On August 26, the National Medical Insurance Administration issued on its official website the "Guiding Opinions on Establishing and Improving the Employee Basic Medical Insurance Outpatient Mutual Aid Guarantee Mechanism (Consultation Draft)" (hereinafter referred to as the "Consultation Draft").

　　Among them, it is clear that it is necessary to establish and improve a mutual aid guarantee mechanism for general outpatient medical expenses for all employees including in-service employees and retirees, with the payment ratio starting at 50%, and appropriate tilt to retirees. This means that minor diseases and common diseases in outpatient clinics will also be included in the payment scope of the medical insurance overall fund.

　　In addition, the draft also pointed out that the funds in the medical insurance personal account can be used to pay for the medical expenses incurred by the spouse, parents, and children in the medical insurance designated medical institutions.

　　Take a look specifically.

　　Outpatient expenses are planned to be included in reimbursement

　　50% reimbursement rate starts

　　Picture Source / Figure Worm

　　Since the reform of the employee medical insurance system, my country’s basic medical insurance system has focused on insuring hospitalization and provided relatively high benefits for hospitalization. In 2019, the medical expenses reimbursement rate within the hospitalization policy of the employee medical insurance reached more than 80%. But at the same time, the outpatient protection of the insured person is relatively weak.

　　On the one hand, employee medical insurance implements a unified account. Except for a limited number of high-cost outpatient chronic diseases that are included in the overall fund payment scope and enjoy higher benefits, most of the other outpatient expenses are mainly paid through personal accounts.

　　On the other hand, personal accounts do not have the function of mutual aid and cannot spread the cost risk among the population, which leads to an abnormally heavy burden of outpatient expenses. Most of the healthy people have a large balance in their personal accounts, while a small number of the elderly and frail people cannot make ends meet and have heavy personal burdens.

　　The draft for comments points out that this reform will include outpatient medical expenses in the payment scope of the basic medical insurance coordinating fund, reforming employee basic medical insurance personal accounts, establishing a sound outpatient mutual aid guarantee mechanism, improving the efficiency of the medical insurance fund, and gradually reducing the medical care of insured persons. Cost burden, to achieve a more fair and sustainable system.

　　The first of the core measures is to establish an outpatient mutual aid guarantee mechanism, starting with chronic diseases such as hypertension and diabetes, which are burdened by the masses, and gradually including common outpatient medical expenses for frequently-occurring and common diseases into the overall planning fund.

　　General outpatient clinics cover all employees who are covered by medical insurance, and the payment ratio starts from 50%. As the affordability of the fund increases and the level of protection is gradually increased, the payment of benefits can be appropriately inclined to retirees.

　　This is a new medical insurance benefit.

　　In addition, according to the draft for comments, all localities can explore the gradual expansion of the scope of outpatient chronic diseases paid by the overall fund. Some special treatments that need to be carried out in outpatient clinics and are more economical and convenient than hospitalization can be managed with reference to hospitalization benefits.

　　What are the benefits of outpatient mutual aid protection?

　　The relevant person in charge of the National Medical Insurance Bureau said that the general outpatient medical expenses can be reimbursed, and explore to expand the scope of outpatient chronic diseases, and outpatient clinics can carry out more economical and convenient special treatment.

　　Before, the basic medical insurance system focused on hospitalization. In 2019, the medical expenses reimbursement rate within the hospitalization policy of employee medical insurance reached more than 80%, but outpatient protection was relatively weak and relatively short.

　　Yang Yansui, director of the Medical Service Governance Research Center of Tsinghua University and a professor at the School of Public Administration, said that in the past, outpatient expenses were mainly paid by personal accounts, but the money in personal accounts was relatively small. Reimbursement for going to the hospital is actually for taking medicine. Therefore, the establishment of an outpatient mutual aid guarantee mechanism is to keep pace with the times and adjust policies according to the needs of the people.

　　The new reform will benefit more than 300 million employees’ medical insurance participants.

　　According to the 2019 National Medical Insurance Development Statistical Bulletin issued by the National Medical Insurance Administration, 329.25 million people participated in employee medical insurance in 2019, an increase of 12.44 million or 3.9% over the previous year.

