| Opinions of the National Healthcare Security Administration on the Medical Insurance Supporting Measures for the Pilot Program of the Centralized Procurement and Use of Drugs Organized by the State | | 国家医疗保障局关于国家组织药品集中采购和使用试点医保配套措施的意见 |
| (No. 18 [2019] of the National Healthcare Security Administration) | | （医保发〔2019〕18号） |
| The medical insurance bureaus of Beijing, Tianjin, Liaoning, Shanghai, Fujian, Guangdong, Chongqing, Sichuan and Shaanxi: | | 北京市、天津市、辽宁省、上海市、福建省、广东省、重庆市、四川省、陕西省医疗保障局： |
| For the purposes of implementing the spirit of the Notice by the General Office of the State Council of Issuing the Pilot Program of the Centralized Procurement and Use of Drugs Organized by the State (No. 2 [2019] of the General Office of the State Council), encouraging the medical insurance departments to implement the pilot work of the centralized procurement and use of drugs, and regulate relevant supporting measures, the guiding opinions are hereby offered as follows: | | 为贯彻落实《国务院办公厅关于印发国家组织药品集中采购和使用试点方案的通知》（国办发〔2019〕2号）精神，做好医疗保障部门落实国家组织药品集中采购和使用试点工作，规范相关配套措施，提出以下指导意见： |
| I. Implementing the policies of medical insurance prepayment | | 一、落实医保基金预付政策 |
| The medical insurance departments of the pilot regions shall, according to the purchasing prices of the selected drugs, the varieties and quantities of drugs agreed upon between medical institutions and pharmaceutical companies during the centralized procurement, measure and calculate the amount of expenses for the drugs procured in certain quantities. In the medical insurance fund budget, the special procurement expenses for the pilot drugs in the centralized procurement and use organized by the state shall be clarified. The medical insurance administrative agencies shall, before the pilot work is officially launched, pay in advance at least 30% of the special procurement budget to the medical institutions, and require such medical institutions to promptly settle the payment with pharmaceutical enterprises according to the contract terms so as to reduce the costs of these enterprises. The medical insurance administrative agencies or government procurement agencies are encouraged to settle the drug payment with or make the payment in advance directly to the enterprises. | | 试点地区医保部门根据集中采购中选药品的采购价格、各医疗机构与企业约定的采购品种及采购数量测算带量采购药费金额。在医保基金预算中明确国家组织药品集中采购和使用试点药品专项采购预算。医保经办机构在试点工作正式启动前，按照不低于专项采购预算的30%提前预付医疗机构，并要求医疗机构按合同规定与企业及时结算，降低企业财务成本。鼓励医保经办或采购机构与企业直接结算或预付药款。 |
| II. Coordinating the medical insurance payment standard with the purchasing price | | 二、做好医保支付标准与采购价的协同 |
All pilot regions shall take proper measures to coordinate the medical insurance payment standards with the purchasing prices of the drugs during the centralized procurement, and consolidate the payment standards of the same drugs among various types of designated medical institutions at different levels within the pilot regions. For original drugs, reference preparations, and generic drugs having passed the consistency evaluation all under the same general name, the winning bid price in the procurement shall in principle be considered as the standard payment price for these drugs under the same name, and the medical insurance funds shall settle the accounts according to the same payment standard. If a patient uses a drug the actual price of which is higher than the standard payment price, the extra amount shall be paid by the patient on his or her own, and the amount within the range of standard payment shall be shared by the patient and the medical insurance fund according to a certain proportion. For a certain drug the actual price of which differs greatly from the winning bid price, the pilot regions may, based on the principle of “gradual adjustment and guidance by categories”, adjust the payment standard step by step until the price is fixed and determined within two to three years. In principle, the adjustments shall be made according to the following rules:
．．．．．． | | 各试点地区要妥善做好集中采购药品医保支付标准与采购价的协同，并统一试点地区内统筹基金支付的各级各类定点医疗机构同一药品的支付标准。对同一通用名下的原研药、参比制剂、通过一致性评价的仿制药，原则上以集中采购中选价作为该通用名药品的支付标准，医保基金按相同的支付标准进行结算。患者使用价格高于支付标准的药品，超出支付标准的部分由患者自付，支付标准以内部分由患者和医保按比例分担。对部分价格与中选药品价格差异较大的药品，试点地区可按照“循序渐进、分类指导”的原则，渐进调整支付标准，在2-3年内调整到位，原则上按如下规则调整：
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