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Notice of the China Insurance Regulatory Commission on Issuing the Interim Measures for the Administration of Insurance Companies' Critical Illness Insurance Business for Urban and Rural Residents
(No. 19 [2013] of the China Insurance Regulatory Commission)
All local offices of the China Insurance Regulatory Commission and all insurance companies:
In order to implement the Guiding Opinions of the National Development and Reform Commission, the Ministry of Health, the Ministry of Finance, the Ministry of Human Resources and Social Security, the Ministry of Civil Affairs, and the China Insurance Regulatory Commission on Carrying out the Work of Critical Illness Insurance for Urban and Rural Residents (No. 2605 [2012] of the National Development and Reform Commission), promote the sound development of critical illness insurance business for urban and rural residents, and protect the lawful rights and interests of the urban and rural residents who are covered by critical illness insurance, the China Insurance Regulatory Commission (CIRC) has formulated upon research the Interim Measures for the Administration of Insurance Companies' Critical Illness Insurance Business for Urban and Rural Residents, which are hereby issued to you for your compliance and implementation.
China Insurance Regulatory Commission
March 12, 2013
Interim Measures for the Administration of Insurance Companies' Critical Illness Insurance Business for Urban and Rural Residents
| | 中国保监会关于印发《保险公司城乡居民大病保险业务管理暂行办法》的通知
（保监发〔2013〕19号）
各保监局，各保险公司：
为贯彻落实国家发改委、卫生部、财政部、人力资源社会保障部、民政部、中国保监会《关于开展城乡居民大病保险工作的指导意见》（发改社会〔2012〕2605号），促进城乡居民大病保险业务健康发展，保护参保城乡居民的合法权益，我会研究制定了《保险公司城乡居民大病保险业务管理暂行办法》。现予印发，请遵照执行。
中国保监会
2013年3月12日
保险公司城乡居民大病保险业务管理暂行办法
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Chapter I General Provisions
| | 第一章 总 则
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Article 1 The term “critical illness insurance for urban and rural residents” (hereinafter referred to as the “critical illness insurance”) as mentioned in these Measures refers to a systematic arrangement that gives a further guarantee to urban and rural residents if large amount of medical expenses are incurred from their critical illness on the basis of basic medical insurance for the purpose of improving the medical security level of urban and rural residents. The concrete practice shall be: appropriating a certain percentage or a certain amount of capitals from the funds of the basic medical insurance for urban residents (hereinafter referred to as the “medical insurance for urban residents”), the funds of the new rural cooperative medical system (hereinafter referred to as NCMS), or the funds of the basic medical insurance for urban and rural residents (hereinafter referred to as the “medical insurance for urban and rural residents”) to serve as the funds of the critical illness insurance, and purchasing critical illness insurance from a commercial insurance company that meets business qualification by means of bid.
Critical illness insurance is an expansion and extension of the basic medical security system.
| | 第一条 本办法所称城乡居民大病保险（以下简称“大病保险”），是指为提高城乡居民医疗保障水平，在基本医疗保障的基础上，对城乡居民患大病发生的高额医疗费用给予进一步保障的一项制度性安排。具体做法是从城镇居民基本医疗保险（以下简称“城镇居民医保”）基金、新型农村合作医疗（以下简称“新农合”）基金或城乡居民基本医疗保险（以下简称“城乡居民医保”）基金中划出一定比例或额度作为大病保险资金，通过招投标方式向符合经营资质的商业保险公司购买大病保险。
大病保险是基本医疗保障制度的拓展和延伸。
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Article 2 These Measures shall apply to critical insurance business that is linked up with the medical insurance for urban residents, the NCMS, or the medical insurance for urban and rural residents. These Measures may also apply to the unified system of critical illness insurance covering urban employees, urban residents and rural residents that is established in some regions.
| | 第二条 本办法适用于与城镇居民医保、新农合或城乡居民医保相衔接的大病保险业务。部分地区建立的覆盖城镇职工、城镇居民、农村居民的统一的大病保险制度也可适用本办法。
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Article 3 The “policy holder” as mentioned in these Measures refers to a department that is authorized by local government; “the insured” refer to all persons covered by the medical insurance for urban residents, the NCMS, or the medical insurance for urban and rural residents in a region where critical illness insurance is to be carried out; and the “beneficiary” refers to the insured himself or herself.
