Patients who make more than 300 outpatient visits per year will have to bear most of their medical costs under a new plan aimed at curbing excessive healthcare use and plugging leaks in the national health insurance budget.
The Ministry of Health and Welfare (MOHW) announced on the 3rd that it has issued a preliminary legislative notice for a partial amendment to the enforcement decree of the National Health Insurance Act. The amendment focuses on reducing so-called "medical shopping" and ensuring the fiscal sustainability of the national health insurance system.
The key change is a tightened threshold for outpatient visits. Under the current system, patients who exceed 365 outpatient visits per year face a 90% copayment rate on visits beyond that limit. The amendment lowers the threshold to 300 visits, requiring patients to shoulder the bulk of their medical expenses once they surpass that number. However, patients with unavoidable circumstances may be granted exceptions under criteria set by the Health and Welfare Minister.
The government will also introduce a real-time monitoring system to strengthen enforcement. A care benefit verification system will be established to track patients' outpatient visit counts in real time and preemptively block excessive use. The Health Insurance Review and Assessment Service (HIRA) will operate the system.
The amendment also includes measures to ease the insurance premium burden on workplace-based subscribers. The deadline for employers to report monthly remuneration related to the annual year-end health insurance premium settlement conducted every April will be extended from March 10 to March 31. The change aims to reduce the administrative burden on businesses.
Criteria for installment payments of insurance premiums will also be relaxed. Currently, installment payments are only allowed when the additional amount owed exceeds the monthly premium. Going forward, the threshold will be lowered to the monthly premium floor, allowing more subscribers to spread out their payments. The measure is intended to ease household financial strain caused by sudden premium settlements.
Additionally, mathematical calculation standards for determining improper claim ratios will be clarified to reduce confusion, and a legal basis will be established for the National Health Insurance Service (NHIS) to request relevant data from HIRA.
The ministry plans to collect public feedback through the preliminary legislative notice until May 4. The real-time verification system will take effect on December 24 this year, while the stricter outpatient visit threshold will apply from January 1, 2027. The extended reporting deadline and relaxed installment payment criteria will take effect immediately upon promulgation.