In order to standardize the management of medical consumables payment under medical insurance and improve the efficiency of fund utilization, the Shandong Provincial Medical Security Bureau has recently officially issued the "Interim Measures for the Payment Management of Medical Consumables under Basic Medical Insurance in Shandong Province." The aim is to establish a unified medical insurance consumables catalog across the province, clarify payment standards, and optimize clinical usage management.

This report will revolve around the core content of the policy, material access conditions, payment ratios, dynamic adjustment mechanisms, and the implementation details in coordinating regions, providing policy interpretations and implementation references for relevant institutions and insured individuals.

Policy Background and Objectives

Recently, the Shandong Provincial Medical Security Bureau issued the "Interim Measures for the Payment Management of Medical Consumables under the Basic Medical Insurance in Shandong Province" [1] (hereinafter referred to as the "Measures"), aiming to regulate the access management of medical consumables for medical insurance payments, improve the level of medical security, and optimize the efficiency of medical insurance fund utilization. The policy will be implemented from February 1, 2025, and will remain valid until January 31, 2028.

The core objectives of this policy reportedly include:

1. Unify the provincial medical consumables directory: Address the significant differences in医保支付范围 (medical insurance payment scope) among different coordinated regions, and establish a unified "Basic Medical Insurance Medical Consumables Directory" province-wide. (Note: There was a part missing in the original Chinese text which said "解决此前各统筹区医保支付范围差异较大的问题". I have provided a suitable translation for it.)

Balancing clinical needs with fund affordability: Through scientific evaluation and dynamic adjustment mechanisms, comprehensively consider factors such as the functionality of medical consumables, clinical value, correspondence with medical service price items, cost levels, and the affordability of medical insurance funds, ensuring that the consumables included in the directory meet the requirements of being "clinically necessary, safe and effective, and reasonably priced."

3. Medical consumables selected through centralized volume-based procurement, which comply with current payment policies, will be prioritized for inclusion in the catalog. Exploration of access for exclusive or high-value products through negotiation or other methods will be conducted.

02

Medical Consumables Directory Management Mechanism

(1) Admission Criteria

Medical consumables must meet the following conditions to be included in the "Basic Medical Insurance Medical Consumables Directory":

1. Compliance: Registered or filed with the drug regulatory authority and within the validity period.

2. Separate charges: Disposable materials that are not included in the pricing structure of medical service projects and can be charged separately.

3. Clinical and Economic Considerations: Clinically essential, safe and effective, reasonably priced, and affordable for the medical insurance fund.

4. Unified coding: Obtain the unified code for medical consumables from the National Medical Security Administration.

(II) Clearly define the scope of exclusion

The following circumstances are not covered by medical insurance payments:

1. Non-therapeutic devices: Such as prosthetic teeth, prosthetic eyes, prosthetic limbs, hearing aids, and other rehabilitation devices.

2. Beauty and healthcare consumables: including non-functional cosmetic and orthopedic-related consumables.

3. Low-value or overburdened consumables: Items with low clinical value or costs exceeding the capacity of the medical insurance fund.

03

Payment Standards and Personal Burden

The individual initial self-payment ratio, reimbursement ratio, and specific payment methods for medical consumables shall be implemented by each coordinating region in accordance with relevant national, provincial, and regional regulations. Each coordinating region must comprehensively consider various factors, such as the cost of medical consumables, the local medical standards, economic development level, the supporting capacity of the medical insurance fund, and the patients' affordability, to reasonably establish the medical insurance payment cap for medical consumables within the region.

1. Classification of payment ratios:

High-value consumables with a unit price exceeding 1,000 yuan require an initial self-payment of 15% by the individual; consumables with a unit price below 1,000 yuan do not require self-payment.

In the centralized volume-based procurement of selected medical consumables, the individual co-payment ratio is 0%.

2. Payment Limit Mechanism:

Each coordinating region sets payment limits based on local economic levels and the fund's affordability. If the cost of medical consumables exceeds the limit, the excess portion is borne by the insured person; if it is below the limit, reimbursement is made proportionally.

04

Dynamic adjustment and execution mechanism

1. Dynamic Adjustment Program:

The directory is managed dynamically. Medical institutions can apply through a process involving submission by the medical institution, preliminary review at the municipal level, and expert review at the provincial level. After filing with the national bureau, it can be published and implemented, and dynamically adjusted.

Priority will be given to including selected products in centralized volume-based procurement, and exploring negotiated access for high-value medical consumables.

2. Transfer Mechanism:

If there are safety risks associated with the consumables, cancellation of registration qualifications, or violations in entering the directory, they will be directly removed after evaluation.

05

Policy Implementation Requirements and Impact

1. Responsibility of medical institutions

Designated medical institutions must prioritize the use of listed medical supplies and products selected in centralized procurement. Violations such as duplicate charges for low-value consumables will be penalized.

2. Information Management:

Leveraging the national medical insurance coding system, unify the classification and payment standards of consumables to ensure transparency in the implementation of the directory.

Social Supervision and Transparency:

Provincial medical insurance departments regularly publish directories and inquiry channels, and each coordinated area needs to strengthen fund usage monitoring and expense review.

06

Policy Significance and Outlook

Shandong Province has balanced clinical needs with the sustainability of the fund through a unified medical consumables directory and dynamic adjustment mechanism. At the same time, it has reduced the burden on patients through priority procurement and payment limits. In the future, policies may further promote price transparency of consumables and cover more innovative products through negotiation mechanisms, thereby improving the efficiency of medical insurance fund utilization.