| Order of the China Banking and Insurance Regulatory Commission | | 中国银行保险监督管理委员会令 |
| (No. 3 [2019]) | | （2019年第3号） |
| The Measures for the Administration of Health Insurance, as adopted at the 6th chairman's meeting of the China Banking and Insurance Regulatory Commission in 2018, are hereby issued and shall come into force on December 1, 2019. | | 《健康保险管理办法》已经中国银保监会2018年第6次主席会议通过。现予公布，自2019年12月1日起施行。 |
| Chairman: Guo Shuqing | | 主席 郭树清 |
| October 31, 2019 | | 2019年10月31日 |
| Measures for the Administration of Health Insurance | | 健康保险管理办法 |
| Chapter I General Provisions | | 第一章 总 则 |
| Article 1 For purposes of promoting the development of health insurance, regulating the business activities of health insurance, protecting the lawful rights and interests of the parties in health insurance activities, and enhancing the health guarantee level of the public, these Measures are developed according to the Insurance Law of the People's Republic of China (hereinafter referred to as the “Insurance Law”) and other laws and administrative regulations. | | 第一条 为了促进健康保险的发展，规范健康保险的经营行为，保护健康保险活动当事人的合法权益，提升人民群众健康保障水平，根据《中华人民共和国保险法》（以下简称《保险法》）等法律、行政法规，制定本办法。 |
| Article 2 For the purpose of these Measures, “health insurance” means insurance whereby an insurance company makes indemnity payment to an insurant due to his or her health cause or occurrence of the medical behavior, mainly including medical insurance, disease insurance, disability income loss insurance, nursing insurance, and medical accident insurance, among others. | | 第二条 本办法所称健康保险，是指由保险公司对被保险人因健康原因或者医疗行为的发生给付保险金的保险，主要包括医疗保险、疾病保险、失能收入损失保险、护理保险以及医疗意外保险等。 |
| For the purpose of these Measures, “medical insurance” means insurance providing guarantee for an insurant's medical treatment, and recovery, among others, as stipulated in the insurance contract. | | 本办法所称医疗保险，是指按照保险合同约定为被保险人的医疗、康复等提供保障的保险。 |
| For the purpose of these Measures, “disease insurance” means insurance providing guarantee for an insurant in the occurrence of diseases as stipulated in the insurance contract. | | 本办法所称疾病保险，是指发生保险合同约定的疾病时，为被保险人提供保障的保险。 |
| For the purpose of these Measures, “disability income loss insurance” means insurance providing guarantee for income reduction or interruption of an insurant within a certain period of time and taking loss of working ability caused by the diseases or accidental injuries stipulated in the insurance contract as the condition for the payment of insurance premium. | | 本办法所称失能收入损失保险，是指以保险合同约定的疾病或者意外伤害导致工作能力丧失为给付保险金条件，为被保险人在一定时期内收入减少或者中断提供保障的保险。 |
| For the purpose of these Measures, “nursing insurance” means insurance providing guarantee for the nursing needs caused by impediments in daily living ability of an insurant as stipulated in the insurance contract. | | 本办法所称护理保险，是指按照保险合同约定为被保险人日常生活能力障碍引发护理需要提供保障的保险。 |
| For the purpose of these Measures, “medical accident insurance” means insurance providing guarantee for an insurant in the occurrence of medical damages not attributable to medical institutions or medical personnel as stipulated in the insurance contract. | | 本办法所称医疗意外保险，是指按照保险合同约定发生不能归责于医疗机构、医护人员责任的医疗损害，为被保险人提供保障的保险。 |
| Article 3 As an important component of the multi-level healthcare guarantee system of the state, health insurance shall stick to the orientation of health insurance as guarantee, encourage insurance companies to follow the principles of prudence and stability, continuously enrich health insurance products, improve health insurance services, expand the coverage of health insurance, reduce prices and operating costs of health insurance through effective management and market competition, and improve the guarantee level. | | 第三条 健康保险是国家多层次医疗保障体系的重要组成部分，坚持健康保险的保障属性，鼓励保险公司遵循审慎、稳健原则，不断丰富健康保险产品，改进健康保险服务，扩大健康保险覆盖面，并通过有效管理和市场竞争降低健康保险价格和经营成本，提升保障水平。 |
| Article 4 Health insurance is classified into long-term health insurance and short-term health insurance according to the insurance period. | | 第四条 健康保险按照保险期限分为长期健康保险和短期健康保险。 |
| Long-term health insurance means the health insurance whose insurance period exceeds 1 year, or that contains a warranty renewal insurance clause though the insurance period does not exceed 1 year. | | 长期健康保险，是指保险期间超过一年或者保险期间虽不超过一年但含有保证续保条款的健康保险。 |
| The insurance period of long-term nursing insurance shall not be less than 5 years. | | 长期护理保险保险期间不得低于5年。 |
| Short-term health insurance means health insurance with the insurance period of not more than 1 year and without the warranty renewal insurance clause. | | 短期健康保险，是指保险期间为一年以及一年以下且不含有保证续保条款的健康保险。 |
