Significant reform of employee basic medical insurance
Text/Wang Xiaoxia
Issued in the 994th issue of China News Weekly on May 5, 2021
Recently, the General Office of the State Council has issued the "Guiding Opinions on Establishing and Improving the Mechanism for Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism" (hereinafter referred to as the "Opinions"). The insurance system undergoes substantial reforms.
At present, the basic medical insurance for employees implements a security model that combines social pooling and personal accounts.
The basic medical insurance premium paid by the employer is divided into two parts, one part is allocated to the overall fund, and the other part is allocated to the personal account.
The proportion of the personal account is generally about 30% of the employer's payment, and the basic medical insurance premiums paid by the individual employees are all included in the personal account.
The overall fund is used to protect the inpatient and outpatient major illnesses, and the personal account is used to protect the expenses of outpatient minor illnesses and medicines.
According to the "Opinions", after the reform is completed, the current system that requires employers to pay about 30% of the premiums to the employee medical insurance personal account will be completely cancelled. After that, all the basic medical insurance premiums paid by the employer will be included in the overall planning fund, and the employees will pay. All of the basic medical insurance premiums continue to be included in personal accounts.
Because retirees do not pay their own contributions, their personal accounts are allocated from the pooling fund at a fixed amount, and the amount is 2% of the average level of the basic pension in the year of the reform.
At the same time, the state will establish an outpatient mutual aid guarantee mechanism.
There are three main measures:
The first is to establish an overall plan for general outpatient clinics, and gradually include frequently-occurring and common diseases in outpatient clinics into the medical insurance pooling fund for reimbursement. These expenses were basically solved by personal accounts;
The second is to gradually expand the scope of outpatient chronic diseases and special diseases that are paid by the overall planning fund, and include some outpatient expenses for diseases that have long treatment cycles, large health damages, and heavy cost burdens into mutual aid guarantees, and some are more suitable for outpatient development than hospitalization. More economical and convenient special treatments are managed with reference to hospitalization benefits;
Third, in addition to attending designated medical institutions, insured persons can settle and purchase medicines at designated retail pharmacies with prescriptions outside the hospital. Those who meet the regulations will be included in the payment scope of the overall planning fund, and the corresponding designated retail pharmacies will also be included in such a designated scope of protection.
After the reform, personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured persons in designated medical institutions or designated retail pharmacies.
It is worth noting that in the future, family members will be allowed to mutually aid each other to use personal accounts: personal accounts can be used to pay for medical expenses incurred by the insured person and his spouse, parents, and children in designated medical institutions for medical treatment, as well as in designated retail outlets. Costs borne by individuals incurred in the purchase of drugs, medical equipment and medical consumables in pharmacies
Chen Jinfu, deputy director of the National Medical Insurance Bureau, stated at a regular briefing by the State Council Information Office on April 22 that the general consideration of this reform is to promote the shift from the personal accumulation insurance model to the social mutual aid and mutual aid insurance model.
By including ordinary outpatient expenses in the reimbursement of the overall planning fund, the protection function of the medical insurance fund is enhanced, the efficiency of the fund is improved, the accessibility of outpatient medical services is correspondingly improved, and the burden of the masses, especially the elderly, on outpatient medical expenses is reduced.
Yang Yansui, a professor at the School of Public Administration of Tsinghua University and director of the Employment and Social Security Research Center, believes that the reform has four major advances: "One is to enhance social mutual aid; the other is to realize family insurance; the third is to open outpatient clinics; and the fourth is the most important thing. Guide medical insurance medical resources to flow to community hospitals and family doctors."
China News Weekly, Issue 16, 2021
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