2025.11.14 本文字数：3733，阅读时长大约6分钟 作者 |第一财经 吴斯旻 惠民保面向全国推广即将进入第六年，"特药责任"俨然已成标配。据行业估算，去年惠民保以不到200 亿的保费规模贡献了约18亿元的创新药支付金额，是2021年的约9倍。 但对于全国每年约1.5亿左右的参保人而言，理赔获得感却不尽相同——有人单次获赔近80万元，有人 一年获赔了30次，但也有慢病患者"月月就医却没有一次达到起付门槛"，有患者因既往症而遭遇"赔付 减半"，还有的异地就医者、新市民被惠民保拒之门外。 低保费、高赔付率目标，叠加老年人和带病体的参保比例增加，让惠民保的发展面临"死亡螺旋"。部分 惠民保为了应对赔付压力，通过提高免赔额、下调高值药支付限额等方式，减缓保费上涨压力，却又隐 形地降低了医疗福利水平。与此同时，今年首版商保创新药目录出台后，惠民保被寄予承接该目录、增 加创新药支付的业界期待。 在此背景下，今年发布的《国家金融监督管理总局办公厅关于推动城市商业医疗险高质量发展的通知》 （下称《通知》）提出，城市商业医疗险（即惠民保）要按照商业保险的基本原则和客观规律开展业 务，坚持保费收取与保障程度相适配、扩面提 ...

Core Insights - The "惠民保" (Huimin Insurance) has expanded its coverage to include chronic diseases, mental health medications, outpatient drugs, overseas drugs, and original research drugs, reflecting a shift in the insurance landscape [1][2] - The insurance scheme has seen a significant increase in claims, with approximately 18 billion yuan paid for innovative drugs in the previous year, a ninefold increase from 2021 [1] - However, the experience of claims varies widely among the 150 million insured individuals, with some facing high out-of-pocket costs due to thresholds and pre-existing conditions [1][6] Group 1: Policy Changes and Trends - The recent notification from the National Financial Regulatory Administration emphasizes the need for commercial health insurance to align premium collection with coverage levels and avoid low-price competition [2] - The 2026 version of "惠民保" has introduced a tiered premium structure, moving away from the previous low-cost model, and has expanded coverage to include more drug categories [2][3] - The number of drugs covered under "惠民保" is expected to reach 672 by 2024, with a significant focus on innovative treatments for cancer and rare diseases [3] Group 2: Coverage Expansion - The 2026 "北京普惠健康保" (Beijing Universal Health Insurance) will cover 87 disease categories and 159 drugs, including new treatments for Alzheimer's and CAR-T therapy [4] - The "齐鲁保2026版" (Qilu Insurance 2026) has expanded its coverage to include 3 high-value medical devices and additional innovative drugs for chronic conditions [4] - Many regions are now including outpatient drugs and original research drugs in their coverage, indicating a trend towards more comprehensive health insurance products [3][4] Group 3: Risk Management and Pricing Strategies - The insurance sector is adopting a risk-based pricing model, allowing for differentiated premiums based on age, health status, and pre-existing conditions [6][10] - The introduction of tiered coverage options aims to balance the need for affordable premiums with adequate benefits, particularly for high-risk groups [6][10] - Recent adjustments have led to increased reimbursement rates for patients with pre-existing conditions, reflecting a shift towards more equitable coverage [8][10] Group 4: Inclusion of New Demographics - The 2026 "惠民保" products are increasingly targeting new citizens and those seeking medical care outside their registered locations, broadening the scope of insured individuals [10][11] - Initiatives to allow family members to share health insurance accounts and to include flexible workers and retirees in coverage are being implemented in various regions [10][11] - The trend towards inclusivity aims to enhance the overall participation rate in the "惠民保" scheme, particularly among younger and healthier individuals [10]