Unless otherwise specified, the “insurance companies” as mentioned in these Measures include insurance companies and their branches.
| | 第三条 本办法所称投保人为地方政府授权的部门；被保险人为大病保险开展地区参加城镇居民医保、新农合或城乡居民医保的全部参保（合）人；受益人为被保险人本人。
如无特别指明，本办法所称保险公司，包括保险公司及其分支机构。
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Article 4 To engage in critical illness insurance business, an insurance company shall give priority to the protection of the lawful rights and interests of the insured, implement the sustainable development of critical illness insurance business by improving operational efficiency, service quality, risk management level, and capacity of monitoring medical services and expenses, and establish good market integrity.
| | 第四条 保险公司开展大病保险业务，应优先维护被保险人的合法利益，通过提高运行效率、服务质量、风险管理水平、医疗服务和费用监控能力，实现大病保险业务可持续发展，树立良好的市场信誉。
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Chapter II Operation Qualification
| | 第二章 经营资质
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Article 5 To engage in critical illness insurance business, the headquarters of an insurance company shall meet the following basic conditions:
| | 第五条 保险公司总公司开展大病保险业务应当具备以下基本条件：
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(1) Its registered capital is no less than 2 billion yuan or its net assets within the latest three years value no less than 5 billion yuan; excluding professional health insurance companies.
| | （一）注册资本不低于人民币20亿元或近三年内净资产均不低于人民币50亿元；专业健康保险公司除外；
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(2) It complies with the provisions on the solvency of an insurance company. The solvency of a professional health insurance at the end of the previous year and at the end of the latest season is no less than 100% and the solvency of an insurance company of any other type is no less than 150% at the end of the previous year and at the end of the latest season.
| | （二）满足保险公司偿付能力管理规定，专业健康保险公司上一年度末和最近季度末的偿付能力不低于100%，其他保险公司上一年度末和最近季度末的偿付能力不低于150%；
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(3) It has engaged in the special business of health insurance within the territory of China for more than five consecutive years, and has obtained mature experience in business operations and management of health insurance.
| | （三）在中国境内连续经营健康保险专项业务5年以上，具有成熟的健康保险经营管理经验；
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(4) Its business operations comply with regulations and it has no violation of laws and regulations within the latest three years.
| | （四）依法合规经营，近三年内无重大违法违规行为；
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(5) It is capable of implementing special management and independent accounting of critical illness insurance business.
| | （五）能够对大病保险业务实行专项管理和单独核算；
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(6) It has good actuarial techniques for health insurance and is capable of setting a scientific and reasonable price for critical illness insurance.
| | （六）具备较强的健康保险精算技术，能够对大病保险进行科学合理定价；
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(7) It has good service network with broad coverage.
| | （七）具备完善的、覆盖区域较广的服务网络；
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(8) It has a team of personnel with professional backgrounds such as medical science and good capacities of underwriting and claim assessment, and risk management.
| | （八）配备具有医学等专业背景的人员队伍，具有较强的核保、核赔能力和风险管理能力；
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(9) It has a relatively independent management system of health insurance information with complete functions, and is capable of reporting data related to critical illness insurance to the insurance regulatory authority as required.
| | （九）具备功能完整、相对独立的健康保险信息管理系统，能够按规定向保险监管部门报送大病保险相关数据；
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(10) Any other conditions as prescribed by the CIRC.
| | （十）中国保监会规定的其他条件。
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Article 6 The number of branch companies of an insurance group company that engages in critical illness insurance business by means of bid in the region subject to overall planning of critical illness insurance shall not exceed one.
The insurance group company shall integrate resources, strengthen guidance, and make overall planning and coordinate its branch companies to conduct well critical illness insurance business.
| | 第六条 同一保险集团公司在一个大病保险统筹地区投标开展大病保险业务的子公司不超过一家。
保险集团公司应当整合资源，加强指导，统筹协调子公司做好大病保险业务。
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Article 7 To engage in critical illness insurance business, provincial branch companies of an insurance company (including branch companies in cities under separate state planning and branch companies under direct management of the headquarters) shall meet the following basic conditions:
| | 第七条 保险公司省级分公司（含计划单列市分公司、总公司直管的分公司）开展大病保险业务应当具备以下基本条件：
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(1) The headquarters is qualified of engaging in critical illness insurance business.
| | （一）总公司具有开展大病保险业务资质；
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(2) The headquarters has approved the subsidiary to engage in critical illness insurance business.
| | （二）总公司批准同意开展大病保险业务；
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(3) A provincial subsidiary has no material violation of laws and regulations within the latest three years.
| | （三）近三年内无重大违法违规行为；
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(4) A provincial subsidiary has a professional service team that knows well local policies of basic medical insurance and has such professional backgrounds as medical science, and is capable of providing special critical illness insurance services such as stationed personnel and inspections.
| | （四）在开展大病保险的地区配备熟悉当地基本医保政策，且具有医学等专业背景的专职服务队伍，能够提供驻点、巡查等大病保险专项服务；
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(5) Any other conditions as prescribed by local offices of the CIRC.
| | （五）当地保监局规定的其他条件。
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Article 8 The CIRC shall, in accordance with these Measures, announce and timely update the list of qualified headquarters of insurance companies.
The local offices of the CIRC shall, in accordance with these Measures and the list of headquarters of insurance companies announced by the CIRC, announce and timely update the list of provincial branch companies of qualified insurance companies (including branch companies in cities under separate state planning and branch companies under direct management of the headquarters).
