Laws and regulations regarding medical insurance.

1. Why is the "Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance" formulated?

On May 12, 1991, the "Notice on Printing and Distributing the Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance" (Labor and Social Security Department Document [1999] No. 15) clearly pointed out that "in order to implement the 'Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees'" (State Document [1998] No. 44), "the 'Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance' was formulated."

Specifically, at present, there is a large number and variety of drugs on the market in our country. By the end of 1997, there were 6,391 pharmaceutical manufacturers in China, producing more than 4,000 kinds of Western medicine preparations and more than 8,000 kinds of traditional Chinese medicine preparations. Due to the imperfect management of the drug circulation system, the price differences of the same drug between different medical institutions and between domestic and imported drugs have increased, with some retail prices differing by dozens of times. Additionally, the quality of marketed drugs varies, and therapeutic and general health care drugs are managed together, leading to a large amount of waste in drug use. The formulation of the Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance can ensure the basic medical medication for employees, reasonably control drug costs, and standardize the management of the scope of medication for basic medical insurance.

2. What are the principles for determining the varieties in the "Drug Catalog"?

The "Drug Catalog" is short for the "Basic Medical Insurance Drug Catalog". Through its formulation, the management of the scope of medication for basic medical insurance is achieved. The principles for determining the varieties of drugs in the "Drug Catalog" are: "considering the basic clinical needs, as well as the economic differences and medication habits between regions, with equal emphasis on both Western and traditional Chinese medicine."

3. Which drugs can be included in the selection range of the "Drug Catalog"?

According to Article 3 of the "Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance", the drugs included in the "Drug Catalog" should be clinically necessary, safe and effective, reasonably priced, convenient to use, and guaranteed to be supplied in the market. At the same time, they must meet at least one of the following conditions:

(1) Drugs that meet the standards issued by the national drug supervision and management department;

(2) Drugs that are officially imported and approved by the national drug supervision and management department;

(3) Drugs listed in the "Pharmacopoeia of the People's Republic of China" (current edition).

4. Which drugs cannot be included in the selection range of the "Drug Catalog"?

According to Article 4 of the "Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance", the following drugs cannot be included in the selection range of the "Drug Catalog":

(1) Various alcoholic preparations made from traditional Chinese medicinal materials and decoction pieces;

(2) Certain animals and animal organs that can be used as medicine, dried (or fresh) fruits;

(3) Blood products and protein products (except for special indications and emergency rescue);

(4) Fruit-flavored preparations and oral effervescent agents among various drugs;

(5) Drugs that mainly serve a nutritional and health supplement purpose;

(6) Other drugs that the Ministry of Labor and Social Security specifies will not be reimbursed by the basic medical insurance fund.

5. What categories of drugs are included in the "Drug Catalog"?

According to Article 5 of the "Interim Measures for the Management of the Scope of Medication for Urban Employees' Basic Medical Insurance", the drugs listed in the "Drug Catalog" include Western medicine, traditional Chinese medicine (including ethnic medicine), and traditional Chinese medicine decoction pieces (including ethnic medicine). Western medicine and traditional Chinese medicine are included in the drug catalog approved for reimbursement by the basic medical insurance fund, with drug names using generic names and indicating dosage forms. Traditional Chinese medicine decoction pieces are included in the drug catalog not reimbursed by the basic medical insurance fund, with drug names using pharmacopoeia names.

6. Why are Western medicine and traditional Chinese medicine included in the drug catalog approved for reimbursement by the basic medical insurance fund?

Western medicine and traditional Chinese medicine are included in the drug catalog approved for reimbursement by the basic medical insurance fund, divided into "Category A" and "Category B" catalogs, because their medicinal components and therapeutic indications are relatively clear, with explicit regulations on drug forms, dosages, specifications, and prices. At the same time, they are widely used and effective, making them necessary for clinical treatment or available for clinical treatment options.

7. Why are traditional Chinese medicine decoction pieces included in the drug catalog not reimbursed by the basic medical insurance fund?

Drugs included in the "Drug Catalog" must be clinically necessary and safe and effective. However, traditional Chinese medicine decoction pieces have a wide range of sources and a variety of medicinal materials, with no clear usage dosages and specifications. Additionally, considering the characteristics of traditional Chinese medicine in China regarding compatibility, traditional Chinese medicine decoction pieces do not meet the above conditions, thus being included in the non-reimbursable catalog.

