Yinchuan Introduces Nation's First Reimbursement Rules for Online Outpatient Care of Major Illnesses

Internet Healthcare Included in Medical Insurance: Yinchuan Takes the Lead Again. VCBeat (WeChat ID: vcbeat) has learned that on September 18, the Yinchuan Municipal Government issued the "Administrative Measures for Internet Hospital Services Related to Outpatient Treatment of Major Diseases under Yinchuan’s Medical Insurance System (Trial)," which comprises a total of 18 articles. The measures clarify the reimbursement details for online outpatient treatment of major diseases and specify distinct reimbursement rates for urban employee basic medical insurance participants and urban and rural resident basic medical insurance participants, respectively.

This means that, going forward, insured employees and urban and rural residents in Yinchuan who meet certain criteria will be able to have their outpatient expenses for serious illnesses reimbursed through internet hospitals—a first in China.

“Administrative Measures for the Management of Internet Hospital Services for Outpatient Major Diseases under Medical Insurance in Yinchuan City (Trial)” stipulates the establishment of an online payment system for medical expenses related to outpatient major diseases, initially piloted with hypertension and diabetes. Insured individuals who have qualified for outpatient major disease benefits for hypertension and diabetes may voluntarily select one internet hospital as their contracted provider for online consultations and treatment of these conditions. Starting from the date of contract signing, insured individuals shall enjoy online outpatient major disease benefits in accordance with relevant regulations. Between June 1 and June 30, and between December 1 and December 30 each year, they may change their contracted internet hospital and sign a new agreement.

In accordance with the provisions of the Administrative Measures for Internet Hospitals (Trial), internet hospitals are permitted to provide follow-up consultations and issue prescriptions for patients with certain common and chronic diseases. Hypertension and diabetes are conditions that frequently require follow-up visits and medication refills, resulting in a high demand for online medical services among patients with limited mobility. For internet hospitals, managing these conditions through follow-up consultations, prescription issuance, and medication delivery enables the completion of a comprehensive diagnosis and treatment process, thereby enhancing the payment mechanisms for these disease categories.

Previously, the National Healthcare Security Administration’s “Guiding Opinions on Improving Price and Medical Insurance Payment Policies for ‘Internet+’ Medical Services” pointed out that medical insurance payment policies should be aligned with eligible “Internet+” medical services in accordance with the principle of fairness between online and offline services. The coordination between online and offline services is reflected in various aspects of Yinchuan’s recent medical insurance policies for internet hospitals, for example:

Funds required for the outpatient special disease fund shall be allocated from the employee basic medical insurance fund and the resident basic medical insurance fund.

Online outpatient services for major diseases are subject to disease-specific maximum payment limits, used in conjunction with offline physical medical institutions, and implemented in accordance with the annual disease-specific maximum limit standards uniformly issued by the Autonomous Region.

Designation as a designated medical insurance provider, agreement signing, connection to the medical insurance information system, expense settlement procedures, annual performance assessments, and medical insurance supervision and management for internet hospitals shall be implemented in accordance with the medical insurance management regulations applicable to physical medical institutions at the district and county levels.

Internet Hospital Guidelines, Source: Official Website of Yinchuan Municipal People's Government

“Administrative Measures for the Management of Internet Hospitals for Outpatient Major Diseases under Yinchuan Medical Insurance (Trial)” came into effect on October 1, 2019, with a trial period of one year (valid until September 30, 2020). Following the implementation of these Measures, the municipal medical security administrative department, in conjunction with relevant departments, shall make timely adjustments to covered conditions, reimbursement ratios, and the trial period based on fund operation status and risk assessment results.

Although healthcare standards and the status of medical insurance funds vary across regions, Yinchuan’s approach may provide a reference for the implementation of medical insurance policies for internet hospitals in other areas.

Article 1 In order to promote the development of the “Internet + Medical Health” industry in our city, further establish and improve a multi-tiered medical security system, continuously amplify the protective effects of medical insurance, enhance the efficiency of medical insurance fund utilization, regulate the service conduct of designated internet medical institutions under outpatient major disease agreements (hereinafter referred to as “Internet Hospitals”), and ensure that insured persons have access to convenient and rational medical care, these Measures are hereby formulated in light of actual conditions.

Article 2 Internet hospitals providing outpatient services for major diseases under medical insurance to insured employees and residents in Yinchuan (hereinafter referred to as "insured persons") shall be governed by these Measures.

Article 3 Establish an online payment system for medical expenses related to major outpatient diseases, initially piloted with hypertension and diabetes.

