The reporter learned from the Office of Medical Reform of the State Council that the National Health and Family Planning Commission issued the "Notice of the Office of Medical Reform of the State Council on Accelerating the Promotion of Critical Illness Insurance for Urban and Rural Residents". The notice pointed out that provinces that have not yet launched pilot projects for critical illness insurance for urban and rural residents must do so. The pilot work will be launched before the end of June 2014.
The National Health and Family Planning Commission proposed that provinces that have launched pilot projects must do a good job in all relevant work, conscientiously organize implementation, promptly study and solve problems existing in the pilot, and gradually expand implementation on the basis of summarizing experience. Scope; provinces that have not yet launched pilot projects must start pilot work before the end of June 2014.
The pilot will establish and improve a coordination and promotion working mechanism led by the Medical Reform Office and involving development and reform, finance, social security, civil affairs, health and family planning, insurance supervision and other departments. The notice requires provinces that have not yet formulated an implementation plan for critical illness insurance to issue relevant documents before the end of May 2014 and submit them to the Medical Reform Office of the State Council and relevant competent authorities for filing.
The notice requires all localities to control unreasonable medical practices and expenses. Strengthen the supervision of commercial insurance institutions, urge them to improve service quality and level through daily spot checks, establish convenient complaint acceptance channels and other methods, prevent information leakage and abuse, and promptly deal with violations of laws and regulations.
The notice also encourages commercial insurance institutions to take advantage of the national network to provide insured persons with "one-stop" instant settlement, off-site settlement and other services to ensure that the public can obtain critical illness insurance compensation conveniently and timely. Establish a critical illness insurance information reporting system. Critical illness insurance financing standards, benefit levels, annual income and expenditures, etc. must be disclosed to the public and accept social supervision.
It is understood that by the end of 2013, 23 provinces had introduced critical illness insurance implementation plans and identified 120 pilot cities. (1) Purchase critical illness insurance from commercial insurance institutions. The local government's health, human resources and social security, finance, and development and reform departments formulate basic policy requirements for critical illness insurance such as financing, reimbursement scope, minimum compensation ratio, and medical treatment and settlement management, and select commercial insurance institutions to undertake critical illness insurance through government bidding. . The bidding mainly includes the specific compensation ratio, profit and loss ratio, equipped undertaking and management strength, etc. Commercial insurance institutions that meet the basic access conditions voluntarily participate in the bidding. After winning the bid, they will undertake critical illness insurance in the form of an insurance contract, bear operating risks, and be responsible for their own profits and losses. The premium income from critical illness insurance provided by commercial insurance institutions is exempt from business tax according to current regulations. Areas that have already launched critical illness protection and supplementary insurance for urban and rural residents must gradually improve the mechanism and make connections.
(2) Standardize critical illness insurance bidding and contract management. All localities must adhere to the principles of openness, fairness, impartiality and good faith, establish and improve bidding mechanisms, and standardize bidding procedures. Commercial insurance institutions must bid in accordance with the law. The tenderer shall sign an insurance contract with the winning commercial insurance institution to clarify the responsibilities, rights and obligations of both parties. The cooperation period shall in principle be no less than 3 years. It is necessary to follow the principles of balancing revenue and expenditure, maintaining principal and making a small profit, reasonably control the profitability of commercial insurance institutions, and establish assessment methods that focus on the level of protection and the satisfaction of insured (partners). In order to facilitate the long-term stable operation of critical illness insurance and effectively protect the actual benefit level of insured persons, a corresponding dynamic adjustment mechanism can be established in the contract for excess balances and policy losses. All localities should continue to improve the content of contracts and explore the formulation of unified contract templates across the province (districts and municipalities). Due to violation of the contract or other circumstances that seriously damage the rights and interests of the insured (partner), both parties to the contract may terminate or terminate the cooperation in advance and be held accountable in accordance with the law.
(3) Strict the basic access conditions for commercial insurance institutions. Commercial insurance institutions undertaking critical illness insurance must meet the following basic conditions: meet the necessary conditions for operating health insurance stipulated by the China Insurance Regulatory Commission; operate special health insurance business in China for more than 5 years and have good market reputation; have a complete service network and strong Professional medical insurance capabilities; equipped with full-time staff with professional backgrounds such as medicine; commercial insurance institution headquarters agrees with branches to participate in local critical illness insurance business and provides business, financial, information technology and other support; and can achieve separate accounting for critical illness insurance business.
