The National Healthcare Security Administration has officially released new guidelines to refine payment management for long-term care insurance, marking a significant step in standardizing how these funds are utilized. The directive clarifies that the insurance fund will cover expenses for disability level assessments conducted by designated evaluation agencies, care services from approved providers, and fees for social forces legally brought in to assist with administrative management.
Regarding assessment fees, the new rules differentiate between various service scenarios and mandate that costs be shared between the fund and individuals, with the aim of preventing unnecessary or excessive use of assessment requests. Specifically, the fund will cover the service fees for a policyholder's initial successful assessment and for periodic re-evaluations required by the system. This includes reassessments organized by administrative agencies before the expiration of an evaluation result, as well as other re-evaluations conducted based on operational needs.
The scope of long-term care service payments will be determined according to the national catalog of long-term care insurance service items, with eligible services covered by the fund as stipulated. Any services falling outside this payment scope must be financed by the policyholder personally or through other channels. The guidelines also explicitly distinguish between the payment boundaries of basic medical insurance and long-term care insurance, stating that the two systems should not provide duplicate coverage for the same services. Costs related to social forces participating in administrative services will be paid from the fund according to agreements, with specific management regulations to be developed separately.
On the standardization of payment methods, the guidelines emphasize a scientific, reasonable, and efficient approach tailored to the supply characteristics of long-term care services. Assessment services will primarily be paid on a per-person basis, while care services will predominantly be billed based on time. The billing unit will vary by service type, with home care services generally using the hour as the payment unit, institutional care using the bed-day as the unit, and community care determining its unit based on specific circumstances. As demographic trends and the system evolve, the national government will explore unified approaches to pay for intelligent services and supportive assistive devices within the insurance coverage, potentially using fixed amounts or per-item pricing.
The guidelines also address the determination of payment standards, which should be set based on the fund's financial capacity, the basic needs of policyholders, and the supply of care services, with provisions for dynamic adjustments. Payment standards for care services should be tiered according to regional economic development, average social wages, industry cost levels, and the professional skills of caregivers. Limits on service duration will be determined by annual budget allocations for care services, the number of beneficiaries, payment standards, and reimbursement ratios, with adjustments based on insurance type. As a general rule, the duration of a single service item should not exceed the recommended maximum in the service catalog, and the annual maximum payment per policyholder is capped at 50% of the region's per capita disposable income for urban and rural residents from the previous year.
Local authorities are encouraged to coordinate home, institutional, and community care models, ensuring a smooth comparison between bed-day and hourly payment standards to promote the use of home and community-based services. Provincial medical security departments are tasked with strengthening oversight to keep payment standards and service durations relatively consistent across regions within their jurisdiction, avoiding excessive disparities. Assessment payment standards should be determined based on regional socioeconomic conditions, evaluator qualifications, and assessment costs, with provinces encouraged to unify these standards where feasible.
In terms of fund management and supervision, the guidelines call for scientifically preparing annual budgets, strengthening performance management, maintaining proper accounting, and establishing mechanisms for operational monitoring and risk prevention. Strict audit and payment procedures must be followed for all expenses, and performance evaluations for designated agencies and social forces should be enhanced. Settlement processes will be improved with intelligent auditing to boost efficiency. Penalties, including partial deductions or full refusal of payment, will apply to non-compliant assessment practices, care services that fail to meet plan requirements or catalog standards, and social forces that do not adhere to management rules. Fund payments must not be delegated to third-party social forces for custody or transfer.
Supervision will be intensified on disability assessments, care service behaviors, and administrative participation, gradually incorporating fund usage into routine inspection, daily oversight, social monitoring, and intelligent regulation, with exploration of extending oversight to individuals. The guidelines also propose researching credit management systems suited to long-term care insurance characteristics and enhancing dynamic monitoring of service fees charged by designated providers and assessment agencies to safeguard policyholder rights.