The trend indicates that tightening payout liabilities is an inevitable development. According to industry experts, the claim ratios for many regional Huiminbao products have already exceeded 90%, even reaching 95%.
In recent years, Huiminbao has been entrusted with the significant expectation of bridging commercial insurance and innovative drugs while filling the coverage gap for individuals with pre-existing conditions. However, as we approach mid-2026, the challenges for Huiminbao have become increasingly prominent under multiple pressures. In the recently launched 2026 versions of Huiminbao in some cities, payouts for pre-existing conditions and specific drug liabilities have notably tightened. Furthermore, some drugs from the first batch of the commercial insurance innovative drug list have been quietly removed from Huiminbao's special drug catalog.
Wang Pingyang, Vice President of the Zhejiang Medical Security Research Association, observed that compared to previous years, the overall claim ratio for Huiminbao nationwide has not significantly improved nor worsened. However, with improved access to innovative drugs and medical devices in hospitals—especially after the policy that "commercial insurance innovative drugs do not count towards DRG quotas" was implemented—the use of high-value drugs and devices has surged in provincial capitals and regions with high medical resources, leading to an increase in commercial insurance claim ratios. Additionally, the overall payout pressure has intensified in some areas following the provincial-level integration of Huiminbao products.
Currently, Huiminbao operations across various regions are still in an exploratory phase regarding their business models and financial balance. Local governments tend to adopt a more inclusive yet cautious attitude and use authorized methods to set policy terms, preserving room for product adjustments to address uncertainties. However, excessive regional disparities and frequent product adjustments not only exacerbate instability in expectations from all parties but also weaken the system's enforceability.
Against this backdrop, key issues have emerged: how can Huiminbao products implement "controlled cost-saving" while pursuing "risk-managed revenue expansion," and can other insurance products for "individuals with pre-existing conditions," along with diversified supplementary mechanisms like charitable assistance and rare disease special funds, take over the role?
Strategies of "Blocking" and "Diverting" After Excessive Claims
Regarding the removal of the Fabry disease treatment drug Agalsidase beta (Fabrazyme) from Shanghai's "Huihubao," local patient groups indicated that while efforts were made to争取 policy continuation, some patients may now face the practical consideration of switching medications following the final decision. Another Fabry treatment, Agalsidase alfa, has been included in the basic medical insurance. However, due to the dose-dependent nature of enzyme replacement therapy, changing drugs carries certain clinical risks.
In recent years, rare diseases have entered the commercial insurance landscape through Huiminbao. Scholars have noted that by 2023, the number of Huiminbao plans covering rare disease medications increased to 68. By 2025, the special drug catalogs for Huiminbao in many regions expanded to around 50 types. However, constrained by low premium pricing, declining participation rates, and a continued downward trend in deductibles, many regions have转而 tightened single-drug payout standards. Rare disease patients, as a "natural group with pre-existing conditions," also face a secondary impact from the reduction in payouts for pre-existing conditions.
Recently, the 2026 version of Shanghai Huihubao went on sale, with the premium remaining unchanged at 129 yuan per year. The total coverage amount increased to 3.25 million yuan, adding coverage for brain-computer interface surgical consumables. The number of domestic special drugs increased to 50 types.
Simultaneously, the new version tightened the认定 of pre-existing conditions, reducing the hospitalization payout ratio for patients with pre-existing conditions to 30%. It also set a 200,000 yuan payout上限 for 9 special drugs including Hires, Weimingzan, and Kaizebai.
Fabrazyme and Axicabtagene ciloleucel (Yescarta) were removed from the relevant drug list. Yescarta is also one of the five CAR-T products included in the first batch of the commercial insurance directory.
The official WeChat account of Shanghai Huihubao explained this move as: "Reasonably optimizing payout ratios to balance fairness and long-term sustainability."