(4) Continuously improve the ability and level of critical illness insurance management services. Fund management shall be standardized, and the premiums obtained by commercial insurance institutions from undertaking critical illness insurance shall be separately accounted to ensure the safety of funds and solvency. Strengthen the connection with urban residents' medical insurance and new rural cooperative medical insurance services, provide "one-stop" instant settlement services, and ensure that people can enjoy critical illness insurance benefits conveniently and in a timely manner. Authorized by the urban residents' medical insurance and new rural cooperative medical care agencies, the necessary information exchange and data sharing can be carried out based on the urban residents' medical insurance and new rural cooperative medical care information systems to improve service processes and simplify reimbursement procedures. Leverage the advantages of the national network of commercial insurance institutions to provide remote settlement and other services to insured persons. Promote the reform of payment methods in collaboration with basic medical insurance, standardize medical behaviors and control medical expenses in accordance with diagnosis and treatment standards and clinical pathways.
Commercial insurance institutions must effectively strengthen management, control risks, reduce management costs, improve service efficiency, speed up settlement, and pay medical expenses to medical institutions in a timely and reasonable manner in accordance with regulations. Commercial insurance institutions are encouraged to provide diversified health insurance products on the basis of undertaking critical illness insurance business. (1) Strengthen the supervision of critical illness insurance undertaken by commercial insurance institutions. All relevant departments must assume their respective responsibilities and cooperate with each other to effectively protect the rights and interests of insured (partners).
The health, human resources and social security departments, as the new rural cooperative medical insurance and urban residents' medical insurance authorities and tenderers, conduct supervision and inspection through daily spot checks, establishing complaint acceptance channels and other methods, and urge commercial insurance institutions to improve service quality and level in accordance with contract requirements. Maintain the information security of insured (partners), prevent information leakage and abuse, and deal with violations of laws and regulations in a timely manner. The insurance regulatory authorities shall carry out professional qualification review, service quality and daily business supervision, strengthen solvency and market behavior supervision, and intensify investigation and punishment of violations and unfair competition by commercial insurance institutions. The financial department shall clarify the corresponding financial expenditure and accounting methods for using basic medical insurance funds to purchase critical illness insurance from commercial insurance institutions, and strengthen fund management. The audit department conducts strict audits in accordance with regulations.
(2) Strengthen the control of medical institutions and medical expenses. Relevant departments and institutions must strengthen supervision and management through various methods, prevent and control unreasonable medical behaviors and expenses, and ensure the quality of medical services. The health department must strengthen supervision of medical institutions, medical service behavior and quality. Commercial insurance institutions should give full play to the role of the medical insurance mechanism, work closely with the health, human resources and social security departments, and strengthen the monitoring of related medical services and medical expenses.
(3) Establish a regulatory system for information disclosure and multi-party social participation. The situation of signing agreements with commercial insurance institutions, as well as financing standards, treatment levels, payment processes, settlement efficiency, and annual income and expenditure of critical illness insurance will be disclosed to the public and accepted for social supervision. (1) Strengthen leadership and conscientiously organize and implement. All localities must fully understand the importance of developing critical illness insurance, plan carefully, deploy carefully, pilot it first, and gradually roll it out. Provinces that have launched critical illness insurance pilots should sum up their experiences in a timely manner and gradually expand the scope of implementation. Provinces that have not yet launched pilot projects can choose several cities (prefectures) to pilot or the entire province. All localities must continuously improve policies in practice. The medical reform leading groups of each province (autonomous region, city) shall submit the implementation plan formulated by the province to the Office of the Medical Reform Leading Group of the State Council, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Security, and the China Insurance Regulatory Commission for filing.
(2) Proceed steadily and pay attention to seeking advantages and avoiding disadvantages. All localities should fully consider the stability and sustainability of critical illness insurance protection, advance it step by step, and focus on exploring the coverage, protection level, fund management, bidding mechanism, and operation specifications of critical illness insurance. Pay attention to summarizing experience, timely study and solve problems found, strengthen evaluation, and summarize the progress and operation of critical illness insurance every year. The provincial (autonomous and municipal) medical reform leading groups must submit annual reports to the State Council Medical Reform Leading Group Office, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Security, the China Insurance Regulatory Commission, and the Ministry of Civil Affairs.
