Group 1 - The National Medical Insurance Administration reported that the personal account mutual aid amount for employee medical insurance has exceeded 100 billion yuan, with over 7.8 billion mutual aid instances in the past five years [1] - A comprehensive outpatient medication guarantee mechanism for hypertension and diabetes has been established, benefiting over 340 million people through major illness insurance [1] - The medical insurance system will continue to support the development of medical institutions, with a full rollout of disease-based payment methods by 2025 [1] Group 2 - The implementation of version 2.0 of the disease-based payment scheme will be completed by 2025, with improvements in special case negotiations and prepayment mechanisms [2] - All medical insurance regions will conduct real-time settlements, reducing the payment timeline to within 20 working days, with some areas achieving next-day settlements [2] - By 2026, version 3.0 of the disease-based payment scheme will be released, supporting the clinical use of new drugs and technologies [2] Group 3 - The National Medical Insurance Administration aims to achieve "no out-of-pocket" expenses for childbirth within the policy scope by 2026, expanding maternity insurance coverage [3] - The maternity insurance program will cover approximately 300 million insured individuals, with 2.55 billion people currently enrolled [3] - By 2026, efforts will be made to include flexible employment workers and migrant workers in the maternity insurance coverage [3] Group 4 - Over the past five years, approximately 120 billion yuan has been recovered from medical insurance fraud, with comprehensive coverage of all provinces through regular inspections [4] - The use of big data models and intelligent supervision systems has helped recover 9.5 billion yuan in fund losses [4] - Continuous efforts will be made to strengthen inspections and maintain the integrity of medical insurance funds, with zero tolerance for illegal activities [5]

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].

Core Insights - The National Medical Insurance Administration (NMIA) has announced several measures and data at the National Medical Security Work Conference, highlighting improvements in medical insurance coverage and support for healthcare institutions. Group 1: Medical Insurance Coverage - The total amount of personal accounts for employee medical insurance has exceeded 100 billion yuan, with over 7.8 billion instances of account sharing in the past five years [2] - A comprehensive outpatient medication guarantee mechanism for hypertension and diabetes has been established, benefiting over 340 million people through major illness insurance [2] - Medical assistance has reached 1.189 billion people, with over 90% reimbursement for rural disadvantaged groups [2] Group 2: Support for Healthcare Institutions - By 2025, the NMIA will implement a comprehensive payment reform based on disease categories, with a 2.0 version of the payment scheme to be introduced [3] - All medical insurance areas will conduct real-time settlements, reducing the payment timeline to within 20 working days after submission, with some areas achieving next-day settlements [3] - The NMIA plans to release a 3.0 version of the payment scheme by 2026, promoting the use of new drugs and technologies in clinical settings [3] Group 3: Maternity and Long-term Care Insurance - The NMIA aims to achieve "no out-of-pocket" expenses for childbirth within policy coverage by 2026, expanding maternity insurance to cover flexible employment and migrant workers [4] - The long-term care insurance system is being developed to cover approximately 300 million insured individuals, benefiting over 3.3 million disabled individuals [4] - Nearly 95% of insurance areas will directly distribute maternity benefits to insured individuals [4] Group 4: Anti-fraud Measures - 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 [5] - The NMIA has utilized big data models and intelligent regulatory systems to recover 9.5 billion yuan in fund losses [5] - In 2026, the NMIA will enhance inspection efforts, focusing on areas with high out-of-pocket rates and ensuring strict penalties for fraudulent activities [6]