National Rural Cooperative Medical Scheme Achieves Direct Settlement for Cross-provincial Healthcare Across Nine Provinces, Benefiting 150 Million Enrollees

According to VCBeat, from January to August this year, China successfully achieved its annual target for the direct settlement of cross-regional medical expenses under the New Rural Cooperative Medical Scheme!

As of the end of August, the New Rural Cooperative Medical Scheme (NRCMS) has successfully completed the annual task targets set by the State Council for networked settlement of cross-regional medical expenses. Direct settlement for intra-provincial cross-regional medical care under the NRCMS now covers all 150 million enrolled participants across nine provinces.

Based on patient flow and settlement needs, China has designated the first batch of 1,518 medical institutions as authorized providers for cross-provincial healthcare services, covering all 31 provinces, autonomous regions, and municipalities. From January to August 2017, direct in-province settlement for New Rural Cooperative Medical Scheme (NRCMS) patients was implemented for 1.914 million visits, with reimbursements totaling RMB 10.52 billion, reducing out-of-pocket advances by an average of RMB 5,496.3 per patient. Meanwhile, networked cross-provincial settlement under the NRCMS covered 18,235 visits, with reimbursed amounts reaching RMB 140 million, reducing out-of-pocket advances by an average of RMB 7,677.5 per patient.

How Does Direct Settlement for Cross-Regional Medical Care Under the New Rural Cooperative Medical Scheme Work? Which Regions Benefit?

First, strengthen top-level design and improve the policy framework for cross-regional medical expense settlement under the New Rural Cooperative Medical Scheme.The National Health and Family Planning Commission, in conjunction with the Ministry of Finance and other departments, issued a series of documents and model agreements, including the Implementation Plan for Networked Settlement of Cross-Regional Medical Expenses under the New Rural Cooperative Medical Scheme (NCMS) and Technical Specifications. These documents clarified the objectives and principles, and established the implementation pathway, technical specifications, settlement procedures, and security standards.

For patients referred due to medical needs, as well as migrant workers and long-term non-local residents who are not enrolled in the urban basic medical insurance, provinces shall be guided to establish relatively unified systems for cross-regional medical referral and registration, standardize policies on reimbursement, settlement, and payment recovery, streamline procedures, strengthen management, and enhance services.

Second, improve the management and handling system and implement relevant responsibilities.With the approval of the State Commission Office for Public Sector Reform, the Institute of Medical Information, Chinese Academy of Medical Sciences, was designated as the “National Health and Family Planning Commission’s Center for Management of Cross-Regional Settlement for the New Rural Cooperative Medical Scheme,” thereby strengthening the Commission’s headquarters-based team for managing cross-regional medical expense settlement.

All nine provinces have strengthened provincial-level administrative management capacity, clarified division of labor, assigned responsibilities to specific individuals, and actively applied for the establishment of special fiscal accounts for cross-regional settlement. Provincial health and family planning commissions in other provinces have also designated responsible departments to enhance supervision and guidance of designated medical institutions within their jurisdictions. All designated medical institutions have established leadership groups comprising hospital executives and representatives from medical insurance, information technology, finance, and other relevant departments, as required, to ensure coordinated oversight and fulfillment of duties.

Third, prioritize practicality by advancing the interconnection of information systems for cross-regional medical treatment under the New Rural Cooperative Medical Scheme.Developed the National New Rural Cooperative Medical Scheme (NRCMS) Inter-provincial Medical Treatment Settlement Information System, enabling functions such as cost verification, referral, settlement, and fund application. Guided nine provinces in upgrading and transforming NRCMS information platforms at all levels to incorporate referral settlement capabilities. Established connectivity channels between information platforms at various administrative levels and designated medical institutions. Directed designated medical institutions to upgrade their Hospital Information Systems (HIS) in accordance with unified technical standards, ensuring direct or indirect connection to the national platform. With the national platform serving as the hub, linking provincial and county-level platforms with designated medical institutions, a basic NRCMS network for inter-regional medical treatment settlement has been established, featuring interconnected data sharing, comprehensive functionality, stable operations, and robust information security.

Fourth, improve mechanisms to enhance the level of management and service.First, a referral mechanism was established. Across various regions, a streamlined and closely coordinated referral system has been widely implemented, initiated by the referring medical institution, reviewed by the handling agency, and confirmed by the receiving medical institution.

Secondly, establish a cross-provincial settlement mechanism. The reimbursement amount shall be determined in accordance with the principle of “applying the medical treatment location’s catalog and the insured location’s policies,” thereby forming a settlement mechanism wherein designated medical institutions are responsible for settlement and advance payment, while handling agencies are responsible for verification, confirmation, and reimbursement.

Finally, establish an information coordination and communication mechanism. Publish the contact persons and telephone numbers for handling cross-regional medical care services in each pooling area to facilitate public inquiries. Leverage channels such as WeChat and telephone to streamline communication between designated medical institutions and platforms at all levels as well as pooling areas, thereby achieving convenient and efficient communication.