Article 4 Insured persons who have qualified for outpatient coverage for major chronic diseases, specifically hypertension and diabetes, in this city may independently select one internet hospital to sign up with for online medical services related to such conditions. Meanwhile, the internet hospital shall establish records containing information on the insured’s initial enrollment, changes in enrollment, and identity verification, and transmit such information to the medical insurance handling agency by 24:00 on the day of signing. The insured person shall be entitled to online outpatient benefits for major chronic diseases in accordance with relevant regulations starting from the date of signing. Between June 1 and June 30, and between December 1 and December 30 each year, they may reselect an internet hospital and sign a new agreement.

Article 5Funding for the outpatient critical illness fund in online consultations shall be drawn from the employee basic medical insurance fund and the resident basic medical insurance fund.。

Article 6Online outpatient services for major diseases are subject to disease-specific maximum payment caps and must be used in conjunction with offline physical medical institutions., in accordance with the annual maximum limit standards for major outpatient diseases uniformly issued by the autonomous region.

For insured individuals eligible for multiple outpatient critical illness benefits, the conversion order of maximum payment limits and the annual cumulative maximum limit for online outpatient critical illness services shall be implemented in accordance with the regulations of the Autonomous Region; the online outpatient critical illness limit shall be the converted maximum payment limit for the specific condition.

Article 7 For medical expenses incurred by urban employee outpatients for serious diseases that exceed the deductible and fall within the scope of the basic medical insurance policy, the reimbursement rate shall be 75%. Personnel eligible for civil servant medical subsidies shall be governed by the relevant regulations on civil servant medical subsidies in Yinchuan City. For participants in the urban and rural resident basic medical insurance who pay premiums under Tier 1, Tier 2, or Tier 3, the reimbursement rates for medical expenses exceeding the deductible and falling within the scope of the basic medical insurance policy shall be 50%, 60%, and 65%, respectively.

Insured individuals shall not be entitled to outpatient coverage for major diseases provided by internet hospitals during their hospitalization.

Article 8 The scope of diagnosis and treatment items and medications for major outpatient diseases in internet hospitals shall be implemented in accordance with the relevant regulations of the autonomous region on major outpatient diseases.

Article 9Internet hospitals shall establish a database of the “Three Catalogs” for medical insurance, and drug prices must not exceed the “Three Unified” prices of the autonomous region., the prices of diagnostic and treatment services and disposable medical consumables shall be strictly implemented in accordance with the relevant regulations of the Autonomous Region and Yinchuan City.

Article 10 The medical expenses for major outpatient diseases at internet hospitals shall be settled in real time. Insured persons receiving online medical care are only required to pay the portion of costs borne by themselves. Medical expenses covered by the pooled fund shall be settled periodically between the medical insurance handling agencies and the internet hospitals. At the time of settlement, 90% of the payable amount shall be settled first, and the remaining balance shall be settled based on the results of the year-end assessment. Settlements for employee basic medical insurance and urban and rural resident basic medical insurance shall be conducted separately.

Article 11 Internet hospitals shall comply with the relevant provisions of the Measures for the Administration of Personal Equity Records of Social Insurance, establish a creditworthiness mechanism, refrain from reselling the personal information of insured persons, and shall not load into their medical institution information systems the data of insured persons who have not entered into service agreements with such hospitals.

Article 12 Internet hospitals shall adhere to the principles of openness and transparency, ensuring reasonable medical practices and reasonable charges. Any act of embezzling or defrauding medical insurance funds through fraud, resale of insured persons’ information, fabrication of materials, or other online means shall be handled in accordance with the Social Insurance Law and other relevant laws and regulations.

Article 13 Internet hospitals shall strengthen the development of information infrastructure, ensure interoperability between their information systems and the expense settlement systems as well as the monitoring (intelligent audit) information systems of basic medical insurance agencies, and upload enrolled patients’ contract signing and medical treatment information to such agencies in a timely, standardized, complete, and accurate manner.

Article 14 After the implementation of these Measures, the municipal healthcare security administrative department shall, in conjunction with relevant departments, make timely adjustments to the covered disease categories, reimbursement ratios, trial periods, and other parameters based on fund operation status and risk assessment results.

Article 15 The designation of internet hospitals as designated medical insurance providers, the signing of agreements, connection to the medical insurance information system, expense settlement procedures, annual assessments, and medical insurance supervision and management shall be implemented in accordance with the medical insurance management regulations for physical medical institutions in districts and cities.

Article 16 The safety control of the Internet medical insurance fund shall be implemented in accordance with the "Measures for the Safety Control of the Internet Medical Insurance Fund in Yinchuan City (Trial)" issued by the General Office of the People's Government of Yinchuan City.

Article 17 These Measures shall not apply to outpatient care for serious diseases provided to insured persons who have completed the filing for residence in a different location under their medical insurance.

Article 18 These Measures shall come into force on October 1, 2019, with a trial period of one year (valid until September 30, 2020).

Source: Official Website of the Yinchuan Municipal People's Government