China Insurance Regulatory Commission [2009] No.71
All insurance regulatory bureaus and insurance companies:
Opinions of the Central Committee of the State Council on Deepening the Reform of the Medical and Health System (Guo Ban Fa [2009] No.6, hereinafter referred to as "Opinions on Medical Reform") and Notice of the State Council on Printing and Distributing the Recent Key Implementation Plan for the Reform of the Medical and Health System (2009-201year) (Guo Fa [2009] No.65438). The following opinions are put forward for the insurance industry to thoroughly implement the spirit of the "opinions on medical reform" and "implementation plan" and actively participate in the construction of multi-level medical security system:
First, fully understand the significance of actively participating in the construction of multi-level medical security system under the new situation of medical reform.
(A) is conducive to accelerating the establishment and improvement of a multi-level medical security system. The "Opinions on Medical Reform" proposes to "accelerate the establishment and improvement of a multi-level medical security system with basic medical security as the main body and other forms of supplementary medical insurance and commercial health insurance as supplements, covering urban and rural residents". Commercial health insurance is an organic part of multi-level medical security system. Giving full play to the professional advantages of efficient operation, flexible security and comprehensive services of the insurance industry and actively participating in the construction of a multi-level medical security system are conducive to innovating the medical security management service mechanism, enriching the security level and improving the security level.
(2) It is helpful to meet diversified health protection needs. Safeguarding and improving people's livelihood is the fundamental purpose of economic and social development. With China's economic development and social progress, the people have higher requirements for improving the level of health protection. Actively developing commercial health insurance, such as medical insurance, sickness insurance, nursing insurance and disability income loss insurance, can reduce the burden of medical expenses, disease loss expenses and nursing expenses outside the basic medical insurance and meet diversified health protection needs.
(3) It is helpful to promote the sound and rapid development of the industry. Health insurance is one of the important areas in the development of insurance industry. The medical reform opinion puts forward that "actively develop commercial health insurance" and "explore entrusting qualified commercial insurance institutions to handle various medical security management services", which broadens the business scope of commercial health insurance and provides good development opportunities for commercial health insurance. The insurance industry should seize this opportunity period, push commercial health insurance to a new stage of development through continuous efforts and exploration, and promote the sound and rapid development of the industry.
Second, vigorously develop commercial health insurance to meet diversified health protection needs.
(4) Further enrich the health insurance product system. Intensify product innovation and provide diversified and personalized choices for enterprises and individuals in terms of insurance liability, insurance premium rate, payment method and service content. Vigorously develop all kinds of medical insurance and sickness insurance, increase the research and development of disability income loss insurance products, design nursing insurance products to meet the needs of the aging population, and provide diversified health protection services for the broad masses of the people.
(5) Vigorously develop supplementary insurance for basic medical insurance. According to the changes in the object and scope of basic medical insurance such as urban workers' basic medical insurance, urban residents' basic medical insurance and new rural cooperative medical care, supplementary medical insurance products will be developed to form a benign complement with the basic medical insurance to meet the people's higher-level health protection needs. Actively provide management services for all kinds of supplementary medical insurance. Explore the establishment of new rural cooperative medical insurance.
Three, actively participate in the basic medical insurance management services, improve the separation mode.
(6) Strive for government support. In order to adapt to the development trend of improving the overall level of basic medical security, coordinating urban and rural areas, and integrating handling resources, qualified insurance companies should actively publicize the position and role of commercial insurance in the multi-level medical security system, introduce the mechanism, technology, service and cost-effective advantages of commercial insurance in handling basic medical security management services, strive for government support, and actively and steadily participate in basic medical security management.
(7) Improve the management mode. Handling basic medical security management services, mainly based on entrusted management mode, mainly providing services such as scheme design, consultation and suggestion, entrusted fund management, medical service investigation, medical expense audit, medical expense reimbursement and payment, and health management. , and does not bear the risk of profit and loss of the protection fund. An insurance company shall sign a management contract with the government, clarify the rights and obligations of both parties, reasonably determine the management fee according to the service content, and gradually explore the establishment of a market-oriented management rate formation and adjustment mechanism. The entrusted management contract shall conform to the national basic medical security policy.
On the premise that the conditions are available and the risks are controllable, insurance companies can explore the basic medical security services in the form of insurance contracts. If the insurance contract is adopted, the insurance company shall bear the responsibility of guarantee in accordance with the contract and earnestly safeguard the interests of the insured.
(eight) improve the management level. Insurance companies should constantly improve their management service systems and processes and establish standardized management service standards. Gradually build a medical service network with reasonable layout, high quality service and standardized management, improve service convenience and ensure the quality of management services.
(9) It meets the requirements for handling. Insurance companies participating in basic medical insurance management should meet the following conditions: first, establish a separate accounting system; The second is to establish a special underwriting and claims settlement system; The third is to establish a health insurance data management system; Fourth, the head office agreed in writing to establish an incentive and restraint mechanism; Fifth, there are branches in the areas to be involved, with strict internal control and strong service capabilities; Sixth, it is equipped with actuarial personnel, underwriting personnel, compensation personnel and full-time management service personnel with relevant professional knowledge; Seventh, it has a fully functional, relatively independent, safe and efficient information management system, which can be docked with the information system of designated medical institutions; Eighth, other conditions stipulated by the China Insurance Regulatory Commission.
