Serious illness insurance is to reimburse the high medical expenses incurred by urban and rural residents due to serious illness. The purpose is to solve the problem of "poverty caused by illness and returning to poverty due to illness", so that most people will not fall into economic difficulties because of illness.
20 12 On August 24th, six ministries and commissions, including the National Development and Reform Commission, the Ministry of Health, the Ministry of Finance, Ministry of Human Resources and Social Security, the Ministry of Civil Affairs and the China Insurance Regulatory Commission, issued the Guiding Opinions on Developing Serious Illness Insurance for Urban and Rural Residents.
In view of the serious illness burden of urban residents' medical insurance and the new rural cooperative medical system (NCMS), the market mechanism should be introduced to establish a serious illness insurance system to reduce the serious illness burden of urban and rural residents, and the reimbursement rate of serious illness medical insurance should not be less than 50%.
Extended data:
According to the Guiding Opinions on Developing Serious Illness Insurance for Urban and Rural Residents:
Five, the way of undertaking serious illness insurance for urban and rural residents
(a) to buy serious illness insurance from commercial insurance institutions. The health, human resources and social security, finance, development and reform departments of local governments shall formulate the financing, reimbursement scope and minimum compensation ratio of serious illness insurance.
As well as the basic policy requirements of medical treatment settlement management, the commercial insurance institutions that undertake serious illness insurance are selected through government bidding. Bidding mainly includes specific compensation ratio, profit and loss rate, contractor and management force.
Commercial insurance institutions that meet the basic access conditions voluntarily participate in bidding. After winning the bid, the company will undertake serious illness insurance in the form of insurance contract, bear business risks and be responsible for its own profits and losses.
The premium income of commercial insurance institutions undertaking serious illness insurance shall be exempted from business tax according to the existing regulations. In areas where serious illness protection and supplementary insurance for urban and rural residents have been carried out, it is necessary to gradually improve the mechanism and make a good connection.
(two) standardize the bidding and contract management of serious illness insurance. All localities should adhere to the principles of openness, fairness, justice, honesty and credibility, establish and improve the bidding mechanism, and standardize the bidding procedures. Commercial insurance institutions shall bid according to law.
The bidder shall sign an insurance contract with the successful commercial insurance institution, specifying the responsibilities, rights and obligations of both parties, and the cooperation period shall not be less than 3 years. It is necessary to follow the principles of balance of payments, capital preservation and meager profit, and reasonably control the profitability of commercial insurance institutions.
Establish an assessment method centered on the level of protection and the satisfaction of the insured (co-insured). In order to facilitate the long-term stable operation of serious illness insurance and effectively protect the actual benefit level of the insured (co-insured), a corresponding dynamic adjustment mechanism can be established for the excess balance in the contract and the policy loss.
All localities should constantly improve the contents of the contract and explore the formulation of a unified contract model for the whole province (autonomous regions and municipalities). Due to breach of contract or other acts that seriously damage the rights and interests of the insured (joint name), both parties to the contract may terminate or terminate the cooperation in advance, and shall be investigated for responsibility according to law.
(3) Strict basic access conditions for commercial insurance institutions. A commercial insurance institution undertaking serious illness insurance must meet the following basic conditions: it meets the necessary conditions for operating health insurance stipulated by the China Insurance Regulatory Commission.
Engaged in health insurance special business in China for more than 5 years, with a good market reputation; Have a perfect medical insurance service network and strong professional ability; Equipped with full-time staff with medical and other professional backgrounds.
The headquarters of the commercial insurance institution agrees that the branches will participate in the local serious illness insurance business and provide business, financial and information technology support; It can realize independent accounting of serious illness insurance business.
(four) continuously improve the ability and level of serious illness insurance management services. Standardize the management of funds, and the premiums obtained by commercial insurance institutions from undertaking serious illness insurance shall be accounted separately to ensure the safety and solvency of funds.
Strengthen the connection with urban residents' medical insurance and the new rural cooperative medical system, and provide "one-stop" instant settlement service to ensure that people can enjoy the treatment of serious illness insurance conveniently and timely. Authorized medical insurance for urban residents and new rural cooperative medical system.
We can exchange information and share data by relying on the urban residents' medical insurance and the new rural cooperative medical information system, improve the service process and simplify the reimbursement procedures. Give full play to the advantages of the national network of commercial insurance institutions.
Provide off-site settlement and other services for the insured (co-insured). Cooperate with the basic medical insurance to promote the reform of payment methods, standardize medical behavior and control medical expenses according to the norms of diagnosis and treatment and clinical pathway.
Commercial insurance institutions should 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 according to regulations. Encourage commercial insurance institutions to provide diversified health insurance products on the basis of undertaking serious illness insurance business.
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