The Measures for the Administration of Health Insurance No.3 (Order No.20 19) issued by the Insurance Regulatory Commission of the Bank of China shall come into force as of 20 19 12 1.

Measures for the administration of health insurance

Chapter I General Principles

Article 1 These Measures are formulated in accordance with the Insurance Law of People's Republic of China (PRC) (hereinafter referred to as the Insurance Law) and other laws and administrative regulations in order to promote the development of health insurance, standardize the operation of health insurance, protect the legitimate rights and interests of the parties involved in health insurance activities and improve the level of people's health protection.

Article 2 The term "health insurance" as mentioned in these Measures refers to the insurance in which an insurance company pays insurance money to the insured due to health reasons or medical behaviors, mainly including medical insurance, sickness insurance, disability income loss insurance, nursing insurance and medical accident injury insurance.

The term "medical insurance" as mentioned in these Measures refers to the insurance that provides protection for the medical treatment and rehabilitation of the insured in accordance with the insurance contract.

The term "sickness insurance" as mentioned in these Measures refers to the insurance that provides protection for the insured in the event of diseases agreed in the insurance contract.

The term "disability income loss insurance" as mentioned in these Measures refers to the insurance that pays insurance benefits on the condition that the illness or accidental injury agreed in the insurance contract leads to the loss of labor ability, and provides protection for the insured's income reduction or interruption in a certain period of time.

The term "nursing insurance" as mentioned in these Measures refers to the insurance that provides protection for the nursing needs caused by the loss of the insured's ability of daily living in accordance with the insurance contract.

The term "medical accident insurance" as mentioned in these Measures refers to the insurance that provides protection for the insured in the event of medical damage not attributable to medical institutions and medical personnel according to the insurance contract.

Article 3 Health insurance is an important part of the national multi-level medical security system. Adhere to the nature of health insurance, encourage insurance companies to follow the principle of prudence and stability, continuously enrich health insurance products, improve health insurance services, expand health insurance coverage, reduce health insurance prices and operating costs through effective management and market competition, and improve the level of protection.

Article 4 Health insurance is divided into long-term health insurance and short-term health insurance according to the insurance period.

Long-term health insurance refers to health insurance whose insurance period exceeds one year or whose insurance period does not exceed one year, but which contains a guarantee renewal clause.

The insurance period of long-term care insurance shall not be less than 5 years.

Short-term health insurance refers to health insurance with an insurance period of one year or less and without a guarantee renewal clause.

The guarantee renewal clause refers to the contractual agreement that the insurance company must continue to underwrite the insurance according to the original clause and the agreed rate before the expiration of the previous insurance period.

Article 5 Medical insurance is divided into cost compensation medical insurance and fixed payment medical insurance according to the nature of insurance payment.

Cost-compensated medical insurance refers to medical insurance that determines the amount of insurance money according to the actual medical and rehabilitation expenses incurred by the insured and the agreed standards.

Fixed payment medical insurance refers to medical insurance that pays insurance benefits according to the agreed amount.

The payment amount of cost compensation medical insurance shall not exceed the amount of medical and rehabilitation expenses actually incurred by the insured.

Article 6 The Insurance Regulatory Commission of the Bank of China (hereinafter referred to as China Banking Regulatory Commission) shall supervise and manage the health insurance activities of insurance companies in accordance with laws, administrative regulations and the authorization of the State Council.

Article 7 Insurance companies shall carry out policy insurance business related to health insurance by referring to these Measures, unless otherwise stipulated by national policies.

These Measures shall not apply to the entrusted management services provided by insurance companies that do not bear insurance risks.

Chapter II Operation and Management

Article 8 Health insurance companies, life insurance companies and endowment insurance companies established according to law may engage in health insurance business with the approval of China Banking Regulatory Commission.

Insurance companies other than those mentioned in the preceding paragraph may engage in short-term health insurance business with the approval of China Banking Regulatory Commission.

Article 9 In addition to health insurance companies, insurance companies shall set up special health insurance departments to operate health insurance business. The Health Insurance Division shall continuously meet the following conditions:

(1) Establishing an independent accounting system for health insurance business;

(two) the establishment of health insurance actuarial system and risk management system;

(three) the establishment of health insurance underwriting system and claims system;

(four) the establishment of health insurance data management and information disclosure system;

(5) Establish a fully functional and relatively independent health insurance information management system;

(six) equipped with actuarial personnel, underwriting personnel, underwriting personnel and management personnel with medical education background with professional knowledge of health insurance;

(7) Other conditions stipulated by China Banking Regulatory Commission.