Fourth, actively explore and participate in the construction of medical service system.
(ten) to explore the health management service model. Encourage the exploration of a comprehensive security service model combining health insurance and health management, and gradually realize the whole process management of health maintenance and diagnosis and treatment activities before, during and after the event. Actively promote health education, health consultation, chronic disease management and other services, improve people's health awareness, improve lifestyle, and prevent the occurrence and development of diseases. Create conditions to establish customer health records, and realize the sharing of customer health records and medical information with medical institutions through various channels. Actively explore the business model of sharing risks and benefits with medical institutions.
(eleven) the development of medical insurance. Actively develop medical practice insurance such as medical accident insurance, medical practitioner liability insurance and medical institution liability insurance, use insurance mechanisms to resolve medical risks, reduce medical disputes, and promote the construction of harmonious doctor-patient relationship.
(12) Explore investing in medical institutions. According to the spirit of medical reform opinions, we should act according to local conditions and capabilities, explore participation in the restructuring of public hospitals, invest in medical institutions, and promote the complementary advantages of insurance industry and medical service industry. Support professional health insurance companies and other related insurance institutions to try first.
Five, strengthen management, and constantly improve the health insurance service ability of the insurance industry.
(thirteen) to strengthen the professional construction. Innovate management, improve the separate accounting system, actuarial system, risk management system, underwriting system, claims system and data management system of health insurance, increase investment and promote the professional development of health insurance.
(14) Strengthen risk management and control. Insurance companies should actively participate in local medical service supervision organizations. Explore the establishment of the management system of designated hospitals in the insurance industry, the negotiation mechanism of medical institutions and various effective payment mechanisms, and give play to the restrictive role of medical security in medical services. By increasing the reimbursement ratio and increasing the service content, we will guide customers to designated hospitals for medical treatment, strengthen the control of medical expenses, and prevent unreasonable compensation risks.
(fifteen) to promote the construction of information systems. According to the characteristics of medical insurance management, establish a fully functional and relatively independent information system, and gradually realize the docking with the information system of medical institutions. Establish and improve basic databases such as disease incidence and medical expenses. Vigorously promote the data processing and statistical analysis functions of the information system, improve the data analysis ability of health insurance business, and realize the in-depth utilization of health insurance business information.
(16) Training professionals. Strengthen the construction of health insurance professionals, especially the cultivation of actuarial, underwriting, claims settlement and health management talents. Improve the training system and improve the professional quality of health insurance practitioners.
Six, strengthen guidance and supervision, and promote the development of health and safety standards.
(seventeen) to strengthen supervision and promote the development of norms. Strengthen market behavior supervision and standardize business behavior. Conscientiously implement the Insurance Law and the Measures for the Administration of Health Insurance, strengthen the supervision of health insurance products and sales processes, prevent misleading risks in sales, fully implement the life insurance business service standards, and focus on solving outstanding problems in health insurance sales, underwriting and claims settlement. Further optimize the claim settlement process, simplify the claim settlement procedures, increase the claim settlement limit, encourage insurance companies to gradually provide real-time claim settlement services for customers, and earnestly safeguard the legitimate rights and interests of the insured. Solidly promote the supervision of corporate governance structure, continuously carry out internal control evaluation, and urge insurance companies to establish a long-term mechanism for standardized operation. Strengthen solvency supervision, strengthen the study of health insurance management rules, improve the scientific and effective supervision, and ensure and promote the sustained and healthy development of the industry.
(eighteen) to strengthen the guidance and management of medical security management services. Insurance companies participating in medical insurance management services should consciously accept the supervision and guidance of medical insurance administrative departments and insurance regulatory departments. Establish and improve the system of pre-filing, exit report and regular report of medical security management services. Insurance companies participating in medical insurance management services shall file with the local insurance regulatory bureau in advance; To withdraw from the medical insurance management service, it shall obtain the consent of the client, do a good job in the aftermath handover, and report to the Insurance Regulatory Bureau in advance, explaining the reasons for withdrawal, withdrawal procedures, handling of remaining problems and related information; Before June 5438+0 and July 20 every year, insurance companies and their branches shall submit reports on the operation of medical insurance management services to the China Insurance Regulatory Commission and the local Insurance Regulatory Bureau respectively.
Strengthen the supervision of medical insurance management service process to ensure the safety of entrusted management funds, service norms and systems in place. Encourage fair competition and be wary of short-term behavior regardless of cost and consequences. Strengthen the supervision and cooperation with the administrative department of medical security, establish a cooperation mechanism with regular communication, clear responsibilities, different emphases and mutual supplementation, form a joint force of supervision, and protect the legitimate rights and interests of the insured.
China Insurance Regulatory Commission (CIRC)
Press release issued on 27 May 2009
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