　　Unit payment plans to no longer enter the personal account

　　Picture Source / Figure Worm

　　According to the draft for comments, the accounting method of medical insurance personal accounts will also be changed: unit payments are no longer entered into personal accounts.

　　In the past, 2% of individual medical insurance payments and 30% of unit payments were credited to personal accounts.

　　After the reform, the part of the unit payment is put into the medical insurance pooling fund, and is no longer credited to the personal account, and the part of the individual payment is still credited to the personal account.

　　Therefore, the amount of money newly transferred to the personal account during the current period will be reduced.

　　What is the use of this money?

　　is used to strengthen outpatient protection. The draft for comments proposes that after the adjustment of the accounting structure, the reduction of funds allocated to personal accounts is mainly used to support and improve the mutual aid protection of outpatient clinics and improve outpatient benefits.

　　Zhu Hengpeng, director of the Public Policy Research Center of the Chinese Academy of Social Sciences, said that based on the income of the employee medical insurance fund in 2019 (the overall fund is 1000.5 billion yuan, the individual account is 584 billion yuan), a rough estimate is that after the reform, the individual account will only be included in the personal payment part, and no longer will be allocated. In the part of unit payment, the overall fund will increase by about 200 billion yuan. Such an increase in the overall planning fund obviously provides a great possibility for improving the level of protection of insured persons and reducing the medical burden of patients.

　　Zhang Yinghua, an executive researcher at the World Social Security Research Center of the Chinese Academy of Social Sciences, said that the cancellation of the part of the unit payment and transfer to the personal account means that the social pooling part of the medical insurance fund has been increased, and the mutual aid between healthy people and sick people has been strengthened. For healthy people, If you become ill in the future, you can also get more mutual aid from members of society.

　　The relevant person in charge of the National Medical Insurance Bureau said that after the adjustment, the overall fund has a stronger protection function for outpatient clinics, that is, the employee medical insurance system will provide better reimbursement for outpatient clinics.

　　Medical insurance personal account can be paid

　　Spouse, parents and children, etc. medical expenses

　　At the same time, the use of personal accounts has also expanded.

　　Before, the funds in the personal account can only be used to pay for the out-of-pocket expenses incurred by the insured employees in the designated medical institutions or designated retail pharmacies.

　　After the reform, it will be expanded to cover the expenses of employees’ spouses, parents and children.

　　Image source / 21st Century Business Herald

　　According to the draft, personal accounts are mainly used to pay for out-of-pocket expenses incurred by insured employees in designated medical institutions or designated retail pharmacies. It can be used to pay for the medical expenses incurred by the employees themselves, their spouses, parents, and children in medical insurance designated medical institutions, and the expenses incurred by individuals incurred in the purchase of drugs and medical consumables in designated retail pharmacies. Explore personal accounts for personal payment for spouses, parents, and children participating in basic medical insurance for urban and rural residents.

　　Experts pointed out that the previous personal accounts did not have the function of mutual assistance and could not spread the cost risk among the population, resulting in an abnormally heavy burden of outpatient expenses. Most of the healthy people had a large balance in their personal accounts, while a small number of the elderly and frail people could not make ends meet. The personal burden is heavy.

　　Zhang Yinghua pointed out that this will help realize family mutual aid. Healthy people and working people can use their own medical insurance personal account funds to "pay" and "pay" for their immediate family members. On the one hand, they can revitalize their idle account funds and on the other. On the one hand, strengthen family mutual help and unity.

　　Yang Yansui believes that the nature of medical insurance is social mutual aid, but the personal account mutual aid ability is poor, young people and healthy people cannot use it, and the elderly are not enough. The expansion of the use of personal accounts will help strengthen family mutual aid. One person participates in insurance. The whole family.

　　Fan Weidong, deputy director of the Treatment Protection Department of the National Medical Security Administration, said that the accumulated part of the personal account still belongs to the individual and will not be affected. After the reform, not only will the medical insurance benefits not be reduced, but also personal contributions will not be increased.