Article 10 An insurance company shall provide professional health insurance training to its employees engaged in underwriting, claim settlement and sales of health insurance.

Article 11 An insurance company shall strengthen the privacy protection of the insured, the insured and the beneficiary, and establish a health insurance customer information management and confidentiality system.

Chapter III Product Management

Article 12 An insurance company shall draw up the insurance clauses and premium rates of health insurance, and submit them for approval or filing in accordance with the relevant provisions of the China Banking Regulatory Commission.

Health insurance products that enjoy preferential tax policies shall meet relevant policies and regulatory requirements in product design and payout ratio.

Article 13 If the health insurance products drawn up by an insurance company contain more than two kinds of health insurance liabilities, the chief actuary shall judge the main liabilities according to general actuarial principles and determine the product types according to the main liabilities.

Fourteenth medical accident insurance and long-term illness insurance products can include death insurance liability. The death payment of long-term illness insurance shall not be higher than the maximum payment of illness. Other health insurance products shall not include death insurance liability, except for death insurance liability caused by illness.

Medical insurance, sickness insurance and medical accident insurance products do not include the liability of survival insurance.

Article 15 A long-term health insurance product shall have a contract hesitation period, and the rights of the insured during the hesitation period shall be clearly defined in the insurance clauses. The hesitation period of long-term health insurance products shall not be less than 15 days.

Article 16 Insurance companies shall sell short-term personal health insurance products in strict accordance with the approved or filed product rates.

Article 17 Except for the family history of genetic diseases, an insurance company shall not make differential pricing based on other genetic information and genetic test data of the insured.

Eighteenth short-term group health insurance products can adjust the product parameters.

Product parameters refer to the insurance amount, minimum compensation amount, compensation ratio, excluded liability, liability waiting period and other matters reasonably adjusted according to the specific conditions of the insured group in the insurance product terms.

Article 19 When an insurance company submits a short-term group health insurance product with adjustable product parameters for examination and approval or filing, the application materials submitted shall include the method for adjusting the product parameters, which shall be signed and confirmed by the chief actuary according to the principle of prudence.

When an insurance company sells short-term group health insurance products with adjustable product parameters, it shall calculate the corresponding insurance premium rate according to the adjustment method of product parameters, its own risk management level and the risk status of the insured group, and the adjustment of product parameters shall not change the rate calculation method and the basic data required for rate calculation.

If an insurance company sells short-term group health insurance products with adjustable product parameters and needs to change the rate calculation method or the basic data required for rate calculation, it shall re-submit the product for approval or filing.

Article 20 An insurance company may adjust the rates of long-term medical insurance products by agreement in its insurance products, and clearly indicate the trigger conditions for rate adjustment.

Long-term medical insurance product rate adjustment should follow the principle of fairness and reasonableness, and the trigger conditions should be objective and universally applicable, and comply with relevant regulatory provisions.

Article 21 For health insurance products with guaranteed renewal clauses, the effective time of the guaranteed renewal clauses shall be clearly agreed.

Health insurance products with guaranteed renewal clauses shall not stipulate that the insurance company has the right to reduce the insurance liability and increase the scope of liability exemption when renewing the insurance.

For health insurance products submitted by insurance companies for examination and approval or filing, the pricing method of guarantee renewal and the calculation method of liability reserve shall be explained in the actuarial report of the products.

Article 22 An insurance company shall respect the insured's right to obtain reasonable medical services when drawing up the terms of medical insurance products, and shall not set unreasonable or contrary conditions in the terms as the conditions for paying insurance benefits.

Article 23 The disease diagnosis standards agreed by insurance companies in the terms of health insurance products shall conform to the prevailing medical diagnosis standards and take into account the development trend of medical technical conditions.

After the health insurance contract comes into effect, if the insured is diagnosed with a disease according to the prevailing medical diagnostic criteria, the insurance company shall not refuse to pay the insurance money on the grounds that the diagnostic criteria are inconsistent with the insurance contract.

