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| Opinions of the CPC Central Committee and the State Council on Deepening the Reform of Medical Insurance System | | 中共中央、国务院关于深化医疗保障制度改革的意见 |
| (February 25, 2020) | | （2020年2月25日） |
| Medical insurance is an important institutional arrangement with an aim to lessen the medical care burden of people, enhance public welfare, and maintain social harmony and stability. The CPC Central Committee and the State Council have attached great importance to the people's health, and established a universal basic medical insurance system. Since the 18th CPC National Congress, the reform of the national medical insurance system has been continuously improved, and breakthroughs have been made to address the difficulties of the people in receiving affordable medical care. For the purposes of further implementing the decisions and arrangements of the 19th CPC National Congress on establishing a medical insurance system with Chinese characteristics, and striving to solve the problem of unbalanced and insufficient health insurance growth, the opinions on deepening the reform of the country's medical insurance system are hereby offered as follows. | | 医疗保障是减轻群众就医负担、增进民生福祉、维护社会和谐稳定的重大制度安排。党中央、国务院高度重视人民健康，建立了覆盖全民的基本医疗保障制度。党的十八大以来，全民医疗保障制度改革持续推进，在破解看病难、看病贵问题上取得了突破性进展。为深入贯彻党的十九大关于全面建立中国特色医疗保障制度的决策部署，着力解决医疗保障发展不平衡不充分的问题，现就深化医疗保障制度改革提出如下意见。 |
| I. General requirements | | 一、总体要求 |
| 1. Guiding ideology. With Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era as the guidance, efforts shall be made to comprehensively implement the spirit of the 19th CPC National Congress and the Second, Third and Fourth Plenary Sessions of the 19th CPC Central Committee, continue to center around the people's health, and accelerate the establishment of a sustainable multi-tiered medical insurance system with universal coverage, urban-rural integration, clear rights and responsibilities, and adequate guarantee. There shall also be efforts to improve the impartiality and coordination of medical insurance, leverage the role of medical insurance funds in strategic purchasing, and advance high-quality and concerted development of medical insurance and medical services through integrated systems, improved policies, upgraded mechanisms and more effective services. The national strategy known as “Healthy China” shall be promoted to make people feel safer, happier, and enjoy a stronger sense of gains. | | （一）指导思想。以习近平新时代中国特色社会主义思想为指导，全面贯彻党的十九大和十九届二中、三中、四中全会精神，坚持以人民健康为中心，加快建成覆盖全民、城乡统筹、权责清晰、保障适度、可持续的多层次医疗保障体系，通过统一制度、完善政策、健全机制、提升服务，增强医疗保障的公平性、协调性，发挥医保基金战略性购买作用，推进医疗保障和医药服务高质量协同发展，促进健康中国战略实施，使人民群众有更多获得感、幸福感、安全感。 |
| 2. Basic principles. Whoever should be insured shall have access to medical insurance, and basic medical insurance shall cover all walks of life in the society. No effort shall be spared to determine the scope and standards of health insurance coverage based on the actual conditions. Prudent and sustained actions shall be taken to prevent risks, and health financing shall be determined in a scientific way. The contributions of all relevant parties to medical insurance payments shall be well-balanced, and the overall plan to coordinate mutual aid shall be strengthened, so as to ensure sustainability of insurance funds. Efforts shall be made to promote equal access to basic health services, strengthen institutional support to narrow the disparity in medical treatment, and provide basic and protective guarantee for the impoverished people. Innovations in governance shall be supported, quality and efficiency shall be improved, the decisive role of the market shall be fulfilled, and the functions of government shall be enhanced so as to decentralize and standardize the governance of medical insurance according to the law and based on intelligent technologies. System integration and efficient collaboration shall be upheld, and the reforms on medical insurance, medical services and medicines shall be jointly carried out in a comprehensive, systematic, and harmonious way, in a bid to guarantee the accessibility of the people to high-quality, efficient, affordable medical services. | | （二）基本原则。坚持应保尽保、保障基本，基本医疗保障依法覆盖全民，尽力而为、量力而行，实事求是确定保障范围和标准。坚持稳健持续、防范风险，科学确定筹资水平，均衡各方缴费责任，加强统筹共济，确保基金可持续。坚持促进公平、筑牢底线，强化制度公平，逐步缩小待遇差距，增强对贫困群众基础性、兜底性保障。坚持治理创新、提质增效，发挥市场决定性作用，更好发挥政府作用，提高医保治理社会化、法治化、标准化、智能化水平。坚持系统集成、协同高效，增强医保、医疗、医药联动改革的整体性、系统性、协同性，保障群众获得高质量、有效率、能负担的医药服务。 |
