medical expenses can be reimbursed, and it is explored to expand the scope of outpatient chronic diseases so that outpatient services can carry out more economical and convenient special treatment.

  More money will be allocated to the medical insurance coordinating fund, the outpatient reimbursement will be better

  More people use and protect more medical scenarios, will the medical insurance benefits worsen?

  of course not.

  But where does the money for better treatment come from?

  The draft also gives the answer:

  Improve personal account crediting methods.

Scientifically and reasonably determine the crediting method and crediting level of individual accounts. The personal accounts of employees are credited by the basic medical insurance premiums paid by individuals, and the crediting standard is controlled within 2% of the insurance payment base of the individual. The basic medical care paid by the unit All insurance premiums are included in the overall planning fund.

  In the past, 2% of individual medical insurance payments and 30% of unit payments were credited to personal accounts.

  After the reform, the part of the unit payment was put into the medical insurance pooling fund and no longer credited to the personal account, and the part of the individual payment was still credited to the personal account.

  In other words, in the current period, less money will be allocated to personal accounts and more money will be allocated to the medical insurance pooling fund, and it is the medical insurance pooling fund that guarantees outpatient reimbursement benefits.

  The draft for comments puts forward:

  After the adjustment of the unified account structure, the reduction of funds allocated to personal accounts is mainly used to support and improve the mutual aid protection of outpatient clinics and improve outpatient benefits.

  Zhu Hengpeng, director of the Public Policy Research Center of the Chinese Academy of Social Sciences, said that based on the income of the employee medical insurance fund in 2019 (the overall fund is 1000.5 billion yuan, the individual account is 584 billion yuan), a rough estimate is that after the reform, the individual account will only be included in the personal payment part, and will no longer be included. In the part of unit payment, the overall fund will increase by about 200 billion yuan.

Such an increase in the overall planning fund obviously provides a great possibility for improving the level of protection of insured persons and reducing the medical burden of patients.

  The relevant person in charge of the National Medical Insurance Bureau also said that after the adjustment, the overall fund has a stronger protection function for outpatients, that is to say, the employee medical insurance system will provide better reimbursement for outpatients.

  The number of enjoyment groups has expanded from the insured person to spouses, parents and children; cardholders use the card more conveniently and have more medical treatments; the gold content of the medical insurance card has also been increased; it can also encourage employees to continue to participate in the insurance and reduce the family's medical burden... …

  In this reform, the employee medical insurance has established an outpatient mutual aid guarantee mechanism, which can truly be said to be advancing with the times and adjusting policies according to the needs of the people.

  Fan Weidong said, “We improve the level of outpatient protection by optimizing the structure of personal accounts, strengthening the overall fund, and expanding the coverage of the fund at the same time, including outpatient minor illnesses into the scope of protection, so that people can be assured and satisfied with the medical services around them. ."

  "China Economic Weekly" reporter Zou Songlin Yang Lin | Report from Beijing

  (This article was published in China Economic Weekly, Issue 16, 2020)