Article 24 When designing medical insurance products with cost compensation, insurance companies must distinguish whether the insured enjoys free medical care, basic medical insurance and other medical insurance with cost compensation, and treat them differently in terms of insurance terms, rates or compensation amount.

Article 25 If the insured holds more than one effective medical insurance policy for expense compensation at the same time, he can decide the order of claim settlement independently.

Article 26 An insurance company may make an agreement with the applicant that the insured shall seek medical treatment in a designated medical institution as a condition for payment of insurance benefits.

Medical institutions designated by insurance companies shall follow the principle of convenience for the insured and reasonable management of medical expenses, guide the insured to rationally use medical resources and save medical expenses, and make explanations and explanations to the insured and the insured.

Twenty-seventh sickness insurance, medical insurance, nursing insurance products waiting period shall not exceed 180 days.

Twenty-eighth medical insurance products can be appropriately tilted to the poor in terms of pricing, compensation conditions and coverage. , and clearly defined in writing.

Article 29 The survival insurance money paid by nursing insurance products before the expiration of the insurance period shall be paid on the condition that the insured needs nursing due to the disability of daily life stipulated in the insurance contract.

Article 30 Insurance companies are encouraged to develop medical insurance products and ensure the application of new drugs, new medical devices and new diagnosis and treatment methods in medical services.

Article 31 Insurance companies are encouraged to adopt new technologies such as big data to improve the level of risk management. For health insurance claims with clear facts and clear responsibilities, insurance companies can use information technology such as the Internet to review the digital claims materials of the insured, simplify the claims process and improve service efficiency.

Article 32 An insurance company shall, according to the actual payment experience of health insurance products, make a retrospective analysis of product pricing, timely revise the rate of new sales of health insurance products, and conduct examination and approval or filing in accordance with the relevant provisions of China Banking Regulatory Commission.

Article 33 Insurance companies are encouraged to provide innovative health insurance products to meet people's multi-level and diversified health protection needs.

Article 34 Innovative health insurance products developed by insurance companies shall conform to the Insurance Law and the basic principles of insurance, and shall be reported to China Banking Regulatory Commission for approval or filing in accordance with relevant regulations.

Chapter IV Sales Management

Article 35 When selling health insurance products, an insurance company shall strictly implement the insurance clauses and insurance rates that have been approved or filed.

Article 36 Unless otherwise stipulated by legal reasons and conditions, an insurance company shall not refuse to provide health insurance products that have been approved or put on record.

Insurance companies selling health insurance products shall not be forced to match other products for sale.

Article 37 An insurance company may not entrust medical institutions or medical personnel to sell health insurance products.

Article 38 When selling health insurance products, an insurance company shall not illegally collect or obtain the genetic information and genetic test data of the insured except the family history of genetic diseases; Nor may the applicant, the insured or the beneficiary be required to provide the above information.

An insurance company shall not take genetic information and genetic test data other than the family history of the insured as underwriting conditions.

Article 39 When an insurance company sells health insurance products, it shall explain the contents of the insurance contract to the applicant in written or oral form, and clearly inform the following matters, which shall be confirmed by the applicant:

(1) Insurance liability;

(2) relief of insurance liability;

(3) The waiting period of insurance liability;

(four) the hesitation period of the insurance contract and the relevant rights and obligations of the applicant;

(five) whether to provide the guarantee renewal and the effective time of renewal;

(6) Claims procedures and claims documents;

(seven) the insurance period of each product in the combined health insurance products;

(8) Other matters stipulated by China Banking Regulatory Commission.

Article 40 When selling health insurance products, an insurance company shall not exaggerate the scope of insurance coverage, conceal the reasons for exemption, or mislead the insured and the insured.

If the applicant and the insured inquire about the insurance terms, such as insurance, medical treatment and diseases, the insurance company shall explain them in clear and understandable language.

Article 41 When an insurance company sells medical insurance with compensation for expenses, it shall ask the insured whether he enjoys free medical care, basic medical insurance or other medical insurance with compensation for expenses, and the insured shall truthfully inform him.

An insurance company shall explain to the applicant the legal consequences of not telling the truth, and make relevant records.

An insurance company shall not induce the applicant to repeatedly purchase medical insurance products with the same or similar protection functions for the same insured.

