Recently, for the purpose of coordinating with the Medical System Reform in China, China Insurance Regulatory Commission (CIRC) issued the Opinions on Implementing the Medical Reform and Actively Engaging in Establishment of the Multilayer Medical Guarantee System (hereinafter referred to as Opinions) on June 11, 2009. For the first time this has stipulated eight requirements for the commercial insurance institutions that are engaged in various medical guarantees administrative services.
The requirements include: (1) an independent account system in the commercial insurance institutions shall be set up for the management and operation of the basic medical guarantee services; (2) a specific acceptance policy and claim settlement system shall be set up for the management and operation of the basic medical guarantee services; (3) a health care insurance data management system shall be established; (4) such business shall be approved by the parent company in writing and a system of incentive and disincentive shall be set up; (5) branches of this shall spread to areas where the medical guarantee business will operate, and the internal management and control to those branches shall be intensive; (6) professional actuaries, employees, managers and operators who specialize in the acceptance of policies and claim examinations shall be recruited; (7) the information management system in the commercial insurance institutions shall be fully functional, relatively independent, safe and effective, which can be connected to the information system in the appointed hospitals to provide the health care services; and finally (8) there are other conditions which are required by the CIRC.
According to the Opinions, the management model for the basic medical guarantee services shall be entrustment. In regards to this sort of management, the president of the KunLun Health Insurance Co. Ltd., stated that the entrustment model is the principle access for the insurance companies to take part in the pilot medical insurance services which is handled by the government. Further, he believes this is a good way to operate the health care system for the Chinese consumer.
The health care information management system is deemed very important and is emphasized in the Opinion. The data exchange and information system between the insurance companies and the medical institutions are based on the insurance companies’ information maintenance capacities; these are fully functional, and relatively independent.