| 3. Reform and development goals. By 2025, the medical insurance system will be more mature and stable; and the reform tasks of important systems of medical treatment insurance, operation of financing arrangements, medical insurance payment, and insurance fund supervision as well as in key fields such as medical service supply and medical insurance management services will be generally fulfilled. By 2030, a medical insurance system in which basic medical insurance plays a dominant role, medical aid provides supporting financial cover for medical expenses, and supplementary medical insurance, commercial health insurance, charitable donations, and medical mutual aid activities co-exist will be established; treatment and guarantee will be fair and appropriate, ; the operation of insurance funds will be stable and sustainable; the management of medical services will be optimized and improved; and the governance of medical insurance will be more modernized; and the goal of providing better guarantee for universal medical services shall be achieved. | | （三）改革发展目标。到2025年，医疗保障制度更加成熟定型，基本完成待遇保障、筹资运行、医保支付、基金监管等重要机制和医药服务供给、医保管理服务等关键领域的改革任务。到2030年，全面建成以基本医疗保险为主体，医疗救助为托底，补充医疗保险、商业健康保险、慈善捐赠、医疗互助共同发展的医疗保障制度体系，待遇保障公平适度，基金运行稳健持续，管理服务优化便捷，医保治理现代化水平显著提升，实现更好保障病有所医的目标。 |
| II. Improving the fair and appropriate treatment and guarantee mechanism | | 二、完善公平适度的待遇保障机制 |
| Fair and appropriate treatment and guarantee mechanism constitutes an intrinsic prerequisite for improving people's health and well-being. The statutory medical insurance system shall be made more mature and stable, the medical insurance and assistance system for major and critical diseases shall be improved, coordinated plans shall be made to promote high-quality development of various medical insurance schemes, and the level of medical insurance shall be increased steadily according to the economic development and affordability of medical insurance funds. | | 公平适度的待遇保障是增进人民健康福祉的内在要求。要推进法定医疗保障制度更加成熟定型，健全重特大疾病医疗保险和救助制度，统筹规划各类医疗保障高质量发展，根据经济发展水平和基金承受能力稳步提高医疗保障水平。 |
| 4. Enhancing the basic medical insurance system. The basic medical insurance system and policy system with universal coverage and subscription according to the law shall be upheld and improved. Employees and urban and rural residents shall be given classified medical insurance, medical treatment shall be linked to insurance payment, separate accounts shall be created for various insurance funds, and separate accounting system shall apply. The pooling levels and the catalogue of basic medical insurance shall be integrated, and the methods of determining medical insurance payment policies shall be standardized. Outpatient costs shall be covered gradually by the pooling fund of basic medical insurance, personal accounts of the basic medical insurance for employees shall be reformed, and the mutual aid outpatient treatment system shall be established and improved. | | （四）完善基本医疗保险制度。坚持和完善覆盖全民、依法参加的基本医疗保险制度和政策体系，职工和城乡居民分类保障，待遇与缴费挂钩，基金分别建账、分账核算。统一基本医疗保险统筹层次、医保目录，规范医保支付政策确定办法。逐步将门诊医疗费用纳入基本医疗保险统筹基金支付范围，改革职工基本医疗保险个人账户，建立健全门诊共济保障机制。 |
| 5. Implementing the system of a list of medical insurance benefits. The system of a list of medical insurance benefits shall be established and improved so that the decision-making power of governments shall be properly regulated, basic schemes, basic policies, basic payment programs and standards shall be precisely and effectively defined, and law-based medical insurance systems, scientific decisions on medical insurance, and well-regulated management of medical insurance shall be advanced. All local authorities shall ensure that their policies and orders will be adequately implemented, and, without approval, they may not issue any policy that extends beyond the scope of medical insurance benefits in the list. The scope and standards of basic insurance payment shall be strictly enforced, equal access to adequate medical insurance shall be provided, and the problems of over insurance and under insurance shall be resolved. | | （五）实行医疗保障待遇清单制度。建立健全医疗保障待遇清单制度，规范政府决策权限，科学界定基本制度、基本政策、基金支付项目和标准，促进医疗保障制度法定化、决策科学化、管理规范化。各地区要确保政令畅通，未经批准不得出台超出清单授权范围的政策。严格执行基本支付范围和标准，实施公平适度保障，纠正过度保障和保障不足问题。 |