Article 42 When an insurance company sells medical insurance, it shall inform the list of medical institutions or qualification requirements agreed by the insured, and provide inquiry service.

If an insurance company adjusts the contracted medical institution, it shall promptly notify the applicant or the insured.

Article 43 Where an insurance company sells health insurance products without guaranteed renewal clauses in the form of additional insurance, the insurance period of the additional insurance shall not be less than that of the main insurance.

Article 44 Where an insurance company sells long-term personal health insurance products, it shall pay a return visit to the applicant within the hesitation period.

If an insurance company finds that the insured is misled during the return visit, it shall do a good job of explanation and clearly inform the insured of the right to terminate the insurance contract according to law.

Article 45 When an insurance company underwrites group health insurance, it shall inform each insured in written or oral form of his participation and related rights and interests.

Article 46 If the applicant cancels the group health insurance contract, the insurance company shall require the applicant to provide valid proof that the insured has been notified to surrender, and return the surrender money to the payment account or other account of the applicant by bank transfer or remittance in accordance with the regulations of China Banking Regulatory Commission on group insurance surrender.

Chapter V Reserve Evaluation

Article 47 An insurance company engaged in health insurance business shall submit the actuarial report or reserve evaluation report of the previous year in accordance with the relevant provisions of these Measures.

Article 48 An insurance company shall withdraw the outstanding claims reserve that has occurred and has been reported.

An insurance company shall use reasonable methods such as transaction estimation method and transaction average compensation method to prudently withdraw the outstanding claims reserves that have occurred, reported and reported.

Where an insurance company uses actuarial methods other than case-by-case estimation method to make provision for reported outstanding claims, it shall report the basic data, parameter setting and estimation method of this method in detail, and explain the source of basic data, data quality and reliability of reserve calculation results.

If the chief actuary of an insurance company cannot confirm the reliability of the estimation method or the relevant business experience data is less than 3 years, it shall withdraw the reported outstanding claims reserve according to the claimed amount.

Article 49 For the compensation or payment that has occurred but has not been claimed, the insurance company shall withdraw the outstanding compensation reserve that has occurred but has not been reported.

An insurance company shall, according to the risk nature and empirical data of insurance products, use at least two methods, namely, the chain ladder method, the case average compensation method, the reserve progress method, the B-F method and the payout ratio method, to evaluate the outstanding loss reserve, and select the maximum value of the evaluation result to determine the best estimated value.

An insurance company shall report in detail the basic data, calculation method and parameter setting of the outstanding claims reserve, and explain the source of the basic data, the data quality and the reliability of the calculation results of the reserve.

If the chief actuary of an insurance company judges that the data base cannot guarantee the reliability of the calculation results, or the relevant business experience data is less than 3 years, it shall withdraw the outstanding claims reserve at a rate of not less than 65,438+00% of the actual claims expenditure in the fiscal year.

Article 50 For short-term health insurance business, the insurance company shall withdraw the unexpired liability reserve.

Short-term health insurance can use one of the following methods to extract the unexpired liability reserve:

(1) quarterly gross premium method (accrued monthly);

(2) Article 365 Gross premium method (accrued on a daily basis);

(3) According to the risk distribution, other more cautious and reasonable methods can be adopted, and the unearned liability reserve shall not be lower than the lesser of methods (1) and (2).

Article 51 The withdrawal amount of the unexpired liability reserve for short-term health insurance shall not be lower than the higher of the following two items:

(a) The balance of estimated future compensation and expenses after deducting relevant investment income;

(2) On the assessment date of liability reserve, it is assumed that all policies will be surrendered.

If the unearned liability reserve is insufficient, the premium shortage reserve shall be withdrawn to make up for the difference between the unearned liability reserve and the larger one in the preceding two items.

Article 52 The term "liability reserve" as mentioned in these Measures refers to business-related reporting liability reserve, and the provision of financial reporting liability reserve and solvency reporting liability reserve shall be implemented in accordance with the relevant provisions of the Ministry of Finance and China Banking Regulatory Commission.

Article 53 The provision of unearned liability reserve for long-term health insurance shall be made in accordance with the relevant regulations of China Banking Regulatory Commission.

