China's National Healthcare Security Administration Seeks Public Comments on Outpatient Mutual Aid Guarantee Mechanism for Employee Basic Medical Insurance

On August 26, the National Healthcare Security Administration released the “Guiding Opinions on Establishing and Improving the Outpatient Mutual Aid Security Mechanism for Employee Basic Medical Insurance (Draft for Comment)” to solicit public comments.

As early as March this year, the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical Security System" pointed out that outpatient medical expenses should be gradually included in the payment scope of the basic medical insurance pooling fund, the personal accounts of employees' basic medical insurance should be reformed, and a sound outpatient mutual aid guarantee mechanism should be established. The current public consultation marks the official launch of the process to establish the outpatient mutual aid guarantee mechanism.

This draft for public comment highlights three key points:First,Establish a sound mechanism for pooled funding and coverage of outpatient medical expenses，The general outpatient pooling covers all employees enrolled in the basic medical insurance for urban workers, with a reimbursement rate starting at 50%. The level of coverage will be gradually improved as the fund’s affordability increases, and benefit payments may appropriately favor retirees; secondly,All basic medical insurance premiums paid by employers are credited entirely to the pooled fund and no longer to individual accounts; third, the scope of use for individual accounts is expanded,Exploring the Use of Personal Accounts for Individual Premiums Paid by Spouses, Parents, and Children Participating in Basic Medical Insurance for Urban and Rural Residents

The full text of the document is as follows:

To further improve the universal health insurance system characterized by mutual assistance and shared responsibility, better address outpatient coverage issues under the Basic Medical Insurance for Employees (hereinafter referred to as “Employee Medical Insurance”), and effectively reduce the medical expense burden on employees, and in accordance with the central government’s deployment of tasks for deepening reforms in the healthcare security system, the following opinions are hereby proposed on establishing and improving the mechanism for mutual assistance in outpatient care under Employee Medical Insurance.

I. Guiding Ideology and Basic Principles

(I) Guiding Principles. Guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, we shall fully implement the spirit of the 19th National Congress of the Communist Party of China and its Second, Third, and Fourth Plenary Sessions. We will make every effort while acting within our means, adhere to the principles that everyone fulfills their responsibilities and everyone shares in the benefits, improve institutions, and manage expectations. We will accelerate reforms in key areas and critical links of basic medical insurance. By including outpatient medical expenses within the scope of payment from the basic medical insurance pooling fund, reforming individual accounts under the employee basic medical insurance, and establishing and improving a mechanism for mutual assistance in outpatient care, we will enhance the efficiency of medical insurance fund utilization, gradually alleviate the financial burden of medical expenses on insured individuals, and achieve a more equitable and sustainable system.

(II) Basic Principles. Adhere to providing basic coverage, implement pooled risk-sharing, and effectively safeguard the rights and interests of insured individuals. Ensure a smooth transition, maintain policy continuity, and achieve seamless alignment of benefits before and after the reform. Promote coordinated linkages by synchronously advancing improvements to the personal account system and enhancements to the outpatient care guarantee mechanism, with a gradual shift in implementation. Adapt measures to local conditions; based on overall design and practical realities, adopt categorized approaches and encourage localities to actively explore effective pathways for strengthening outpatient care guarantees under the Employee Basic Medical Insurance scheme.

II. Key Measures and Content

(I) Strengthen the mutual aid function of outpatient care. Establish and improve a pooling mechanism for general outpatient medical expenses, starting with outpatient chronic diseases that impose a heavy burden on the public, such as hypertension and diabetes, and gradually include the general outpatient medical costs of frequently occurring and common diseases within the scope of payment by the pooled fund.General outpatient pooling coverage extends to all employees enrolled in the basic medical insurance for urban workers, with an initial reimbursement rate of 50%. The level of coverage will be gradually increased as the fund’s payment capacity strengthens, and benefit payments may be appropriately tilted toward retirees.In light of the characteristics of outpatient medical services, scientifically determine the deductible standards and maximum payment limits, and ensure proper coordination with inpatient payment policies.

In accordance with the financial capacity of the pooled fund, localities may explore gradually expanding the scope of outpatient chronic and special diseases covered by the pooled fund, thereby including medical expenses for certain outpatient chronic and special conditions—characterized by prolonged treatment cycles, significant health impairment, and heavy economic burden—within the coverage of the pooled fund. For certain special treatments that need to be administered on an outpatient basis and are more economical and convenient than hospitalization, management may reference the reimbursement policies applicable to inpatient care. As the outpatient mutual aid security mechanism is progressively improved, exploration should be conducted to transition from disease-specific coverage to expense-based coverage.

