CIRC encourages medical insurance to protect new drugs and technologies

Source: from November 15, 2017 to November 16, 2017, CIRC issued the health insurance management measures (Draft for comments) (hereinafter referred to as the draft for comments) This is after the health insurance management measures were promulgated in 2006, 11 years later, the relevant departments started to revise the health insurance regulatory measures again The draft stipulates that the waiting period of disease insurance, medical insurance and nursing insurance products shall not exceed half a year, and adds relevant provisions on "cooperation between health management services and medical insurance" The draft encourages insurance companies to realize information interconnection and data sharing with medical institutions, basic medical insurance departments, etc., and also proposes that insurance companies shall not entrust medical institutions or medical staff to sell health insurance products Medical insurance can be divided into two kinds of health insurance mentioned in the draft for comments, which is the insurance that the insurance company pays insurance benefits to the insured due to health reasons or medical behaviors, mainly including medical insurance, disease insurance, disability income loss insurance, nursing insurance and medical accident insurance According to the draft, medical insurance can be divided into expense compensation type medical insurance and quota payment type medical insurance according to the payment nature of insurance benefits Meanwhile, medical accident insurance and long-term disease insurance products can include death insurance liability The amount of death benefit of long-term disease insurance shall not be higher than the maximum amount of disease benefit Other health insurance products shall not include death insurance liability Medical insurance, disease insurance and medical accident insurance products shall not include survival insurance liability In combination with social security, the draft for comments has added relevant regulations on the integration of social security It is stipulated that when an insurance company designs expense compensation medical insurance products, it is necessary to distinguish whether the insured has public expense medical insurance, basic medical insurance and other expense compensation medical insurance, and treat them differently in terms of insurance terms, rate or compensation amount In combination with the health management services, the draft also adds relevant provisions on health management services The opinion points out that insurance companies can combine health insurance products with health management services, provide health risk assessment and intervention, provide disease prevention, health examination, health consultation, health maintenance, chronic disease management, health care and other services, reduce health risks and disease losses When health insurance products provide health management services, the allocated cost shall not exceed 20% of the net premium If the service exceeds the above limit, it shall be priced separately, not included in the premium, and the price of health management service shall be indicated in the contract It is worth mentioning that the opinion encourages medical insurance products to guarantee the application expenditure of new drugs, new medical devices and new diagnosis and treatment methods in medical services And encourage insurance companies to actively participate in medical service behavior, can follow the principle of convenient for the insured and reasonable management of medical costs to designate medical service organization network, guide the insured to use medical resources reasonably and save medical expenses At the same time, we should supervise the authenticity and legitimacy of medical behaviors, and strengthen the management of the rationality and necessity of medical expenses Appendix: Chapter I general provisions of health insurance management measures (Draft for comments) Article 1 These measures are formulated in accordance with the insurance law of the people's Republic of China (hereinafter referred to as the "insurance law") and other laws and administrative regulations in order to promote the development of health insurance, regulate the operation of health insurance, protect the legitimate rights and interests of the parties involved in health insurance activities, and improve the level of people's health protection Article 2 the "health insurance" mentioned in these Measures refers to the insurance that the insurance company pays insurance benefits to the insured due to health reasons or medical behaviors, mainly including medical insurance, disease insurance, disability income loss insurance, nursing insurance and medical accident insurance, etc The medical insurance mentioned in these Measures refers to the insurance that provides guarantee for the medical treatment and rehabilitation of the insured in accordance with the insurance contract The term "disease insurance" as mentioned in these Measures refers to the insurance that provides guarantee for the insured in case of diseases stipulated in the insurance contract The term "loss of disability income insurance" as mentioned in these Measures refers to the insurance that takes the loss of working ability due to the disease or accidental injury stipulated in the insurance contract as the condition for the payment of the insurance benefits and provides guarantee for the decrease or interruption of the income of the insured within a certain period of time The term "nursing insurance" as mentioned in these Measures refers to the insurance that provides guarantee for the nursing needs caused by the insured's daily living ability obstacle in accordance with the insurance contract The medical accident insurance mentioned in these Measures refers to the insurance that provides guarantee for the insured in case of any medical damage that cannot be attributed to the medical institution or medical personnel, which cannot be predicted and prevented according to the insurance contract Article 3 health insurance is an important part of the national medical insurance system It adheres to the guarantee attribute of health insurance, encourages insurance companies to continuously enrich health insurance products, improve health insurance services, expand the coverage of health insurance, and through effective supervision and market competition, reduce the price and operating cost of health insurance, and improve the guarantee level Article 4 health insurance is divided into long-term health insurance and short-term health insurance according to the insurance period Long term health insurance refers to health insurance with an insurance period of more than one year or an insurance period of less than one year but with a guaranteed renewal clause The period of long-term care insurance shall not be less than 5 years Short term health insurance refers to the health insurance with an insurance period of one year or less and without guarantee renewal clauses The term of guarantee renewal refers to the contract in which the applicant applies for renewal