Government Discusses Reforms for Reimbursable and Actual Expense Insurance: "Comprehensive Management System Needed"

Supplementary Measures for Non-Reimbursable Services and Actual Expense Insurance Discussed
Committee Considers “Managed Benefit” Category and Adjustments to Co-Payment Rates

The Essential Medical Care and Fair Compensation Subcommittee under the Special Committee on Medical Reform (SCMR) discussed measures for managing non-reimbursable services and reforming actual expense insurance.

Noh Yeonhong, Chairman of the Special Committee on Medical Reform, is delivering a greeting at the policy discussion on non-reimbursed service management and actual expense insurance reform measures for the normalization of the medical system held at the Korea Press Center in Jung-gu, Seoul, on the 9th of last month. Photo by Yonhap News

On February 19, at a meeting held at the Korea Press Center in Jung-gu, Seoul, the SCMR addressed supplementary measures based on the non-reimbursable and actual expense insurance reform plans unveiled at a policy discussion on January 9, taking into account feedback received during and after the forum.

At the time, the reform proposal focused on introducing a new “managed benefit” category to strengthen oversight of non-reimbursable treatments with high potential for abuse, such as manual therapy, and on reducing actual expense insurance coverage for non-severe illnesses.

The Ministry of Health and Welfare reported that the committee members agreed on the need to establish a comprehensive management system to ensure that non-reimbursable services, which are being overused beyond medical necessity, are properly managed. This should be done while respecting the autonomy of medical professionals and patients’ right to choose, but also to alleviate the public’s medical expenses and prevent distortions in the healthcare system.

One proposal involved converting non-reimbursable items with high risk of abuse into managed benefits under the national health insurance system, applying a patient co-payment rate of 90-95%. However, specific items to be included were not detailed.

The scope of parallel treatment restrictions has also not been finalized. Parallel treatment refers to the practice where, in order to claim actual expense insurance, a patient receives reimbursable treatment alongside non-reimbursable procedures such as cosmetic or plastic surgery, resulting in the patient bearing the full cost of the reimbursable treatment as if it were non-reimbursable.

The government reportedly proposed that a separate committee will determine which items should be classified as managed benefits, focusing on treatments with significant price disparities among medical institutions and those with rapidly increasing costs, particularly in selective, preventive, and supplementary care.

There was also a suggestion to adjust the support ratio for the health insurance co-payment portion covered by actual expense insurance. During the previous discussion, the government had proposed equalizing the co-payment rates for health insurance and actual expense insurance for non-severe patients’ reimbursable treatments.

Opinions were raised that further review is needed regarding the scope of severe illnesses, which will serve as the basis for calculating coverage rates.

Based on the opinions presented at the meeting, the committee plans to convene the subcommittee at least once more to further elaborate on supplementary measures.

The SCMR is expected to announce the second phase of medical reform measures, including the non-reimbursable and actual expense insurance reform plans, as early as next month.

This content was produced with the assistance of AI translation services.