| Warranty renewal insurance clause means the contractual stipulation that an insurance company must continue insurance underwriting according to the original clause and agreed premium rate if an insurant applies for renewal prior to the expiration of the preceding insurance period. | | 保证续保条款，是指在前一保险期间届满前，投保人提出续保申请，保险公司必须按照原条款和约定费率继续承保的合同约定。 |
| Article 5 Medical insurance is classified into compensatory medical insurance and rationed payment medical insurance according to the nature of the payment of insurance premium. | | 第五条 医疗保险按照保险金的给付性质分为费用补偿型医疗保险和定额给付型医疗保险。 |
| Compensatory medical insurance means the medical insurance under which the amount of insurance premium is determined according to the agreed standards on the basis of an insurant's actual medical and rehabilitation expenses. | | 费用补偿型医疗保险，是指根据被保险人实际发生的医疗、康复费用支出，按照约定的标准确定保险金数额的医疗保险。 |
| Rationed payment medical insurance means the medical insurance whereby insurance premium is paid on the basis of the agreed amount. | | 定额给付型医疗保险，是指按照约定的数额给付保险金的医疗保险。 |
| The payment amount of compensatory medical insurance shall not exceed an insurant's actual medical rehabilitation expenses. | | 费用补偿型医疗保险的给付金额不得超过被保险人实际发生的医疗、康复费用金额。 |
| Article 6 The China Banking and Insurance Regulatory Commission (“CBIRC”) shall, according to the laws and administrative regulations, and as authorized by the State Council, supervise and administer insurance companies' activities of operating health insurance. | | 第六条 中国银行保险监督管理委员会（以下简称银保监会）根据法律、行政法规和国务院授权，对保险公司经营健康保险的活动进行监督管理。 |
| Article 7 Except as otherwise prescribed by the policies of the state, the policy-related insurance business concerning health insurance carried out by insurance companies shall be implemented, mutatis mutandis, to these Measures. | | 第七条 保险公司开展的与健康保险相关的政策性保险业务，除国家政策另有规定外，参照本办法执行。 |
| These Measures are not applicable to the entrustment management services for which insurance companies do not undertake insurance risks. | | 保险公司开展不承担保险风险的委托管理服务不适用本办法。 |
| Chapter II Business Operation and Management | | 第二章 经营管理 |
| Article 8 Health insurance companies, life insurance companies and pension insurance companies established according to the law may, with the approval of the CBIRC, engage in health insurance business. | | 第八条 依法成立的健康保险公司、人寿保险公司、养老保险公司，经银保监会批准，可以经营健康保险业务。 |
| Insurance companies other than those prescribed in the preceding paragraph may, with the approval of the CBIRC, engage in short-term health insurance business. | | 前款规定以外的保险公司，经银保监会批准，可以经营短期健康保险业务。 |
| Article 9 To engage in health insurance business, insurance companies, except health insurance companies, shall establish specialized health insurance business departments. A health insurance business department shall continuously meet the following conditions: | | 第九条 除健康保险公司外，保险公司经营健康保险业务应当成立专门健康保险事业部。健康保险事业部应当持续具备下列条件： |
| (1) It has established a separate accounting system for health insurance business. | | （一）建立健康保险业务单独核算制度； |
| (2) It has established an actuarial system and risk management system for health insurance. | | （二）建立健康保险精算制度和风险管理制度； |
| (3) It has established an underwriting system and claim settlement system for health insurance. | | （三）建立健康保险核保制度和理赔制度； |
| (4) It has established a data management and information disclosure system for health insurance. | | （四）建立健康保险数据管理与信息披露制度； |
| (5) It has established a relatively independent health insurance information management system with complete functions. | | （五）建立功能完整、相对独立的健康保险信息管理系统； |
| (6) It has employed actuarial, underwriting, and claims assessment personnel with professional knowledge in health insurance, and management personnel with medical education background. | | （六）配备具有健康保险专业知识的精算人员、核保人员、核赔人员和医学教育背景的管理人员； |
| (7) Other conditions prescribed by the CBIRC. | | （七）银保监会规定的其他条件。 |
| Article 10 An insurance company shall provide professional trainings on health insurance for its practitioners engaging in underwriting, claim settlement and sale of health insurance. | | 第十条 保险公司应当对从事健康保险的核保、理赔以及销售等工作的从业人员进行健康保险专业培训。 |
| Article 11 An insurance company shall strengthen the protection of the privacy of insurance applicants, insurants, and beneficiaries, and establish an information management and confidentiality system for health insurance clients. | | 第十一条 保险公司应当加强投保人、被保险人和受益人的隐私保护，建立健康保险客户信息管理和保密制度。 |
| Chapter III Management of Products | | 第三章 产品管理 |
| Article 12 An insurance company shall, in accordance with the relevant provisions of the CBIRC, submit the insurance clauses and insurance premium rates of health insurance drafted for examination and approval or recordation. | | 第十二条 保险公司拟定健康保险的保险条款和保险费率，应当按照银保监会的有关规定报送审批或者备案。 |
| Health insurance products enjoying preferential tax policies shall comply with the relevant policies and supervision requirements in terms of product design, loss ratio and other respects. | | 享受税收优惠政策的健康保险产品在产品设计、赔付率等方面应当遵循相关政策和监管要求。 |
