Strictly crack down on behaviors such as inducing hospitalization and reselling medicines for insurance fraud. The new medical insurance regulations will take effect tomorrow.

As the medical insurance system continues to improve, new ways of committing fraud to cheat insurance benefits keep emerging. On March 21, Huang Huabo, deputy director of the National Healthcare Security Administration, disclosed that since 2021, medical insurance departments at all levels have recovered over 120 billion yuan in medical security funds through agreement-based handling and administrative penalties.

Now, ordinary people’s “medical expense money” and “life-saving money” are set to face new regulatory rules—《Detailed Implementation Rules for the Supervision and Administration of the Use of the Medical Security Fund》 (hereinafter referred to as the “Implementation Rules”), which will take effect on April 1, 2026.

At a press conference held today by the National Healthcare Security Administration, it was stated that the “Implementation Rules” provide specific definitions for prominent problems of fraud, such as inducing hospital admission and trafficking in pharmaceuticals, that have emerged in medical insurance supervision in recent years, offering a clearer legal basis for cracking down on fraud.

Compared with the “Regulations on the Supervision and Administration of the Use of the Medical Security Fund” issued in 2021, this “Implementation Rules” respectively address designated medical and pharmaceutical institutions and individuals, clarifying the boundaries of fraudulent conduct.

The “Implementation Rules” state that designated medical and pharmaceutical institutions and their staff who, by means such as persuasion, false publicity, waiving fees, or providing additional property or services, induce or guide others to seek treatment or purchase medicines under another person’s name or with false information may be deemed to fall under the circumstances of “inducing others to seek treatment or purchase medicines under another person’s name or with false information” as stipulated in the Regulations.

Designated medical and pharmaceutical institutions and their staff who knowingly assist others in seeking treatment or purchasing medicines under another person’s name or with false information for the purpose of defrauding medical security funds may be deemed to fall under the circumstances of “assisting others to seek treatment or purchase medicines under another person’s name or with false information” as stipulated in the Regulations.

In addition, designated medical and pharmaceutical institutions that organize others to use medical insurance to defraud purchases of medicines and medical consumables and then illegally acquire and sell them; include non-pharmaceutical expenses in the settlement of medical insurance funds; or carry out re-settlement of already settled expenses—these five types of conduct will also be subject to penalties in accordance with the law.

Regarding individuals’ use of medical insurance cards, the “Implementation Rules” clarify that relying on medical service documents and prescriptions issued by designated medical and pharmaceutical institutions to other insured persons and using them to seek treatment and purchase medicines, and engaging in any of six types of conduct, such as purchasing and selling basic medical insurance medicines to or from unspecified trading counterparties on a long-term or multiple-times basis, may be deemed to exist where the purpose is to defraud medical security funds.

The “Implementation Rules” also specify that in fund supervision and administration work, if the medical security administrative authority discovers 12 categories of suspected conduct that either constitutes a violation of public security administration or is suspected of a crime—such as organizing fraud to cheat insurance benefits, trafficking in medical insurance medicines, or forging documents and materials—it shall promptly transfer the matter to public security authorities.

According to the National Healthcare Security Administration’s “2025 Statistical Bulletin of the Development of the Healthcare Security Undertaking,” in 2025, across the country, the medical insurance system recovered 34.2 billion yuan of medical insurance funds in total. Of this, 27.8 billion yuan was recovered through auditing and verification by medical insurance agencies, 1,626 institutions involved in confirmed fraud were identified, 1,678 cases were transferred to judicial authorities, 19,000 cases were transferred to discipline inspection and supervision organs, and 59,000 cases were transferred to administrative departments such as health and healthcare; in conjunction with public security authorities, 3,776 medical insurance cases were investigated and handled, and 10,357 criminal suspects were detained; and losses of 3.0 billion yuan in medical insurance funds were prevented and recovered through the intelligent supervision subsystem. In 2025, a total of 1.558 million yuan in reward funds for reporting was issued nationwide.