2025.11. 23 本文字数：2389，阅读时长大约4分钟 作者 | 第一财经 吴斯旻 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业 健康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长 8.2％，增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元， 有业内人士预测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付 支出与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论， 而这显著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健 康险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50％保费规模的重疾险，并非实报实销类保险，它的保障期长，存 ...

根据研究，长期医疗险的赔付率稳定在55%～80%，短期健康险中个人业务实际综合赔付率达50%～ 70%，团体业务赔付率位于100%～120%区间。 在老龄化加速、基本医保基金持续承压的背景下，商业健康险发展始终伴随争议。争议背后是，商业健 康险被公众质疑为赔付总额低、与保费规模的增长节奏不匹配。 国家金融监管总局数据显示，2024年，中国商业健康险保费收入合计达到9774亿元，同比增长8.2％， 增速较去年同期提升3.8个百分点。2025年前8个月，商业健康险保费收入突破7599亿元，有业内人士预 测今年全年商业健康险保费规模有望突破万亿元大关。 而从赔付情况来看，2024年，商业健康险赔付支出约4037.77亿元。如果使用简单赔付率(当年赔付支出 与当年保费收入之比)单一指标进行评估，不难得出中国商业健康险赔付率在40％左右的结论，而这显 著低于发达国家水平(70%～85%)。 但在商保业界人士看来，这样的测算有失偏颇，甚至与实际情况相去甚远，无法真实反映中国商业健康 险的保障效能与盈利状况。 这是因为疾病保险(以重疾险为主)与医疗保险作为商业健康险的主要险种，贡献了超过95％的保费规 模，但其中占据约50 ...

Core Insights - The transition of Huiminbao from "post-compensation" to "prevention" is highlighted, indicating a shift in focus towards proactive health management and risk reduction in the insurance sector [1][4] Group 1: Market Dynamics - The payment paradox between insurance companies and pharmaceutical firms is discussed, where insurers aim to cover healthy individuals to control costs, while drug companies focus on medication usage for market value [1] - The expected market size for innovative drug sales in 2024 is projected to reach 162 billion yuan, with commercial health insurance expenditures estimated at 12.4 billion yuan, contributing only 7.7% [1] - Huiminbao's share in the compensation for innovative drugs is 15%, which is lower than disease insurance and million medical insurance, accounting for 47% and 22% respectively [1] Group 2: Product Development and Challenges - The proportion of normally operating Huiminbao products decreased from 74.3% in 2023 to 66.68% in 2024, indicating ongoing challenges in market performance [3] - The decline in Huiminbao product numbers is attributed to lower-than-expected participation rates and difficulties in expanding the risk pool [3] - New product offerings are being introduced, such as health check management services, to enhance participant engagement and address operational pressures [3] Group 3: Health Management Integration - The integration of health management into commercial health products is emphasized as a means to reduce the risk of major diseases through early detection and intervention [4] - The model of "health management + Huiminbao" aims to shift the focus from post-event compensation to preemptive measures, enriching risk management strategies [4] - The combination of preventive health checks and innovative drug coverage is seen as a significant advancement in insurance, potentially lowering the disease burden on the population [4] Group 4: Industry Trends - The rise of health management services in insurance has been noted since 2016, although growth remains slow due to a lack of experience in managing medical models [5] - The potential of commercial health insurance in the innovative drug payment sector is yet to be fully realized, with ongoing exploration needed for deeper integration of technology, payment, and value [5]

