Overview
Recently, the Insurance Association of China (IAC) held its 6th Standing Council 5th session and approved three industry model clauses: the General Commercial Medical Insurance (Short-term) Model Clause with its drug list, the General Commercial Medical Insurance (Long-term) Model Clause with its drug list, and the City-Customized Commercial Medical Insurance Model Clause. The aim is to better protect consumers’ rights, raise the service quality and standardization of commercial health insurance, and meet the sector’s new realities.
The model clauses give the industry a unified reference on core elements—product definition, coverage, exclusions and claims rules—reducing ambiguity, curbing mis-selling, and providing a clear yardstick for product filing and regulatory assessment. The accompanying drug lists make coverage more transparent and comparable.
Long-term care insurance is advancing in parallel: Zhongshan (Guangdong), Taiyuan (Shanxi) and Hubei issued LTCI implementation rules, with employee rates mostly at 0.3% and the unified 36-item national service catalog, marking the “sixth insurance” moving from pilot to institutional expansion.
Background & Interpretation
1. Regulatory and Industry Context
The September 2024 State Council opinion on high-quality insurance development set the transformation roadmap; early 2025 saw the dynamic pricing-rate mechanism for life insurance land, pushing products toward floating-return structures. Under the regulatory push to “abandon scale fixation, shift to quality and efficiency,” standardization became the foundation of healthy health-insurance growth.
2. Core Drivers and Underlying Mechanism
The core mechanism is “standardization for fairness, transparency for risk reduction.” A unified liability framework and drug lists compress insurers’ discretion in clause design, curbing past issues of shrunk coverage, over-broad exclusions and claims disputes, while lowering consumers’ comparison and comprehension cost. The city-customized clause balances inclusiveness and sustainability, guiding “Huiminbao”-type products.
3. Market Structure and Industry Impact
For insurers, model clauses raise the compliance floor, forcing a shift from “fees and rhetoric” to “service and risk control.” For health-insurance third-party administrators (TPA), PBM and medical-data vendors, standardized lists bring more certain cooperation interfaces. LTCI expansion opens space for nursing and rehabilitation services.
Implications & Outlook
Near term, model clauses become the industry’s design baseline; attention is needed on old-new product transition and legacy remediation. Key variables: regulatory enforcement intensity, the dynamic update mechanism for drug lists, and the national pace of LTCI institutionalization. Health insurance should shift from scale expansion to quality growth “managing health risk.”
Takeaways for Industry Participants
Insurers should rebuild products and sales scripts on the model-clause floor and strengthen claims and service. Intermediaries and agents must improve professional interpretation to avoid mis-selling compliance risk. Medical and health-management service providers can design value-added services around standardized lists and, compliantly, embed into the health-insurance ecosystem, capturing the deterministic LTCI-expansion opportunity.
This column compiles industry information and shares technical perspectives; it does not constitute investment advice.