MOHRSS Drafting Inter-provincial Medical Expense Settlement Regulations and Information System

Huang Huabo, Deputy Director of the Social Insurance Management Center under the Ministry of Human Resources and Social Security, recently disclosed progress on the cross-regional settlement of medical insurance. He stated that the operational procedures for networked settlement of cross-provincial medical treatment and the development of the corresponding information system are currently being drafted.

At the “Wenjin Roundtable Seminar on Deepening Healthcare System Reform and Advancing the Healthy China Initiative,” recently co-hosted by the Chinese Government Online platform and Xinhua News Agency, Huang Huabo disclosed the aforementioned information.

In March this year, during the Two Sessions, Premier Li Keqiang pledged at his press conference that, on the basis of basically achieving direct settlement of cross-city medical expenses within provinces this year, efforts would be made to enable direct settlement of hospitalization costs for elderly patients receiving care across provincial borders within two years.

Huang Huabo stated that following the Premier’s commitment, the Ministry of Human Resources and Social Security immediately carried out special deployments, established a dedicated task force, formulated detailed work plans and action agendas, arranged tasks according to a countdown timeline, and coordinated work progress on a weekly basis.

He stated that over the course of more than a month, the Ministry of Human Resources and Social Security (MOHRSS) conducted field research in Jiangsu, Chongqing, Guangdong, Hunan, Sichuan, and other regions. Additionally, three regional meetings were held in Beijing, Shanghai, and Guangdong to study and deploy settlement and clearing models, draft operational procedures for networked direct settlement of cross-provincial medical expenses incurred outside the insured’s home region, and formulate business requirements for information system development. Furthermore, centralized work has commenced on information system development, including drafting technical construction specifications, conducting overall system design, preparing card usage environments across regions, and performing technical validation for the universal application of social security cards.

Huang Huabo pointed out that the nationwide networked settlement for cross-regional medical care is a complex systematic project, involving multiple aspects such as policy, administration, information systems, and fund settlement and clearing. At present, there are still many problems: First, the direct settlement for cross-provincial medical care is still in the stage of spontaneous exploration, with inconsistent models. The point-to-point negotiation and docking between provinces entail high costs, low efficiency, poor stability, and significant difficulties in promotion and replication. Second, the working models for direct settlement of intra-provincial cross-regional medical care are inconsistent, and progress is uneven; in some provinces where such work has been launched, a small number of prefecture-level cities have not yet been included.

In light of this, he stated that, regarding the business model, the Ministry of Human Resources and Social Security (MOHRSS), having comprehensively considered local experiences and lessons learned, is preparing to adopt a ministry-level unified settlement model. Platforms for settlement will be established at both the ministerial and provincial levels; provinces will no longer directly interface and settle with other provincial platforms, but will only interface with the ministerial platform, thereby improving work efficiency. Meanwhile, efforts will be made to establish a revolving fund system to fundamentally resolve the issue of medical treatment locations being unwilling or unable to advance funds for cross-regional medical care. Furthermore, individuals receiving cross-provincial medical care will be subject to unified management by the location where treatment is received, and will be uniformly incorporated into that location’s intelligent monitoring and management system, thereby fundamentally addressing issues such as fraudulent invoices and fictitious medical treatments.

In addition, he revealed that after multiple rounds of communication, the National Development and Reform Commission (NDRC) has agreed to provide a “green channel” for the “Golden Insurance Project Phase II,” which supports cross-regional medical expense settlement. The project is currently in the expert review stage and is expected to secure its initial funding tranche relatively soon. To address the issue of inconsistent standards, the Ministry of Human Resources and Social Security (MOHRSS) has formulated the *Standard for Classification and Codes of Drugs in Social Insurance* and promoted its adoption across most provinces with interconnected systems. The *Classification and Code Standard for Medical Service Items in Social Insurance* is currently open for public comment.