近期，多地上新2026版惠民保产品，并开放投保通道。《金融时报》记者观察发现，今年惠民保产品卖 点集中在"保障升级""全面升级"，比如，保费不变、保额更高；理赔门槛降低、保障范围扩大。 惠民保，又称城市定制型商业医疗保险，是由地方政府相关部门指导、保险公司商业运作、居民自愿参 保的一种补充医疗保险产品。从2015年第一款惠民保产品——"深圳市重特大疾病补充医疗保险"算起， 惠民保已走过十年发展历程，成为我国多层次医疗保障体系中的重要补充。 如何从一款现象级"网红"产品成长为"保民生、防大病"的基础性制度安排？业内专家在接受《金融时 报》记者采访时表示，当前，惠民保已经从"价格竞争"转向"价值竞争"，这既是居民健康需求升级的结 果，也是政策、市场、社会等多方博弈的结果。未来，惠民保仍需在精准定价、深度保障、生态协同上 不断发力，以实现可持续发展。 从"追求规模"转向"寻求价值" 同时，不少惠民保产品还建立了动态调节机制，根据参保人实际情况灵活调整理赔门槛，让保障更具针 对性。比如，海南"惠琼保"2026版建立了免赔额与赔付记录联动机制，对连续参保且未发生理赔的参保 人适当降低免赔额。 "整体来看，2026版惠民 ...

11月以来，广州等多地的惠民保产品进入2026年投保期。上海证券报记者注意到，不少产品在维持低保 费的基础上，也在保障责任、起付线、特药目录等方面进行了升级。 作为普惠保险的典型产品，惠民保从试点到全国推广，已走过十年发展历程。十年间，各地惠民保"百 花齐放"，产品数量稳定在两百款左右，已成为缓解群众"看病贵"难题的重要力量。但在"死亡螺旋"与 保障范围扩宽等挑战之下，惠民保未来如何实现可持续发展与健康运营，也是业内关注的话题。 "存量优化"格局 历经十年发展，惠民保市场格局已从"增量扩张"转向"存量优化"。当前正常运营产品稳定在202款，传 统型惠民保占比超八成，市场基本盘趋于稳固。 就2025年新产品来看，市场呈现"双轮驱动"格局：一方面，保障网络持续下沉，湖北十堰、内蒙古呼和 浩特、云南保山等地新增市级统筹产品，将普惠保障延伸至更广袤的下沉市场；另一方面，存量市场深 耕升级，广东新增普惠重疾险产品，广西同步上线3款"守护保"系列重疾险产品，通过丰富产品层次满 足居民多样化需求。 在广州，记者采访中国人寿(43.100, 0.08, 0.19%)获悉，近5年来，广州"穗岁康"每年参保人数稳定在360 万人 ...

◎记者 周亮 11月以来，广州等多地的惠民保产品进入2026年投保期。上海证券报记者注意到，不少产品在维持低保 费的基础上，也在保障责任、起付线、特药目录等方面进行了升级。 作为普惠保险的典型产品，惠民保从试点到全国推广，已走过十年发展历程。十年间，各地惠民保"百 花齐放"，产品数量稳定在两百款左右，已成为缓解群众"看病贵"难题的重要力量。但在"死亡螺旋"与 保障范围扩宽等挑战之下，惠民保未来如何实现可持续发展与健康运营，也是业内关注的话题。 "存量优化"格局 惠民保，又称城市定制型商业医疗保险，是由地方政府相关部门指导、保险公司商业运作、居民自愿参 保的一种补充医疗保险产品。惠民保最早于2015年在深圳出现，2020年开始在全国范围内推广。 根据复旦大学经济学院副院长、风险管理与保险学系主任许闲教授团队发布的《2025年城市定制型商业 医疗保险（惠民保）知识图谱》，截至2025年7月31日，全国累计推出313款地方性惠民保产品。 历经十年发展，惠民保市场格局已从"增量扩张"转向"存量优化"。当前正常运营产品稳定在202款，传 统型惠民保占比超八成，市场基本盘趋于稳固。 就2025年新产品来看，市场呈现"双轮 ...

