Medical Insurance is one of the five compulsory insurance schemes of the Chinese Social Security System (the remaining four include: Pension Fund, Work Injury Insurance, Unemployment Insurance and Maternity Insurance). In China, medical insurance is required to be paid by both – the employer as well as the employees on a monthly basis and in the event of illness or non-occupational injury, an employee may have part of the treatment cost covered by their medical insurance.

Key Points 

In order to actively participate to the reform of the Medical Security System on December 27th, 2022, the Nanjing Municipal Government issued the Measures for the Implementation of the Outpatient Service and Protection Mechanism for Employees' Basic Medical Insurance in Nanjing (hereinafter referred to as the “Measures”), which was implemented from January 1st 2023.

In this article, we will share the most important and major changes following the announcement:

I. Establishment of a New Outpatient Service Policy

1. A merging of the "Employee Medical Insurance Outpatient Service" and "Outpatient Chronic Diseases" into the "New Outpatient Service";

2. Abolishment of the original 600-2200 RMB (depending on various factors, e.g., age, outpatient or inpatient, employed or retired, etc.) starting payment standard;

3. An increase of the maximum outpatient expenses from RMB 3,333 - 12,000 to RMB 15,000;

4. The implementation of cost segmentation in order to protect the annual outpatient cost limit of the new outpatient service.

II. Standardization of Outpatient Special Disease Coverage for Employees' Medical Insurance

1. On the basis of the original four categories of outpatient special diseases (malignant tumor, dialysis treatment for chronic renal failure, post-transplant anti-rejection treatment,  (including hematopoietic stem cells,) and hemophilia), nine new categories of diseases have been added: including aplastic anemia, systemic lupus erythematosus, intracranial benign tumor, myelofibrosis, motor neuron disease, non-dialysis treatment for chronic renal failure, tuberculosis, severe mental disorder and AIDS.

2. Abolishment of the connection between the payment limit with the course of disease and setting the original maximum payment limit as the new cap.

III. Adjustment of Individual Account Crediting Policy

1. The crediting rate of the monthly basic medical insurance premiums paid by individuals to their personal accounts will be 2% of the base amount of their insurance contributions.

2. The personal accounts of retirees will be credited at a fixed monthly rate in accordance with the amount allocated to their personal accounts in December 2022; new retirees in 2023 will be credited at 5.4% of their pension in the month of retirement.

IV. Regulating the Scope of Use of Personal Accounts

Individual account funds are mainly used to pay for non-reimbursable expenses at designated medical institutions within the scope of the policy, and to enable family members to share their personal individual funds.

V. Establishment of a Health Incentive Mechanism for Individual Accounts

In case no payment has been made from the medical insurance Fund in a natural year (including sporadic reimbursement of medical expenses, excluding outpatient consultation fees, general treatment fees and nucleic acid testing), an additional RMB 200 will be credited to the relevant personal account in the following year, and an additional RMB 100 will be added if no payment is made from the medical insurance fund for 2 consecutive years, with a cumulative increase of RMB 300, up to a maximum of RMB 500.

Conclusion

After the implementation of the Measures, it is envisioned to improve the outpatient treatment of participants and reduce the burden of outpatient medical expenses on the public, especially for retirees.

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