8. What living service items and service facility costs are not covered by basic medical insurance?

According to the "Opinions on Determining the Scope and Payment Standards of Medical Service Facilities for Urban Employees' Basic Medical Insurance", basic medical insurance medical service facilities refer to the living service facilities provided by designated medical institutions that are necessary for insured individuals during diagnosis, treatment, and nursing processes, mainly including hospitalization bed fees and outpatient (emergency) observation bed fees. For daily necessities, in-hospital transportation supplies, and costs for water and electricity already included in hospitalization bed fees or outpatient (emergency) observation bed fees, the basic medical insurance fund will not make additional payments, and designated medical institutions are not allowed to charge insured individuals separately.

The living service items and service facility costs not covered by the basic medical insurance fund mainly include the following five categories:

(1) Companion fees, nursing fees, cleaning fees, outpatient decoction fees;

(2) Meal fees;

(3) Air conditioning fees, television fees, telephone fees, infant incubator fees, food warmer fees, electric stove fees, refrigerator fees, and compensation for damaged public property;

(4) Transportation fees for referrals (or transfers), ambulance fees;

(5) Entertainment activity fees and other special living service costs.

At the same time, due to differences in living environments and economic levels in various regions, whether other medical service facility items (such as heating fees, etc.) are included in the payment scope of the basic medical insurance fund is determined by the labor security administrative departments of each province (autonomous region, municipality).

9. What is the payment standard for basic medical insurance hospitalization bed fees? How is it determined?

The payment standard for basic medical insurance hospitalization bed fees is determined by the labor security administrative departments of each planning area according to the standard for ordinary hospitalization ward bed fees set by the provincial price departments. The payment standard for hospitalization bed fees for isolation and critically ill patients is determined by each planning area based on actual conditions.

The establishment of this standard is mainly based on the reimbursement regulations for ordinary ward bed fees in public health and labor insurance medical systems. This is in line with the national conditions of our country in the primary stage of socialism and is also consistent with the principle of basic medical insurance providing basic medical care.

10. What is the payment standard for basic medical insurance outpatient (emergency) observation bed fees?

The payment standard for basic medical insurance outpatient (emergency) observation bed fees is determined according to the charging standards set by the provincial pricing department, but it cannot exceed the payment standard for basic medical insurance inpatient bed fees.

11. How to ensure that insured individuals receive appropriate medical service facilities when seeking medical treatment?

According to the provisions in the "Opinions on Determining the Scope and Payment Standards of Medical Service Facilities for Urban Employees' Basic Medical Insurance," in order to ensure that insured individuals receive appropriate medical service facilities in a timely manner during medical treatment, designated medical institutions must publicly disclose the bed charging standards and the payment standards for basic medical insurance bed fees. When arranging wards or outpatient (emergency) observation beds, the charging standards for the arranged beds should be communicated to the insured individuals or their families. Insured individuals can choose different levels of wards or outpatient (emergency) observation beds based on the recommendations of designated medical institutions. If, due to bed shortages or other reasons, designated medical institutions must arrange insured individuals in beds that exceed the standard, they should first obtain the consent of the insured individuals or their families.

12. Why are various health check-ups not included in the scope of basic medical insurance treatment projects?

According to the "Opinions on the Management of Treatment Projects for Urban Employees' Basic Medical Insurance," basic medical insurance treatment projects refer to various medical technology service projects and diagnostic and treatment projects using medical instruments, equipment, and medical materials that meet the following conditions:

(1) Those for which charging standards have been established by the pricing department;

(2) Necessary for clinical diagnosis, safe and effective, and reasonably priced;

(3) Provided by designated medical institutions within the scope of designated medical services for insured individuals.

In conjunction with the above conditions, several non-disease treatments, including various health check-ups, are included in the scope of treatment projects for which basic medical insurance does not cover costs, as stated in the attachment "Scope of National Basic Medical Insurance Treatment Projects" of the aforementioned opinions. At the same time, this regulation is a continuation of the past public health and labor insurance medical policies.

Health check-ups are divided into general health examinations and health check-ups for specific purposes. General health examinations are preventive disease screening measures organized by employers to detect and treat diseases early, with the examination costs borne by the employers and not expended from public health or labor insurance medical funds; health check-ups for specific purposes are examinations conducted by employees based on specific requirements, such as those required for job applications, processing overseas procedures, or purchasing commercial health insurance, with costs generally borne by individuals. Therefore, after the reform of the medical insurance system, various health check-ups are not included in the scope of basic medical insurance treatment projects, while the health check-up costs organized by units are borne by the employers; the costs of health check-ups for specific purposes that were originally paid by individuals are still borne by individuals.