Article 54 An insurance company shall report the results of reserve withdrawal to the China Banking Regulatory Commission before and after reinsurance.

Chapter VI Health Management Services and Cooperation

Article 55 An insurance company may combine health insurance products with health management services to provide health risk assessment and intervention, disease prevention, health examination, health consultation, health maintenance, chronic disease management, health care and other services to reduce health risks and disease losses.

Article 56 Where an insurance company provides health management services, the contents of the health management services may be stipulated in the terms of the insurance contract, or a separate health management service contract may be signed.

Fifty-seventh health insurance products to provide health management services, the cost of sharing shall not exceed 20% of the net insurance premium.

Services exceeding the above limits shall be priced separately and shall not be included in the insurance premium, and the price of health management services shall be specified in the contract.

Article 58 When operating medical insurance, an insurance company shall strengthen cooperation with medical institutions, health management institutions and rehabilitation service institutions to provide the insured with high-quality and convenient medical services.

When operating medical insurance, insurance companies should supervise the authenticity and legality of the insured's medical behavior according to relevant policy documents, and strengthen the management of the rationality and necessity of medical expenses.

Article 59 Insurance companies should actively play the role of health insurance rate adjustment mechanism in controlling medical expenses and risks, and reduce unreasonable medical expenses.

Article 60 An insurance company should actively play its role as a third party in the doctor-patient relationship, help alleviate the information asymmetry between doctors and patients, and promote the settlement of contradictions and disputes between doctors and patients.

Article 61 The cooperation between an insurance company and a medical institution or health management institution shall not harm the legitimate rights and interests of the insured.

Article 62 An insurance company shall, in accordance with the provisions of laws and administrative regulations, fully protect customer privacy and data security, and conduct necessary information interconnection and data sharing with medical institutions and basic medical insurance departments according to the scope and objects of services.

Chapter VII Reinsurance Management

Article 63 An insurance company shall abide by the Insurance Law and the provisions of China Banking Regulatory Commission on the management of reinsurance business when handling health insurance reinsurance business.

Article 64 No branch of an insurance company may engage in health insurance reinsurance business, except for the branch of a reinsurance company.

Chapter VIII Legal Liability

Article 65 Insurance companies and their branches that violate these Measures shall be punished by China Banking Regulatory Commission and its dispatched offices in accordance with laws and administrative regulations; Where there are no provisions in laws and administrative regulations, the China Banking Regulatory Commission and its dispatched offices shall order it to make corrections and give a warning. If there is illegal income, a fine of 1 times and less than 3 times shall be imposed, but the maximum amount shall not exceed 30,000 yuan; if there is no illegal income, a fine of 654,380+0,000 yuan shall be imposed; Anyone suspected of committing a crime shall be transferred to judicial organs for criminal responsibility according to law.

Article 66 Employees of insurance companies and employees of branches of insurance companies who violate these Measures shall be punished by China Banking Regulatory Commission and its dispatched offices in accordance with laws and administrative regulations; Where there are no provisions in laws and administrative regulations, the China Banking Regulatory Commission and its dispatched offices shall order it to make corrections and give a warning. If there is illegal income, a fine of 1 times and less than 3 times shall be imposed, but the maximum amount shall not exceed 30,000 yuan; if there is no illegal income, a fine of 654,380+0,000 yuan shall be imposed; Anyone suspected of committing a crime shall be transferred to judicial organs for criminal responsibility according to law.

Chapter IX Supplementary Provisions

Article 67 These Measures shall apply to health insurance operated by mutual insurance organizations.

Article 68 These Measures shall apply to the sales of health insurance products by insurance intermediaries and their employees.

Article 69 Whoever sells health insurance products through banks, postal services and other channels shall abide by the provisions of the relevant regulatory authorities.

Article 70 Where the provisions promulgated by the former China Insurance Regulatory Commission before the implementation of these Measures are inconsistent with these Measures, these Measures shall prevail.

Article 71 The China Banking Regulatory Commission shall be responsible for the interpretation of these Measures.

Article 72 These Measures shall come into force as of 20 19 12 1. The Measures for the Administration of Health Insurance issued by the former China Insurance Regulatory Commission on August 7, 2006 (Order No.8 of China Insurance Regulatory Commission in 2006) shall be abolished at the same time.