An industry insider familiar with the drug revealed that Shanghai Huihubao paid out approximately 45 million yuan for Fabrazyme last year. Previously, only a few provinces included Fabrazyme in their local coverage. Given Shanghai's relatively high level of specialized treatment, the issue of "commercial insurance migration" has indeed persisted locally.
As for the other removed innovative drug, Yescarta, its previous coverage under Shanghai Huihubao was not under the special drug liability but was listed as a separate item—CAR-T and innovative gene therapy drug costs. This意味着 greater flexibility for单独 adjusting coverage for such "sky-high priced cancer drugs."
However, over the past few years, Shanghai Huihubao consistently adopted the practice of "100% payout for both individuals with and without pre-existing conditions." The number of products and indications covered under this liability also increased annually. This strategy of "lenient entry and generous payouts" enhanced Huihubao's appeal but also brought significant payout pressure.
A responsible person from the Shanghai Medical Insurance Bureau stated in late 2024 that the overall payout scale for CAR-T under Huihubao had reached 50 million yuan at that time. In the same year, Yescarta's new second-line indication was补充纳入 Huihubao's coverage. According to公开 data from the manufacturer (Fosun Kite), by mid-2025, over 80 patients using Yescarta had benefited from "Huihubao," with cumulative理赔金额 exceeding 40 million yuan over four years.
Under multiple factors, more regions have joined the queue in tightening payout standards for pre-existing conditions and special drugs.
In Chengdu, the 2024 "Huirongbao" domestic special drug payout standard was 75% for non-pre-existing conditions, 30% for连续参保 individuals with pre-existing conditions, and 0% for首次 or non-continuous参保 individuals with pre-existing conditions. By 2026, the payout ratios for the aforementioned two types of参保者 under "Huirongbao's" domestic special drug standards were reduced to 60% and 20%, respectively.
Wang Pingyang believes that when个别 special drugs experience "excessive claims," insurance companies typically employ two strategies: "blocking" and "diverting." "Blocking" involves tightening payouts for pre-existing conditions and special drugs. "Diverting" involves achieving product differentiation based on risk pricing.
"After all, there's only so much 'flour' (funds). If个别 high-priced drugs excessively consume the funding pool, it will inevitably dilute the rights of other参保人, affecting the fairness of Huiminbao," Wang Pingyang said. "When the proportion of people who actually receive payouts from a Huiminbao product in a given period falls below 2%, meaning hardly anyone gets paid in a year, will anyone renew their policy the next year? At that point, the product's sustainability will also face a 'major test.'"
Zhang Qiang, Deputy Director of the Research and Consulting Department at Access Health International, explained that generally, a comprehensive赔付率 of 60% to 70% is reasonable for health insurance. For Huiminbao, the comprehensive赔付率 might be higher, around 80% to 85%. However, exceeding 90% indicates high operational risk.
Wang Pingyang added that as the commercial insurance innovative drug directory continues to expand, Huiminbao's hospitalization liabilities will also face stricter constraints in the future. With "premium tiering, establishing and dynamically adjusting special drug lists, and tightening payouts for pre-existing conditions" becoming consensus practices across regions, the evolutionary direction of the Huiminbao model is becoming clearer.
Pursuing Risk-Managed Revenue Expansion Alongside Cost Control
To counter参保人's perception of "shrinking benefits," many Huiminbao operators typically pursue risk-managed "revenue expansion" during the "cost-saving" process.
For example, while the 2026 Shanghai Huihubao tightened payout standards for pre-existing conditions, it expanded several value-added services related to health management and care. Some interviewed commercial insurance professionals believe that since such value-added services are usually not written into the "insurance liability" but are附加 commercial service promises provided by the insurer or third-party service providers, they do not amplify the insurer's underwriting risk exposure.
Furthermore, although Yescarta was removed from the目录, the 2026 Shanghai Huihubao added two other domestic CAR-T drugs, ensuring the lymphoma treatment field仍然 retains two CAR-T drug options.
Meanwhile, an increasing number of Huiminbao products are shifting from pursuing absolute fairness through uniform pricing towards risk-graded differential pricing.