Fifth, strengthen training and supervision to vigorously advance the work.Conduct centralized training and remote guidance to promptly address difficulties and challenges encountered at the local level. Employ measures such as meetings, circulars, admonitory talks, and supervision to vigorously accelerate network connectivity and settlement across regions, thereby ensuring effective implementation of work. In the recent period, actively cooperate with the State Council’s fourth round of major inspections, work jointly with provincial health and family planning departments to carry out rigorous self-inspection and rectification, and further improve relevant policies and measures.

The implementation of cross-regional medical expense settlement under the New Rural Cooperative Medical Scheme (NRCMS) has eliminated the burden of upfront payments, reduced the costs and time associated with administrative errands, and has been warmly welcomed by participating farmers and widely affirmed by all sectors of society. It is generally regarded as a significant and tangible benefit delivered to participating farmers by the CPC Central Committee and the State Council.

First, minimize the burden on patients.Adhering to the principle of convenience and efficiency, settlement processes are designed in compliance with policy requirements and under the premise of ensuring fund security. Procedures for referral, information submission, and counter payments are streamlined to the greatest extent possible. By using the national ID card as the sole medium, the level of informatization and intelligence across all stages is enhanced, thereby reducing patients’ waiting, form-filling, and queuing times, as well as administrative formalities.In July 2017, Shenzhen successfully implemented China’s first cross-provincial settlement of basic medical insurance payments via WeChat Pay, drawing widespread public attention.

Next, social forces were introduced to address bottleneck issues. In active response to the national call for streamlining administration and delegating power, China Life Insurance, China UnionPay, and Tencent were brought in to resolve these bottlenecks.To address the issue of prolonged payment cycles, China Life Insurance has contributed RMB 100 million as a revolving fund for cross-provincial settlement of medical expenses under the New Rural Cooperative Medical Scheme (NRCMS) across China, innovatively establishing a rapid reimbursement mechanism.

Currently, China Life has cumulatively disbursed RMB 12.197 million in revolving funds, reducing the reimbursement cycle for cross-provincial medical settlements under the New Rural Cooperative Medical Scheme (NRCMS) to within one month. This has significantly alleviated cash flow pressures on healthcare institutions and participating provinces, earning widespread recognition.

Finally, further reduce the burden on patients. Various regions are actively exploring the inclusion of critical illness insurance and medical assistance in the scope of direct settlement, thereby further alleviating patients' financial burdens and the hassle of running around for reimbursements. Nine provinces have basically achieved "one-stop" intra-provincial settlement for the New Rural Cooperative Medical Scheme (NRCMS) and critical illness insurance.

Anhui and Hainan have also incorporated civil affairs assistance funds into the scope of “one-stop” settlement. In Bijie, Zunyi, and other areas of Guizhou Province, the first batch of nationwide “one-stop” settlements for the New Rural Cooperative Medical Scheme (NRCMS) and critical illness insurance has been implemented, covering more than 16 million enrolled participants.

Interprovincial Direct Settlement for the New Rural Cooperative Medical Scheme (NRCMS) is a novel initiative characterized by strong policy orientation, broad scope, and complex procedures. Although the annual targets have been achieved, further consolidation and improvement are required. In the next phase, our Commission will strengthen publicity and guidance, enhance supervision and inspection, expand the network of designated medical institutions, and improve the management and service quality of interprovincial direct settlement.

So, which specific regions stand to benefit?

On August 1, 2017, a 19-year-old female patient from the Nagqu Prefecture of Tibet received cross-provincial healthcare services with direct online settlement under the New Rural Cooperative Medical Scheme at Peking Union Medical College Hospital in Beijing, becoming the first patient in the Tibet Autonomous Region to achieve nationwide cross-provincial medical expense direct settlement.The total medical expenses amounted to over RMB 84,000. Based on the reimbursement scope of the place where medical services were received and the reimbursement rate of the place of insurance participation, the actual reimbursed amount was over RMB 54,000, with a compensation ratio of nearly 65%.

The patient had severe heart disease, and the local hospital considered the surgery to be highly challenging. Following the referral recommendation from the Second People's Hospital of Tibet Autonomous Region, the patient sought treatment at Peking Union Medical College Hospital (PUMCH). After visiting the outpatient clinic of the Department of Cardiac Surgery at PUMCH on July 13, the patient was admitted to the hospital that same afternoon.

Following a comprehensive evaluation, the patient was diagnosed with valvular heart disease, severe mitral regurgitation; congenital heart disease, patent ductus arteriosus (PDA); and cardiac arrhythmia, specifically atrial fibrillation. In consideration of the patient’s unique lifestyle habits and language barriers, the Cardiac Surgery Ward endeavored to provide accommodations, such as customized meal plans and permitting one family member to accompany the patient. Based on the patient’s specific clinical condition, the department conducted thorough preoperative discussions regarding the surgical plan.

