Core Insights - The National Medical Insurance Administration (NMIA) has announced significant advancements in China's medical insurance system, including the establishment of a comprehensive medical insurance mechanism for outpatient medications for hypertension and diabetes, and the implementation of a payment reform by disease type by 2025 [1][2]. Group 1: Medical Insurance Developments - The total amount of personal account mutual aid in the employee medical insurance system has exceeded 100 billion yuan, benefiting over 780 million people in the past five years [1]. - A long-term mechanism to prevent poverty due to illness has been established, with medical assistance benefiting 1.189 billion people, and over 90% reimbursement for rural disadvantaged groups [1]. - The NMIA aims to achieve "no out-of-pocket" expenses for childbirth within the policy scope by 2026, expanding coverage for maternity insurance and long-term care insurance [3]. Group 2: Payment Reform and Management - By 2025, the NMIA will implement version 2.0 of the disease-based payment scheme, enhancing mechanisms for special cases, advance payments, and negotiation [2]. - All medical insurance regions will conduct real-time settlements, with monthly payment timelines reduced to within 20 working days after application, alleviating financial pressure on medical institutions [2]. - The NMIA plans to release version 3.0 of the disease-based payment grouping scheme in 2026, supporting the clinical use of new drugs and technologies [2]. Group 3: Fraud Prevention and Regulation - Over the past five years, approximately 120 billion yuan has been recovered from fraudulent medical insurance claims, with comprehensive coverage of inspections across all provinces [4][5]. - The NMIA has utilized big data models and intelligent regulatory systems to recover 9.5 billion yuan in fund losses, and has implemented drug traceability measures to combat illegal activities [4]. - In 2026, the NMIA will intensify inspection efforts, focusing on regions with high out-of-pocket rates and ensuring strict penalties for violations [5].

Group 1 - The core viewpoint of the article emphasizes the development of maternity and long-term care insurance in China, aiming for comprehensive coverage and financial support for childbirth by 2026 [1] - The National Medical Insurance Administration plans to include flexible employment workers, migrant workers, and new employment forms in maternity insurance coverage, with a goal of achieving "no out-of-pocket" expenses for childbirth within the policy scope [1] - Recent improvements in hospitalization costs for childbirth have been noted, with provinces like Jilin, Jiangsu, and Shandong leading the way in making childbirth financially accessible [1] Group 2 - By 2026, the optimization of the medical insurance payment settlement mechanism is set to promote healthy development in the medical sector, including the release of a new version of the disease-based payment grouping plan [2] - The administration will implement quarterly or monthly special case reviews to support the clinical use of new drugs and technologies, as well as the treatment of complex severe cases [2] - There will be an emphasis on supporting grassroots medical institutions and promoting tiered diagnosis and treatment, alongside increasing prepayment of medical insurance funds and exploring quarterly settlements [2]

Core Viewpoint - The National Medical Insurance Administration emphasizes the need to optimize the medical insurance payment settlement mechanism by 2026 to promote the healthy development of the medical sector [1] Group 1: Policy Initiatives - The meeting introduced the version 3.0 grouping scheme for payment by disease [1] - It will fully implement quarterly or monthly special case single negotiations and reviews to support the clinical use of new drugs and technologies, as well as the treatment of difficult and severe cases [1] - There is a focus on supporting the healthy development of grassroots medical and health institutions and promoting hierarchical diagnosis and treatment [1] Group 2: Financial Measures - The meeting calls for an increase in the prepayment of medical insurance funds and the full promotion of instant settlement of medical insurance funds [1] - Exploration of quarterly clearing is also part of the financial strategy [1] - The completion of 40 batches of project guideline compilations is aimed at achieving a basic national uniformity in medical service pricing items [1]