An interviewed commercial insurance professional stated that, from the current situation, premium tiering does not significantly boost sales volume. However, this approach helps提升 the overall premium scale and allows for better management of risks associated with an aging续保 population and increased use of innovative drugs and devices.
For instance, Shanxi's "Jinhuibao" offers three premium tiers. The lowest-priced version (69 yuan/year) does not provide any payout for individuals with pre-existing conditions.
The premium stratification for Shandong's "Qilubao" is more complex. The 2026 version is divided into 9 premium tiers based on coverage levels and参保人 age. Among them, the highest-priced "美好生活版" is newly added for the year and is官方 promoted as the main product, covering nine major liabilities.
Analysis reveals that these nine liabilities, while seemingly complex,实际上 involve a significant portion of精细拆分 the original special drug list. Instead of the previous practice of "bundling" special drugs into one liability, they are meticulously split into independent coverage liabilities such as specific high-cost drugs and innovative drugs, rare disease drugs, proton radiotherapy, and specific drug-device combinations. The payout ratios, coverage amounts, and认定 of pre-existing conditions differ for each liability.个别 rare disease drugs have been额外设置 "time thresholds"—newly diagnosed patients in 2026 are not covered for the costs of drugs like Fabrazyme and思而赞 under the rare disease drug liability.
Some pharmaceutical companies, to maintain access to Huiminbao's special drug list, choose to accept price negotiations.
"As long as the drug is not removed from the目录, we can cover patients' out-of-pocket portions through patient assistance programs or other subsidy methods. Once it's out of the list, and with no hope for national price negotiations, the drug might become completely unsellable in the domestic market," a rare disease affairs负责人 from a pharmaceutical company stated.
Several interviewed industry professionals pointed out that commercial insurance companies and medical institutions are market entities. Their support for innovative drugs, including commercial insurance innovative drugs,必然 stems from commercial interests.
However,对于 Huiminbao, which carries a普惠 nature, pharmaceutical companies and individuals with pre-existing conditions often hold high expectations. Faced with market demands that超越 general risk-pricing logic, Huiminbao operators often find themselves反复拉扯 between moral hazard, public opinion pressure, and operational底线.
An interviewed Huiminbao researcher believes that "the biggest problem now is the lack of a higher-level legal basis for Huiminbao," which leads to unclear boundaries of product liability. If Huiminbao is positioned as a social-commercial integrated insurance, it needs to体现 a certain degree of social responsibility. On the basis of guaranteed参保群体, it could more actively respond to and implement the commercial insurance innovative drug directory.
Currently, there is another颇具共识性的 view within the industry. While Huiminbao's inclusion of high-priced innovative drugs through the "special drug directory" has created a certain "crowding-out effect" in the short term—where some consumers, after obtaining basic coverage, reduce their willingness to purchase traditional commercial insurance—the introduction of the Huiminbao special drug directory also holds "insurance启蒙" significance. It has awakened public awareness of the risks associated with high medical expenses.
As Huiminbao's liability margins收敛, market认知 of "medical consumption" gradually forms. Some individuals will adjust their own insurance structures under the new environment. In the long run, this will倒逼 the commercial insurance system to accelerate internal stratification,推动 the construction of a more refined multi-level medical security格局.
Data from the "2026 China Innovative Drugs and Devices Multi-Payment White Paper" jointly released by China Re Life and镁信健康 shows that in 2025, the sales of innovative drugs in China reached 195 billion yuan, with commercial insurance支付 15.2 billion yuan, accounting for 7.8%, showing little improvement.
Within this, in 2025, Huiminbao's contribution to innovative drug支付 was 1.8 billion yuan, flat compared to the previous year, with Huiminbao special drug理赔速度 slowing down that year. In contrast, payments for innovative drugs from personal medical insurance (million-yuan insurance/mid-to-high-end insurance/insurance for individuals with pre-existing conditions) saw a significant 40% growth compared to the previous year.