The insurance companies that are included in the list may, in accordance with these Measures, engage in critical illness insurance business.
| | 第八条 中国保监会根据本办法，公布并及时更新具有资质的保险公司总公司名单。
保监局根据本办法和中国保监会公布的保险公司总公司名单，公布并及时更新具有资质的保险公司省级分公司（含计划单列市分公司、总公司直管的分公司）名单。
列入资质名单的保险公司可以依照本办法开展大病保险业务。
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Article 9 When the headquarters of a direct insurance company serves as the reinsurer or retrocession accepter of critical illness insurance, it shall meet the basic conditions as prescribed in Article 5 of these Measures and be qualified of engaging in critical illness insurance business; when a branch of the headquarters of a direct insurance company serves as the reinsurer or retrocessionaire of critical illness insurance, the branch shall meet the basic requirements as prescribed in Article 7 of these Measures and be qualified of engaging in critical illness insurance business.
| | 第九条 直接保险公司总公司作为大病保险的再保险接受人或转分保接受人时，应具备本办法第五条规定的基本条件，并应具有大病保险经营资质；其分支机构作为大病保险的再保险接受人或转分保接受人时，该分支机构应具备本办法第七条规定的基本条件，并应具有大病保险经营资质。
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Chapter III Bid Management
| | 第三章 投标管理
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Article 10 An insurance company that is qualified of engaging in critical illness insurance business may, on the basis of meeting the qualification conditions as prescribed in the bidding document, bid for critical illness insurance as a bidder.
| | 第十条 具备大病保险经营资质的保险公司，在符合招标文件规定资格条件的基础上，可作为投标人参加大病保险投标。
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Article 11 A bidder shall, as required in the bidding document, prepare the bid and provide substantial response to the requirements and conditions as prescribed in the bidding document. The bid shall, according to the empirical data of basic medical insurance provided by the tenderee and the requirements for management services raised by the bidder, scientifically pre-estimate underwriting risks and management service costs, reasonably determine insurance premiums, insured amount, minimum amount, and payment ratio, and at the same time, include such contents as beneficiaries of critical illness insurance, insurance term, scope of cover, excluded liability, settlement methods, medical management, and service measures.
The bid shall be approved by the headquarters of an insurance company and the headquarters of the insurance company shall provide the written actuarial opinion, the written legal opinion, and the relevant power of attorney.
| | 第十一条 投标人应按照招标文件的要求编制投标文件，对招标文件提出的要求和条件作出实质性响应。投标文件应根据招标人提供的基本医保经验数据及提出的管理服务要求，科学预估承保风险和管理服务成本，合理确定保险费、保险金额、起付金额、给付比例，同时包括大病保障对象、保障期限、责任范围、除外责任、结算方式、医疗管理和服务措施等内容。
投标文件应经保险公司总公司批准同意，并由总公司出具精算意见书、法律意见书和相应授权书。
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Article 12 A bidder may not make falsification, submit a bid in collusion, maliciously force prices down in competition, impede other bidders' fair competition, impair the lawful rights and interests of the tenderee and any other bidder, win the bid by bribing the tenderee or the bid evaluation committee, or adopting any other improper competition means, or disclose information of the insured provided by the tenderee.
| | 第十二条 投标人不得弄虚作假，不得相互串通投标报价，不得恶意压价竞争，不得妨碍其他投标人的公平竞争，不得损害招标人或者其他投标人的合法权益，不得以向招标人、评标委员会成员行贿或者采取其他不正当竞争手段谋取中标，不得泄露招标人提供的参保人员信息。
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Article 13 A bidder shall, seven work days before submitting a bid, report such basic information as the name of the critical illness insurance project for which it intends to bid, the tenderee, and date of bid opening to the local office of the CIRC.
The local office of the CIRC shall follow up the whole process of bid and supervise an insurance company to bid for critical illness insurance in accordance with laws and regulations. Where it is clear that the bid price is relatively low, the local office of the CIRC shall conduct comprehensive evaluation and prohibit vicious competition.
| | 第十三条 投标人应在投标7个工作日之前，向当地保监局报告拟投标大病保险项目的名称、招标人、投标时间等基本情况。
保监局应全程跟踪招投标过程，监督保险公司依法合规参与大病保险投标。对投标价格明显偏低的，保监局要进行综合评估，禁止恶性竞争。
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Article 14 After winning a bid, the bidder shall, in accordance with the bid, enter into a cooperation agreement of critical illness insurance. In principle, the term of the cooperation agreement of critical illness insurance shall not be less than three years, and the content of the critical illness insurance contract may be negotiated once every year.
．．．．．． | | 第十四条 投标人在中标后，应按照招投标文件内容规定，与投保人签订大病保险合作协议。大病保险合作协议的期限原则上不低于三年，大病保险合同内容可每年商谈确定一次。
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