The government is pushing a plan to designate non-critical and non-covered treatments as "managed benefits" and to significantly raise the patient burden rate from the current average of 20% to over 90%. Along with this, it plans to reduce the coverage for non-critical and non-covered treatments and establish a 5th generation real insurance that focuses on critical diseases, inducing holders of 1st to 3rd generation real insurance products to switch.
Treatments such as physical therapy and nutritional injections are cited as representative non-critical non-covered treatment items. In many cases, these have been provided in conjunction with covered items, increasing the financial burden on the health insurance system, and the goal is to raise the patient burden rate to improve so-called medical shopping and overtreatment behaviors.
On the afternoon of the 9th, the government held a policy debate titled "Non-Covered Management and Real Insurance Reform Plan" at the Korea Press Center, revealing the direction of major improvement plans. The Medical Reform Special Committee plans to prepare a second execution plan for medical reform, reflecting the opinions collected through the debate. On this day, SuNam, the head of the Non-Covered Management Department at the National Health Insurance Service, announced the government's improvement plan for non-covered management, stating, "The use of non-covered services in non-critical areas combined with real insurance is driving the increase in overall non-covered medical expenses," and disclosed the major improvement plans.
◇Combining covered and non-covered treatments increases patient burden
First, the government will convert items with high abuse concerns into "managed benefits" to incorporate them into the health insurance system and plans to implement a patient burden rate of 90% to 95%. Once they become managed benefits, prices and treatment standards can be set and managed within the health insurance system. This means that non-covered treatment costs, which currently vary widely by medical institution, can be unified.
The Deputy Minister took physical therapy as an example, explaining, "If you received physical therapy worth 100,000 won, you will pay 95,000 won, and the National Health Insurance Corporation will bear 5,000 won." He noted, "The specific items for managed benefits have yet to be defined," and added that "the conversion to managed benefits will be prioritized for items where the treatment volume suddenly increases or where there is excessive disparity in treatment costs by medical institution, through monitoring such as the non-covered reporting system."
The government is also pushing for restrictions on covered treatment for parallel treatments that involve non-covered treatments such as beauty and plastic surgery to claim real insurance. In these cases, all covered treatment costs will be borne by the patient as non-covered.
For example, in cataract surgery involving the insertion of multifocal lenses, previously, the surgical fee was billed to the National Health Insurance Service while the cost of inserting the multifocal lenses was borne entirely by the individual, but in the future, this will be fully the patient's responsibility. If covered physical therapy and non-covered physical therapy are mixed and treated simultaneously, even the costs for physical therapy, which is covered, will be borne by the patient. The Deputy Minister stated, "We plan to create separate criteria to ensure that patients who are disadvantaged by the restrictions on parallel treatment can have their treatments covered if there is a medical necessity."
Through the reevaluation of non-covered services, the purposes and targets will be clarified, and items that lack safety and effectiveness after reevaluation will be eliminated. The names of some non-covered items that differ by medical institution will be standardized. For example, non-covered injections known as "Cinderella injections" will be labeled as "thioctic acid injections" based on active ingredients.
Information on not only the prices of non-covered treatments but also the total medical expenses, price differences by type of medical institution and region, safety and effectiveness evaluation results, and substitute covered items will also be disclosed in detail. This information will be posted on a newly established "Non-Covered Integrated Portal" (tentative name), allowing patients to compare the lowest and highest prices nationwide for specific non-covered items. Additionally, when providing non-covered services, medical staff will explain the price, prescription reasons, and alternative treatment methods and will be required to obtain consent forms to strengthen patient choice.
◇The 5th generation real insurance focuses on critical illnesses… new coverage for pregnancy and childbirth
The main outline of the 5th generation real insurance, which limits non-critical and non-covered services and focuses on critical illnesses, has also been revealed. The government is designing the 5th generation real insurance to be critical-centered, while promoting a buy-back plan that induces early subscribers of the 1st and 2nd generations to switch by providing certain compensation funds. The current 4th generation insurance structure guarantees health insurance coverage as the main contract and the individual's burden for non-covered treatments as a supplementary agreement, with a burden rate of 20% for covered treatments and 30% for non-covered.
The 5th generation real insurance distinguishes between general and critical patients for covered services and varies the patient burden rates accordingly. For general patients, the plan will implement a method that combines the health insurance burden rate with the real insurance burden rate. For outpatient care, the health insurance burden rate is at a level of 30% to 60% depending on the type of medical equipment, and a similar level will be applied to the real insurance burden rate, resulting in patients paying between 9% and 36%.
Considering that previously, patients bore a final burden of 6% to 12% by applying an average real insurance burden rate of 20% on top of the health insurance burden rate, this represents a significant increase. However, for critical patients such as those with cancer, cerebrovascular and heart diseases, and rare diseases, the minimum burden rate of 20% will apply to maintain the current level of coverage.
Additionally, there are plans to newly cover the expenses for pregnancy and childbirth that were previously not covered. Also, for the supplementary clauses that cover non-covered treatments, they will be released at different times based on the distinction between critical and non-critical.
Initially, the 5th generation real insurance will only cover non-critical non-covered services, and after evaluating the management situation of non-covered services, products covering non-critical services will be introduced after June 2026. Even if supplementary clauses that cover non-critical and non-covered treatments are launched later, the coverage limit will be reduced from the current 50 million won to 10 million won, and the patient burden rate will be raised from the current 30% to 50%. The Financial Supervisory Service plans to strengthen the review process for non-covered items with many real insurance claims.