(3) Overall coordination and strengthening departmental collaboration. Carrying out critical illness insurance involves multiple departments and multiple systems. Each locality must, under the leadership of the medical reform leading group, establish a system composed of development and reform (medical reform leading group office), health, human resources and social security, finance, insurance supervision, civil affairs and other departments. Coordination and promotion mechanism for critical illness insurance work. Relevant departments of the central government have strengthened guidance and coordination on critical illness insurance for urban and rural residents. Departments such as health, human resources and social security, finance, and insurance supervision must implement the measures according to their division of responsibilities, refine supporting measures, and strengthen communication and collaboration to form synergy. The offices of the local medical reform leading groups should play the role of overall coordination and service, and do a good job in tracking analysis, monitoring and evaluation.
(4) Pay attention to publicity and guide public opinion. It is necessary to strengthen the publicity and interpretation of critical illness insurance policies, closely track and analyze public opinion, and enhance the awareness of insurance responsibilities in the whole society, so that this policy can be deeply rooted in the hearts of the people, gain understanding and support from the general public and all sectors of society, and create a good social environment for the implementation of critical illness insurance. environment. In August 2012, six ministries and commissions issued the "Guiding Opinions on Carrying out Critical Illness Insurance for Urban and Rural Residents", requiring all localities to underwrite critical illness insurance business through commercial insurance institutions. Up to now, 13 insurance companies across the country have launched critical illness insurance business. Among them, large insurance companies are more active. For example, China Life underwrites more than 70 critical illness insurance projects in Qinghai, Shandong and other provinces and cities; China Life Insurance underwrites more than 80 critical illness insurance projects in Guangdong, Jiangsu and other provinces and cities.
On November 29, 2012, the General Office of the Fujian Provincial Government forwarded the "Implementation Opinions on Further Improving Critical Illness Insurance for Urban and Rural Residents" jointly formulated by the Provincial Development and Reform Commission, the Department of Health and other departments. Seven aspects, including protection of species and needy groups, fund raising, and methods of undertaking, have been clarified that serious illness insurance for urban and rural residents will be fully implemented from January 1, 2013.
The "Implementation Opinions" clearly state that critical illness insurance protection targets all urban residents' medical insurance and New Rural Cooperative Medical Insurance (co-insured) persons. When the hospitalization expenses of the insured (combined) persons are reimbursed in accordance with the current medical insurance policies, and the annual cumulative compliant medical expenses of the individual reach the deductible, they will be included in the critical illness medical insurance, and the actual reimbursement ratio shall not be less than 50%, based on the medical expenses. The payment ratio is determined in high and low segments. In principle, the higher the medical expenses, the higher the payment ratio. In principle, the maximum payment limit including basic medical insurance is not less than 200,000 yuan.
The financing standards for critical illness insurance in Fujian Province are, in principle, based on 5% of the current year’s medical insurance financing standards for local urban and rural residents, and no additional critical illness insurance premiums will be charged to insured persons. Where conditions permit, financing standards may be raised based on actual conditions.
The "Implementation Opinions" also proposed that the level of protection for specific diseases and needy groups will be further improved. For 20 specific diseases such as uremia and childhood leukemia, the coverage will be based on "basic medical insurance + serious illness insurance + medical assistance" According to the method, the actual payment ratio of compliant medical expenses for civil assistance recipients shall not be less than 90%.
In addition, after the Fujian Provincial Red Cross Society has reimbursed and compensated for the New Rural Cooperative Medical System, urban medical insurance, commercial insurance, civil assistance, etc., there are serious diseases where the medical cost burden is still too heavy, the economy is in trouble, and it is even impossible to sustain continued treatment. The rescue object will be given another rescue. In 2013, the focus of rural medical security in my country will shift to serious diseases. All 20 diseases, including lung cancer and gastric cancer, are included in the scope of critical illness protection. The actual reimbursement ratio for hospitalization expenses for patients with critical illnesses is not less than 70% and can reach a maximum of 90%.
Twenty diseases included in critical illness protection: childhood leukemia, congenital heart disease, end-stage renal disease, breast cancer, cervical cancer, severe mental illness, drug-resistant tuberculosis, AIDS opportunistic infections, hemophilia, chronic Granulocytic leukemia, cleft lip and palate, lung cancer, esophageal cancer, gastric cancer, type I diabetes, hyperthyroidism, acute myocardial infarction, cerebral infarction, colon cancer, and rectal cancer. The Ministry of Human Resources and Social Security held a press conference at 10 a.m. on October 25, 2013 to introduce the progress of human resources and social security work in the third quarter of 2013. Yin Chengji, spokesperson of the Ministry of Human Resources and Social Security, said that the Ministry of Human Resources and Social Security has actively promoted the pilot program of critical illness insurance for urban and rural residents. 23 provinces have issued critical illness insurance implementation plans and 120 pilot cities have been identified.