before the expiration of the previous insurance period, and the insurance company must continue to underwrite in accordance with the original terms and the agreed rate Article 5 medical insurance is divided into expense compensation type medical insurance and quota payment type medical insurance according to the payment nature of insurance benefits Expense compensation type medical insurance refers to the medical insurance that determines the amount of insurance according to the agreed standard according to the actual medical and rehabilitation expenses incurred by the insured The medical insurance of fixed payment type refers to the medical insurance that pays the insurance benefits according to the agreed amount The payment amount of expense compensation medical insurance shall not exceed the actual medical and rehabilitation expenses of the insured Article 6 the China Insurance Regulatory Commission (hereinafter referred to as the "CIRC") shall supervise and manage the health insurance activities of insurance companies in accordance with the law Article 7 unless otherwise required by the policy, the policy insurance business related to health insurance carried out by insurance companies shall be implemented with reference to these measures These measures are not applicable to the entrusted management services of insurance companies that do not undertake insurance risks Article 8 life insurance companies, health insurance companies and endowment insurance companies established in accordance with the law may operate health insurance business with the approval of CIRC Insurance companies other than those mentioned in the preceding paragraph may operate short-term health insurance business with the approval of the CIRC Article 9 in addition to health insurance companies, insurance companies shall establish a special health insurance business department for health insurance business, and shall continuously meet the following conditions: (1) establish a separate accounting system for health insurance business; (2) establish an actuarial system and a risk management system for health insurance; (3) establish an underwriting system and a claim settlement system for health insurance; （4） Establish a health insurance data management system; (5) establish a health insurance information management system with complete functions and relatively independent functions; (6) equip actuaries, underwriters, claims reviewers and managers with medical education background with health insurance professional knowledge; (7) other conditions stipulated by the CIRC Article 10 An insurance company shall provide health insurance professional training to the employees engaged in the underwriting, claims settlement and sales of health insurance Article 11 An insurance company shall strengthen the privacy protection of the applicant, the insured and the beneficiary, and establish a health insurance customer information management and confidentiality system Article 12 An insurance company shall, in accordance with the relevant provisions of the CIRC, submit for examination and approval or record the insurance terms and premium rates of its health insurance Health insurance products enjoying preferential tax policies shall comply with relevant policies and regulatory requirements in product design, loss ratio, etc Article 13 if the health insurance products proposed by an insurance company contain more than two kinds of health insurance responsibilities, the actuarial responsible person shall determine the main responsibilities according to the general actuarial principles and determine the product type according to the main responsibilities Article 14 medical accident insurance and long-term disease insurance products may include death insurance liability The amount of death benefit of long-term disease insurance shall not be higher than the maximum amount of disease benefit Other health insurance products shall not include death insurance liability Medical insurance, disease insurance and medical accident insurance products shall not include survival insurance liability Article 15 a contract hesitation period shall be set for long-term health insurance products, and the rights of the applicant within the hesitation period shall be listed in the insurance terms The hesitation period of long-term health insurance products shall not be less than 15 days Article 16 short term personal health insurance products may be subject to rate fluctuation The floating range of short-term health insurance rate shall not exceed 30% of the base rate The floating of premium rate refers to that when an insurance company sells products, on the basis of the benchmark premium rate and within the floating range of premium rate, it reasonably determines the specific premium rate according to the risk situation of the insured and its own risk management level The insurance company shall not fluctuate the rate based on the genetic information and genetic testing data of the insured except the family genetic history Article 17 when a short-term personal health insurance product with floating rate is submitted for examination and approval or filing, the application materials submitted by an insurance company shall include the method and scope of base rate and floating rate, and shall be signed and confirmed by the actuarial responsible person in accordance with the principle of prudence Article 18 the parameters of short-term group health insurance products can be adjusted Product parameters refer to the insurance amount, starting amount, payment proportion, exclusive liability, liability waiting period and other matters that can be reasonably adjusted according to the specific situation of the insured group in terms of insurance products Article 19 when an insurance company submits a short-term group health insurance product with adjustable product parameters for examination and approval or filing, the application materials submitted shall include the method for adjusting product parameters, and shall be signed and confirmed by the actuarial responsible person in accordance with the principle of prudence When an insurance company sells short-term group health insurance products with adjustable product parameters, it shall calculate the corresponding insurance premium rate according to the adjustment method of product parameters, the risk situation of the insured group and its own risk management level, and the adjustment of product parameters shall not change the calculation method of premium rate and the basic data needed for the calculation of premium rate If an insurance company sells a short-term group health insurance product with adjustable product parameters and needs to change the rate calculation method or the basic data needed for rate calculation, it shall re submit the product for approval or record Article 20 an insurance company may agree in its insurance products to adjust the rate of long-term health insurance products, and clearly indicate the trigger conditions for the rate adjustment The rate adjustment of long-term health insurance products shall follow the principle of fairness and reasonableness, and shall be submitted for approval or filing again