| 6. Establishing a sound, unified and well-regulated medical assistance system. A mechanism by which medical assistance recipients can be precisely identified shall be established so as to determine the range of medical assistance in a scientific manner. The policies of supporting key assistance recipients in subscription to and payment for medical insurance shall be fully implemented, and the medical expense assistance system for key recipients shall be enhanced. An effective mechanism of preventing and resolving the issue of becoming poor or returning to poverty because of illness shall be built. The role of medical assistance supporting financial cover for medical expenses shall be strengthened, medical costs shall be reduced by clarifying diagnosis plans, regulating referrals, and other means, medical aid limits per annum shall be raised, and the out-of-pocket ratio of impoverished people shall be controlled within the policy arrangement. | | （六）健全统一规范的医疗救助制度。建立救助对象及时精准识别机制，科学确定救助范围。全面落实资助重点救助对象参保缴费政策，健全重点救助对象医疗费用救助机制。建立防范和化解因病致贫返贫长效机制。增强医疗救助托底保障功能，通过明确诊疗方案、规范转诊等措施降低医疗成本，提高年度医疗救助限额，合理控制贫困群众政策范围内自付费用比例。 |
| 7. Improving the insurance system for medical rescue and treatment expenses during major epidemics. Efforts shall be made to ensure that medical institutions can rescue patients before charging them during an epidemic outbreak or any other emergency. The policy of medical insurance payment for medical rescue and treatment during major epidemics, and the system of direct settlement of out-of-area medical expenses shall be improved so that patients' medical treatment shall not be affected by medical expenses. A system of exempting special groups of patients and special diseases from medical expenses shall be studied and established, and specific restrictive clauses on the catalogue of basic medical insurance, payment limits and medicine dosages shall be removed so as to ease the burden of needy people after medical treatment. The use of medical insurance funds and public healthcare funds shall be coordinated, the ratio of insurance payment to basic-level medical institutions shall be increased, and the transition between public health services and medical care shall be supported. | | （七）完善重大疫情医疗救治费用保障机制。在突发疫情等紧急情况时，确保医疗机构先救治、后收费。健全重大疫情医疗救治医保支付政策，完善异地就医直接结算制度，确保患者不因费用问题影响就医。探索建立特殊群体、特定疾病医药费豁免制度，有针对性免除医保目录、支付限额、用药量等限制性条款，减轻困难群众就医就诊后顾之忧。统筹医疗保障基金和公共卫生服务资金使用，提高对基层医疗机构的支付比例，实现公共卫生服务和医疗服务有效衔接。 |
| 8. Boosting the development of a multi-tiered medical insurance system. The triple insurance functions, including basic medical insurance, critical illness insurance and medical aid, shall be strengthened. The mutual complement and coordination of various medical insurance schemes shall be promoted. The insurance for major and critical diseases and diverse medical demands shall be improved. Critical illness insurance for residents, large-sum medical expenses subsidy for working residents, medical subsidy for civil servants, and supplementary medical insurance of enterprises shall be enhanced and standardized. The development of commercial health insurance shall be accelerated, more health insurance products shall be supplied, the individual income tax policies for commercial health insurance shall be applied in a more effective way, and the expansion of the scope of insurance products shall be studied. The supervision of market behaviors shall be intensified, and the supervision of design, sale and compensation of insurance products shall be emphasized so as to improve health insurance service capacity. Charitable donations shall be encouraged, and charitable medical assistance forces shall be mobilized to support the orderly development of medical mutual aid activities. An insurance mechanism for orphan drugs shall be explored. | | （八）促进多层次医疗保障体系发展。强化基本医疗保险、大病保险与医疗救助三重保障功能，促进各类医疗保障互补衔接，提高重特大疾病和多元医疗需求保障水平。完善和规范居民大病保险、职工大额医疗费用补助、公务员医疗补助及企业补充医疗保险。加快发展商业健康保险，丰富健康保险产品供给，用足用好商业健康保险个人所得税政策，研究扩大保险产品范围。加强市场行为监管，突出健康保险产品设计、销售、赔付等关键环节监管，提高健康保障服务能力。鼓励社会慈善捐赠，统筹调动慈善医疗救助力量，支持医疗互助有序发展。探索罕见病用药保障机制。 |
| III. Making the financing operation mechanism robust and sustainable | | 三、健全稳健可持续的筹资运行机制 |
Reasonable financing and steady operation provide basic guarantee for a sustainable medical insurance system. A financing mechanism that is consistent with China's basic national conditions at the primary stage of socialism, matches the affordability of all parties, and meets the people's basic health needs shall be established. The management of medical insurance funds shall be effectively strengthened, early warning of risks shall be enhanced, and efforts shall be made to ensure that no systemic risks arise in this regard.
．．．．．． | | 合理筹资、稳健运行是医疗保障制度可持续的基本保证。要建立与社会主义初级阶段基本国情相适应、与各方承受能力相匹配、与基本健康需求相协调的筹资机制，切实加强基金运行管理，加强风险预警，坚决守住不发生系统性风险底线。
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