(II) Improve the method for crediting individual accounts. Scientifically and reasonably determine the method and level of contributions to individual accounts,Personal accounts for employed individuals are credited with the basic medical insurance premiums paid by the individuals themselves; the crediting rate is generally capped at 2% of the individual’s contribution base. All basic medical insurance premiums paid by employers are credited to the pooled fund.; In principle, funds are allocated to the personal accounts of retirees from the pooled fund on a fixed-amount basis. The allocation amount is calculated at approximately 2% of the basic pension in the respective region at the time of the reform and will not be adjusted in subsequent years. The specific allocation ratio or standard for personal accounts shall be determined by provincial-level medical security departments, in accordance with the aforementioned principles, by guiding the pooling regions to conduct coordinated studies and make determinations based on local conditions. The reduction in funds allocated to personal accounts following the adjustment of the structure between the pooled fund and personal accounts is primarily used to support the improvement of the outpatient mutual aid guarantee system and to enhance outpatient benefits.

(3) Standardize the scope of personal account usage. Personal accounts are primarily used to cover out-of-pocket expenses incurred by insured employees at designated medical institutions or designated retail pharmacies, within the policy-defined coverage scope.It can be used to cover out-of-pocket medical expenses incurred by the employee, their spouse, parents, and children for medical treatment at designated healthcare institutions, as well as out-of-pocket costs for purchasing medicines and medical consumables at designated retail pharmacies.Explore the use of personal account funds to cover individual premiums for spouses, parents, and children participating in the Basic Medical Insurance for Urban and Rural Residents. Personal accounts shall not be used for other expenditures outside the scope of basic medical insurance coverage, such as public health expenses, sports and fitness activities, or wellness and healthcare consumption. Improve and refine the management measures for personal account usage, and ensure accurate statistical reporting of income and expenditure information.

(4) Strengthening supervision and management. Improve management and service measures, innovate institutional operating mechanisms, guide the rational utilization of medical resources, and ensure the stable operation of the medical insurance fund and the effectiveness of institutional safeguards. Strictly implement the fund budget management system, and strengthen the construction of fund audit systems and internal control systems. Establish a dynamic management mechanism for the entire process of personal accounts, and enhance reviews of key links such as the use and settlement of personal accounts. Strengthen supervision over outpatient medical behaviors and medical expenses, establish mechanisms for fund security risk prevention and control, severely crack down on fraud and deceptive claims against the insurance fund, and ensure the safe, efficient, and rational use of the fund. Innovate management methods for outpatient medical services, improve the monitoring, analysis, and assessment system for medical services, and guide medical institutions to control medical service costs. Accelerate informatization construction in accordance with the requirements for building a nationally unified medical insurance information platform, and explore pathways for achieving cross-regional settlement of outpatient medical expenses. Guide insured individuals to seek initial diagnosis at primary care levels by collaboratively promoting the construction of primary medical service systems, improving family doctor contract services, and implementing long-term prescription systems. In conjunction with improving management measures for chronic and special diseases in outpatient settings, standardize diagnostic, treatment, and referral practices in primary medical institutions.

(5) Improve the payment mechanisms suited to the characteristics of outpatient care. Capitation-based payment may be adopted for primary healthcare services, with active exploration of integrating capitation with chronic disease management; for day surgeries and eligible special outpatient conditions, implement diagnosis-related group (DRG) and condition-based payment; for outpatient expenses not suitable for bundled payment, fee-for-service payment may be applied. Accelerate the establishment of reimbursement standards for insured drugs to guide medical institutions and patients toward the proactive use of medications with proven efficacy and reasonable pricing.

III. Organizational Leadership

(I) Diligent Organization and Implementation. Improving the outpatient care mechanism for employee basic medical insurance involves the vital interests of a vast number of insured individuals. Healthcare security and finance departments in all localities must attach great importance to this matter, formulate detailed implementation rules based on local conditions. Regions that have already carried out relevant explorations should further refine and improve their policies and standardize institutional frameworks in accordance with these Guidelines. Regions that have not yet undertaken such work should actively and prudently develop plans and accelerate initiation and implementation.

(II) Strengthen overall coordination. Improving the outpatient care guarantee mechanism for employee basic medical insurance is a complex undertaking with broad implications, requiring strong policy and technical expertise. Healthcare security and finance departments at all levels must make comprehensive arrangements, engage in scientific decision-making, and ensure meticulous implementation. Proper attention must be paid to ensuring a smooth transition of outpatient coverage policies before and after the reform, thereby guaranteeing that insured individuals experience a stable transition in their benefit entitlements during the reform period. Proactive engagement with development and reform, health, trade union, and other relevant departments should be strengthened to establish coordination mechanisms and promote collaborative implementation. Appropriate policy publicity and interpretation should be conducted, contingency plans prepared, and conflicts effectively resolved.

(3) Promote implementation in a proactive and prudent manner. These Opinions shall take effect from [Month] [Year]. All localities shall issue provincial-level documents by the end of [Month] [Year] to guide all pooling regions in ensuring effective implementation. In accordance with the spirit of these Opinions and in light of local conditions, policy adjustment ranges shall be further clarified, unified and detailed provisions shall be formulated, and policy provisions inconsistent with these Opinions shall be reviewed and revised. During the implementation process, any new circumstances or issues shall be promptly reported to the National Healthcare Security Administration.