Jiangxi to Introduce Star Rating System for Medical Insurance Designated Facilities; Assessment Tied to Fund Settlements

Recently, the Jiangxi Provincial Medical Security Bureau issued an announcement soliciting public comments on the "Draft Notice on Further Improving Performance Tiered Management for Medical Insurance Designated Healthcare Institutions." According to the document, Jiangxi Province plans to implement a performance tiered management system for all designated medical institutions and retail pharmacies within the province. Based on assessment scores, facilities will be classified into six tiers: one-star to five-star, as well as no-star. The rating results will directly impact core settlement indicators such as the retention ratio of the medical insurance fund quality security deposit and the premium coefficient for payment method reform.

The draft states that the tiered management will cover all medical institutions and retail pharmacies already designated for medical insurance services across the province. Newly designated facilities or those with service agreements signed for less than one year will temporarily not participate in the assessment. The evaluation employs a 100-point system, covering four major dimensions: implementation of medical insurance reform policies, management and utilization of medical insurance funds, standardization and informatization of medical insurance, and local independent evaluations. Differentiated scoring criteria will be applied based on the type of institution (with inpatient services, without inpatient services, retail pharmacy).

The assessment process includes self-evaluation by the institution, application, evaluation by the medical insurance department, and public disclosure of results. Institutions initially rated as four-star or above require re-evaluation by the municipal medical insurance handling department, and the final results must be reported to the provincial medical insurance department within the specified timeframe. The draft emphasizes that the assessment process must adhere to the principles of fairness, impartiality, and transparency, combining daily management with annual evaluations for dynamic adjustment.

The performance tier results will be substantively linked to medical insurance fund settlements. Regarding incentives, the tier results directly influence the retention ratio of the medical insurance fund quality security deposit for the healthcare facility. For three-star and lower institutions, the retention ratio will not exceed 5%; for four-star, not exceeding 4%; and for five-star, not exceeding 3%. For institutions rated as no-star or those that did not participate in the assessment (excluding newly added ones), the quality security deposit from the previous year will be fully withheld.

Furthermore, for designated medical institutions participating in medical insurance payment method reforms, their premium coefficient will receive a stepwise increase based on their star rating. For each higher star level, the premium coefficient can be increased by 0.1%.

In terms of constraints, designated healthcare facilities rated as no-star or those not participating in the assessment (excluding newly added, temporarily non-participating institutions) will be ordered to rectify within a set period. For those that refuse to rectify or fail re-evaluation after rectification, the medical insurance handling agency may, according to regulations, suspend or even terminate their medical insurance service agreement.

Additionally, the draft specifies that institutions under the following circumstances will be ineligible for a five-star rating: failure to properly rectify after administrative penalties, suspension of medical insurance fund settlements, or negative media exposure causing adverse effects. If serious violations, fraud, or insurance deception are identified, institutions may face severe penalties including downgrading of stars, treatment as a no-star facility, or agreement suspension.

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