The discussion consistently centered on the following principles: first, how to maximize the improvement of patients' quality of life, and on that basis, how to best safeguard their financial interests. Patients may undergo prosthetic valve replacement surgery; however, both mechanical and bioprosthetic valves have inherent limitations that cannot be entirely overcome. Mechanical valves require lifelong anticoagulation therapy and regular monitoring of coagulation function, whereas bioprosthetic valves have limited durability, with a service life of approximately 15 years. For very young patients, this entails the likelihood of requiring future valve re-replacement.

Importantly, regardless of the type of prosthetic valve used, the cost is relatively high. Therefore, the discussion ultimately led to the decision to proceed with mitral valve repair, a procedure that is technically more challenging but significantly reduces costs.

On July 19, Professor Miao Qi’s team in the Department of Cardiac Surgery successfully performed patent ductus arteriosus closure, radiofrequency ablation for atrial fibrillation, and mitral valve plasty after five hours of meticulous effort. Leveraging their exceptional surgical expertise, the team ensured a smooth procedure with satisfactory outcomes, giving the patient a new lease on life. The entire course of care fully embodied the patient-centered principle of individualized treatment. Expressing their high satisfaction with the medical care received at Peking Union Medical College Hospital, the patient and family presented a silk banner to the Department of Cardiac Surgery as a token of gratitude.

“Shenzhen Without Rural Areas” Sets a Good Example for Fellow Citizens with Rural Hukou Across China!

Mr. Yang, a young man from Dazhou, Sichuan Province, had his first experience while caring for his hospitalized wife, Ms. Jian.

“My wife and I have been working in Shenzhen, while our social insurance is covered by the New Rural Cooperative Medical Scheme (NRCMS) back in our hometown in Sichuan. In the past, we couldn’t use the NRCMS for medical treatment in Shenzhen; we had to pay out-of-pocket first and then return to our hometown to seek reimbursement. Unexpectedly, WeChat has now enabled cross-regional reimbursement, which is incredibly convenient. We can check how much we spent and how much was reimbursed right on our phones, and even settle payments upon discharge via mobile. Most people from our county are working in Guangdong, and they can all benefit from this service when they fall ill, relieving a major concern for us.” Ms. Jian’s total hospitalization cost was RMB 14,853.96, of which RMB 6,180.66 was covered by the NRCMS and directly billed through the system. She only paid the remaining out-of-pocket amount of RMB 8,673.30 via WeChat Pay.

WeChat Pay for the New Rural Cooperative Medical Scheme (NRCMS) offers exceptional convenience. Users can successfully link their referral forms by simply entering personal information, their place of insurance coverage, and the referral number within WeChat. During hospitalization, patients can review daily cost breakdowns and reimbursement amounts, and complete payment and settlement with a single click via WeChat upon discharge. Prior to the establishment of the National NRCMS Inter-provincial Medical Settlement Information System, patients seeking medical care outside their home regions had to pay all medical expenses upfront and then endure a reimbursement process that often involved traveling thousands of kilometers and waiting one to three months or longer. With real-time settlement through WeChat, the entire process now takes just one minute, requiring patients to pay only the out-of-pocket portion, thereby significantly alleviating their financial burden.

Currently, WeChat Pay for the New Rural Cooperative Medical Scheme is accelerating its expansion into more cities and is integrating with hospitals such as Nanshan Hospital of Shenzhen, Bao’an People’s Hospital of Shenzhen, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Yunnan Cancer Hospital, West China Second University Hospital of Sichuan University (online solution), and Chengdu Fifth People’s Hospital (online solution), to enhance the healthcare experience for more patients.

On September 5, 2017, Mr. Wu from Xishui, Guizhou Province, received the first nationwide real-time cross-provincial settlement under the New Rural Cooperative Medical Scheme’s “Basic Medical Insurance + Critical Illness Insurance” at the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University.

Mr. Wu, a 36-year-old migrant worker in Guangdong Province, suffered from acute pancreatitis. Finding hospital care in Guangdong unaffordable, he returned to his hometown of Xishui for treatment. One day after admission, the local hospital determined that it was unable to provide adequate care and proactively referred him to the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University in Sichuan Province. He was formally admitted to the hospital on August 30 and has largely recovered after one week of treatment.

Upon discharge, Mr. Wu received direct reimbursements of RMB 4,258 under the New Rural Cooperative Medical Scheme (NRCMS) and RMB 4,401.83 under the Critical Illness Insurance, achieving a combined reimbursement rate of 91.8%. He expressed his excitement, stating, “I am delighted that cross-provincial direct settlement for NRCMS and Critical Illness Insurance is now available through the national network. This has eliminated the unnecessary financial burden I would have incurred by traveling to Xishui County in Guizhou Province for reimbursement, while also reducing my out-of-pocket expenses at the hospital. I am deeply grateful for these beneficial policies implemented by the Party and the State!”