| Article 13 Where a health insurance product developed by an insurance company includes two or more health guarantee liabilities, the chief actuary shall judge the primary liability under the general actuarial principles, and determine the product type according to the primary liability. | | 第十三条 保险公司拟定的健康保险产品包含两种以上健康保障责任的，应当由总精算师按照一般精算原理判断主要责任，并根据主要责任确定产品类型。 |
| Article 14 Medical accident insurance and long-term disease insurance products may include death insurance liability. The amount of death benefit in long-term disease insurance shall not exceed the maximum benefit amount for diseases. Other health insurance products shall not include death insurance liability, except the death insurance liability resulting from diseases. | | 第十四条 医疗意外保险和长期疾病保险产品可以包含死亡保险责任。长期疾病保险的死亡给付金额不得高于疾病最高给付金额。其他健康保险产品不得包含死亡保险责任，但因疾病引发的死亡保险责任除外。 |
| Medical insurance, disease insurance, and medical accident insurance products shall not include any survival insurance liability. | | 医疗保险、疾病保险和医疗意外保险产品不得包含生存保险责任。 |
| Article 15 A cooling-off period shall be set in long-term health insurance products and the rights of insurance applicants within the cooling-off period shall be specified in the insurance clauses. The cooling-off period of a long-term health insurance product shall not be less than 15 days. | | 第十五条 长期健康保险产品应当设置合同犹豫期，并在保险条款中列明投保人在犹豫期内的权利。长期健康保险产品的犹豫期不得少于15天。 |
| Article 16 An insurance company shall sell short-term individual health insurance products in strict accordance with the product rates approved or recorded. | | 第十六条 保险公司应当严格按照审批或者备案的产品费率销售短期个人健康保险产品。 |
| Article 17 Except family genetic history, an insurance company shall not set different pricing on the basis of an insurant's other genetic information or genetic testing materials. | | 第十七条 除家族遗传病史之外，保险公司不得基于被保险人其他遗传信息、基因检测资料进行区别定价。 |
| Article 18 The product parameters of short-term group health insurance products may be adjusted. | | 第十八条 短期团体健康保险产品可以对产品参数进行调整。 |
| “Product parameters” means insurance amount, minimum amount, proportion of compensation, excluded liabilities, liability waiting period and other matters in insurance product clauses that are rationally adjusted in light of the true circumstances of the insured group. | | 产品参数，是指保险产品条款中根据投保团体的具体情况进行合理调整的保险金额、起付金额、给付比例、除外责任、责任等待期等事项。 |
| Article 19 When submitting short-term group health insurance products whose parameters may be adjusted for examination and approval or recordation, an insurance company shall submit the application materials including the methods of adjusting the product parameters, and the chief actuary shall affix a signature thereto for confirmation under the principle of prudence. | | 第十九条 保险公司将产品参数可调的短期团体健康保险产品报送审批或者备案时，提交的申请材料应当包含产品参数调整办法，并由总精算师遵循审慎原则签字确认。 |
| An insurance company selling short-term group health insurance products whose parameters may be adjusted shall, according to the methods of adjusting the product parameters, its risk management level, and risk situation of the groups purchasing the insurance policies, calculate the corresponding insurance premium rates. The adjustment to the product parameters shall not change the methods of calculating the premium rates or the basic data required for the calculation of the premium rates. | | 保险公司销售产品参数可调的短期团体健康保险产品，应当根据产品参数调整办法、自身风险管理水平和投保团体的风险情况计算相应的保险费率，且产品参数的调整不得改变费率计算方法以及费率计算需要的基础数据。 |
| An insurance company that sells a short-term group health insurance product whose parameters may be adjusted and that needs to change the methods of calculating the premium rates or the basic data required for the calculation of the premium rates shall re-submit the product for examination and approval or recordation. | | 保险公司销售产品参数可调的短期团体健康保险产品，如需改变费率计算方法或者费率计算需要的基础数据的，应当将该产品重新报送审批或者备案。 |
| Article 20 An insurance company may stipulate the adjustment of the premium rates of long-term medical insurance products in its insurance products, and specify the triggering conditions for adjustment to the premium rates. | | 第二十条 保险公司可以在保险产品中约定对长期医疗保险产品进行费率调整，并明确注明费率调整的触发条件。 |
| The premium rates of long-term medical insurance products shall be adjusted under the principles of fairness and rationality, and the triggering conditions shall be objective and universally applicable, and comply with the relevant regulatory provisions. | | 长期医疗保险产品费率调整应当遵循公平、合理原则，触发条件应当客观且能普遍适用，并符合有关监管规定。 |
Article 21 A health insurance product containing a warranty renewal clause shall specify the effective date of the stipulated warranty renewal clause.
．．．．．． | | 第二十一条 含有保证续保条款的健康保险产品，应当明确约定保证续保条款的生效时间。
．．．．．． |
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