Overview of medical insurance catalog

The medical insurance catalog is a reimbursement list of drugs, diagnosis and treatment items and medical consumables formulated by the National Medical Insurance Bureau.Category A(full reimbursement) andCategory B(Partially paid out of pocket), aiming to reduce patients’ medical burden. Core content includesinclusion criteria(clinically necessary, safe and effective, reasonably priced),dynamic adjustment mechanism(updated annually) andlocal supplementary directory(Provincial differentiated adjustment). The focus is on the composition, functions and usage rules of the medical insurance catalog, and mainly on alternatives to self-pay items outside the catalog.

The composition and classification of the medical insurance catalog

Medical insurance directory is provided byMedicines,Diagnosis and treatment itemsandMedical service facilitiesComposed of three parts. In the drug catalog, Class A drugs (such as penicillin) are uniformly formulated by the state, while Class B drugs (such as some anti-cancer drugs) require patients to pay a certain percentage out of pocket. Diagnosis and treatment items include surgeries, examinations, etc., such as CT scans; medical service facilities include inpatient bed fees, etc. The catalog ensures cost-effectiveness through expert review and price negotiation (such as the inclusion of PD-1 inhibitors). Some high-priced drugs are included after price reductions through negotiation, such as the 111 new drugs added in 2023.

Dynamic adjustments and local differences in the medical insurance catalog

The medical insurance catalog is adjusted every year to add innovative drugs and eliminate drugs with poor efficacy or risks. For example, the new coronavirus treatment drug Azivudine tablets will be added in 2022. Each province can add no more than 15% of Class B drugs (for example, Yunnan includes local characteristic Chinese medicines), but after 2020, local addition authority will be canceled to unify standards. Patients need to pay attentionDifference in reimbursement ratio, for example, economically developed areas may increase reimbursement for Class B drugs to 90%, while less developed areas may only increase reimbursement to 70%.

Use and restrictions of the medical insurance catalog

To use the medical insurance directory, you must meet the following requirements:Designated institution(such as public hospitals),Indications restrictions(For example, anticancer drugs are limited to specific cancers) and other conditions. Expenses outside the catalog need to be paid out of pocket, such as proton therapy for cancer (about 200,000 yuan/course). Some cities will pilotRare disease drugs(such as the SMA specific drug nosinaxin sodium) is included in the reimbursement, but special approval needs to be applied for. Patients can check whether the drug is in the catalog and the reimbursement rate through the National Medical Insurance Service Platform APP.

Summary and Notes

The medical insurance catalog is the core basis for medical reimbursement, but it needs to be used flexibly in conjunction with local policies and personal conditions. It is recommended that patients confirm whether the medicine/item is in the catalog before seeking medical treatment, and keep a list of prescriptions and expenses for reimbursement. In the future, the medical insurance catalog will cover more innovative drugs and rare disease drugs. For example, in 2023, the price of orebatinib (leukemia drug) will be reduced from 240,000 per year to 36,000 per year through negotiation. For needs outside the catalog, supplementary commercial insurance or charitable assistance programs may be considered.

Citing sources

1. National Medical Security Administration's "National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog (2023)"
2. China Medical Insurance Research Association's "Research Report on the Adjustment Mechanism of the Medical Insurance Catalog"
3. CCTV News "The Case of "Soul Bargaining" in Medical Insurance Negotiations" (January 2023)