Relations with 1.36 billion people!
The national medical insurance benefit list has landed, and these items are not reimbursed
The implementation of the National Medical Insurance Benefit List (2020 Edition) (hereinafter referred to as the "List (2020 Edition)") marks a critical step in the medical insurance benefit list system that concerns the vital interests of 1.36 billion insured persons.
The National Medical Insurance Administration and the Ministry of Finance recently announced the "Opinions on Establishing a Medical Security Benefit List System" (hereinafter referred to as the "Opinions"), regarding the basic systems and policies of medical insurance, as well as the items and standards paid by the medical insurance fund. The scope of payment is clearly defined.
The opinion stated that my country should gradually establish and improve the medical security benefit list system.
The formulation of the national medical insurance benefit list has been an important task since the establishment of the National Medical Insurance Bureau, and is a pilot project for the management reform of the national basic public service expenditure list for people’s livelihood.
This opinion was publicly solicited from the public as early as July 2019, and the National Medical Insurance Bureau and the Ministry of Finance issued it to the provinces in January this year.
Zhu Minglai, director of the Research Center for Health Economics and Medical Security of Nankai University, told China Business News that the opinion clarified that my country’s medical insurance system consists of three parts: the basic medical insurance system, the supplementary medical insurance system, and the medical assistance system, ensuring the sustainability of the fund. Standardized management and keeping the boundaries of government responsibility also leave room for the development of commercial insurance.
Clarify that six types of projects are not reimbursed
Liao Cangyi, a researcher at the Medical Service Governance Research Center of Tsinghua University, said in an interview with China Business News that the opinions clarified the scope of basic medical insurance. 32 items are listed, clarifying the connotation and payment boundary of basic medical insurance, which is equivalent to giving the society and the public a certain expectation of basic medical insurance benefits.
The list (2020 version) stipulates that the scope of non-payment includes those that should be paid from the work-related injury insurance fund; those that should be borne by a third party; those that should be borne by public health; those who seek medical treatment abroad; Physical examination; six types of items including other expenses that are not paid by the basic medical insurance fund prescribed by the state.
During the National People’s Congress and the National People’s Congress this year, some major representatives proposed to include certain items in the scope of medical insurance reimbursement, such as cervical cancer vaccination, national screening for high-incidence malignant tumors, and deafness genetic screening.
In response to such suggestions, the National Medical Insurance Bureau stated that according to the current institutional arrangements of my country’s medical and health system, public health services provide public health interventions to all residents. Projects that mainly play a role in disease prevention and control belong to public health services. category.
Article 30 of the "Social Insurance Law of the People's Republic of China" stipulates that medical expenses that should be borne by public health are not included in the scope of payment by the basic medical insurance fund.
The medical insurance payment for the new crown vaccine is an exception. Before the large-scale vaccination of the vaccine, some people in the industry also pointed out that the vaccine cost is a public health expenditure and should be paid by public health funds.
In this regard, the opinions also specifically pointed out that in order to deal with sudden and major situations, it is really necessary to break through the national list limit, it is necessary to report to the medical security administrative department and the financial department of the State Council in a timely manner.
The list (2020 version) stipulates that the basic medical insurance fund stipulated by the state does not pay other expenses.
In case of a major impact on economic and social development, temporary adjustments may be made after legal procedures.
Zhu Minglai said that the introduction of the list (2020 version) means that medical insurance has a unified national standard. The medical insurance bureau manages three systems: the basic medical insurance system, the supplementary medical insurance system, and the medical assistance system. In addition to the system, establish a new system.
At present, some places have financed the introduction of supplementary insurance with six guarantees and eight guarantees during poverty alleviation. These benefits are unsustainable and have also caused an impact on the benefits and levels of basic medical insurance, which should be cleared up as soon as possible.
Liao Cangyi believes that the opinions unify the establishment and decision-making authority of the basic medical insurance system.
In the future, any basic medical insurance system will be formulated, adjusted and released by the National Medical Insurance Bureau in conjunction with relevant departments. Provincial medical insurance units only have the right to dynamically adjust according to local conditions, and the municipal coordinating districts only have the right to formulate and implement the implementation rules, and they are not allowed. Places outside the scope of the list "build houses" by themselves.
The opinions demand that all localities shall not establish new systems outside of the basic system framework, and that other existing system arrangements in the localities shall be gradually cleaned up and transitioned to the basic system framework.
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.
Reserve space for business
The basic benefit payment policy stipulated in the checklist (2020 version) proposes that localities should adapt to local conditions and formulate inpatient and outpatient payment thresholds, payment ratios, and maximum payment limits within the scope of national regulations.
Don’t make your own personal or family account policies.
Gradually standardize the payment period policy.
In terms of the maximum payment limit of the fund, the National Medical Insurance Benefit List (2020 version) stipulates that the maximum payment limit for employee medical insurance plus employee large-scale medical expense subsidy and resident medical insurance plus serious illness insurance shall in principle reach the average annual salary of local employees and the disposable resident. About 6 times the income.
Based on the national average level, in 2020, the average annual salary of employees in urban non-private units is 97,379 yuan, and the average annual salary of employees in urban private units is 57,727 yuan. Based on this calculation, the national urban employee medical insurance cap is 300,000~ Compared with 600,000, the disposable income of residents is relatively low. In 2020, the national per capita disposable income of residents is 32,189 yuan. Based on this calculation, the ceiling of the residents’ medical insurance is about 200,000.
The situation varies from place to place, and the funds paid by regional funds with higher incomes will be higher.
Zhu Minglai said that for serious illness, if the reimbursement of basic medical insurance is not enough, you can consider purchasing some supplementary commercial insurance. For example, Huimin Insurance that is being launched in various places can play a role of supplementary medical insurance. From this perspective Said that the benefit list delineates the scope of "basic guarantee", which also provides room for the development of commercial insurance.
Liao Cangyi believes that the opinions point out the development direction of commercial insurance, that is, under the framework of a multi-level medical insurance system, commercial health insurance can be developed for projects and services outside the boundaries of basic medical insurance business, and play a role in supplementary protection for basic medical insurance. The above is also encouraging the development of commercial health protection, which will help commercial insurance companies to clarify their development strategies, design scientific product content and provide accurate health protection services.
(Author: Guo Jinhui)