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 Viewpoint - The article discusses the evolution and challenges of the "Hui Min Bao" (惠民保) insurance scheme in China, highlighting its rapid growth in coverage and the increasing complexity of claims and benefits, particularly in relation to innovative drugs and treatments [3][4][6]. Group 1: Overview of Hui Min Bao - Hui Min Bao has been promoted nationwide for nearly six years, with "special drug liability" becoming a standard feature. In the previous year, it contributed approximately 1.8 billion yuan in innovative drug payments from a premium scale of less than 20 billion yuan, marking a ninefold increase from 2021 [3][4]. - The scheme faces challenges due to varying experiences among the 150 million insured individuals, with some receiving substantial claims while others struggle to meet deductibles or face reduced payouts due to pre-existing conditions [3][4]. Group 2: Regulatory Changes and Trends - The recent notification from the National Financial Regulatory Administration emphasizes the need for commercial health insurance, including Hui Min Bao, to align premium collection with coverage levels and avoid chaotic low-price competition [4][8]. - The 2026 version of Hui Min Bao is introducing a trend of "premium stratification," moving away from low premiums to better match coverage levels, with new inclusions for chronic diseases and overseas drugs [4][6]. Group 3: Expansion of Special Drug Coverage - As of 2024, 90% of Hui Min Bao projects include "special drug liability," with a total of 672 drugs covered, reflecting a 1.8 times increase since 2021. The focus remains on cancer and rare disease medications, with over 40% of the drugs being innovative cancer treatments [6][7]. - Some regions are expanding their special drug coverage to include high-value drugs for chronic diseases, with certain plans approaching the coverage levels of pure commercial health insurance [7][8]. Group 4: Pricing and Risk Management - The core of commercial health insurance is the dynamic balance between funding and benefits. The low premium model of Hui Min Bao has slowed funding growth, impacting benefit enhancements [10][12]. - The 2026 version of Hui Min Bao is adopting a risk stratification approach, allowing for differentiated pricing based on factors like age and health status, which aims to enhance fairness and adaptability in product offerings [10][11]. Group 5: Inclusion of New Citizens and Cross-Regional Medical Services - The new Hui Min Bao products are increasingly targeting healthy individuals and young people by lowering deductibles and enhancing coverage for outpatient services and common illnesses [16][18]. - Several regions are allowing the use of personal medical insurance accounts for family members and expanding coverage to include new citizens and those seeking medical services across regions [17][18].

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]

Core Insights - The industry has not reached a consensus on the relationship between negotiated discount prices and claims for innovative drugs under commercial insurance [1][2] - The first version of the commercial insurance innovative drug directory is set to be released on the first weekend of December and will be implemented starting January 1 of next year [1] - A total of 121 drugs have been reviewed through the commercial insurance innovative drug directory this year, with around 80 drugs applying for both the basic medical insurance directory and the commercial insurance innovative drug directory [1] Group 1: Expectations and Challenges - Different stakeholders have varying expectations from the commercial insurance innovative drug directory; pharmaceutical companies hope to expand coverage through discount commitments, while commercial health insurance companies aim to manage high-cost drug reimbursement risks [1][2] - Two main challenges identified include clarifying the relationship between negotiated prices and claims responsibilities, and establishing a clear mechanism for pharmaceutical companies to return discounts to insurers [2][5] Group 2: Pricing Mechanisms - The introduction of the commercial insurance innovative drug directory aims to enhance the payment capabilities for innovative drugs and strengthen the associated policy framework [3] - The National Healthcare Security Administration (NHSA) proposes a mechanism for price confidentiality, allowing pharmaceutical companies to negotiate discounts with insurers while keeping the negotiated prices confidential [3][4] Group 3: Implementation and Operational Challenges - The successful implementation of the directory requires addressing challenges related to the existing actuarial models of commercial insurance products and compliance with industry regulations [7][8] - The path for returning discounts from pharmaceutical companies to insurers remains unclear, with the NHSA requiring the industry to explore solutions within three months of the directory's launch [9][10] Group 4: Opportunities and Market Dynamics - The directory's introduction provides an opportunity for insurers to engage directly with pharmaceutical companies, enhancing negotiation capabilities [14] - The complexity of discount return mechanisms and price confidentiality may still involve intermediaries, indicating potential challenges in the practical application of these agreements [14]