On August 26, 2026, the National Medical Security Administration issued the "Guiding Opinions on the Payment Management of Long-term Care Insurance" (hereinafter referred to as the "Guiding Opinions"), which provides a unified system for the payment management of long-term care insurance (hereinafter referred to as long-term care insurance) from the five dimensions of payment scope, payment method, payment standard, fund supervision and service quality evaluation.
During the operation of the system, how does the annual payment limit balance the sustainability of the fund and the protection needs of disabled families? What are the fraud loopholes in the disability assessment as the entrance to the fund? What are the practical difficulties in building a long-term care insurance system? Focusing on these issues, reporters from the "Rule of Law Daily" conducted interviews.
Delineating a “ceiling” for fund expenditures
According to official data from the National Medical Security Administration, since the national organization launched the long-term care insurance pilot in 2016, 49 pilot areas have conducted useful explorations in long-term care insurance payment policies, coverage and other aspects. As of September 2025, the long-term care insurance system covers 190 million people, with expenditures exceeding 85 billion yuan. With the increasing development of the long-term care insurance system, problems such as inconsistent payment scopes, inconsistent connotations of service items, and uneven service management quality levels among regions have become prominent. It is urgent to improve the uniformity and standardization of long-term care insurance payment management and promote the equalization of long-term care insurance services.
Huang Lijun, a member of the Lawyer Expert Database of "Rule of Law Daily" and a senior partner of Beijing Dacheng Law Firm, pointed out that the problems of fragmentation of payment standards during the pilot phase are concentrated in three areas: First, the same level of disability is treated differently in different co-ordination areas, which damages fairness. Second, cross-regional chain nursing institutions cannot form a unified cost model and service package, and expansion in different places must be based on "one city, one policy" to re-quote and allocate personnel. Third, the payment standard is not linked to the evaluation grade, service length, and nursing skills. Institutions tend to undertake services based on “bump-sum prices” and nursing skills are difficult to reflect in the price, which limits the professional development of the team.
"During the pilot period, the pilot cities each designated payment items, reimbursement ratios, and service hours, which directly resulted in incomparable treatment between regions. It is difficult for nursing institutions to replicate the mature model when expanding their business across cities, and there is even a phenomenon of 'the treatment is directly doubled when changing to another coordinating area, and institutions compete to package projects instead of providing real care services.'" said Long Ge, deputy director of the Innovation and Risk Management Research Center of the University of International Business and Economics.
The reporter noticed that the "Guiding Opinions" paid attention to the problem of inconsistent regional standards, upgraded the payment management of long-term care insurance from "individual administration" of each locality to a unified national standard, and set a bottom-line rule that "the annual maximum payment limit shall not exceed 50% of the per capita disposable income of urban and rural residents in the coordinated area in the previous year."
In Longe’s view, the 50% annual maximum payment limit anchors the per capita disposable income level of local urban and rural residents and only delineates the “ceiling” of fund expenditures without limiting specific service content. This can prevent regions with weak financial and fundraising capabilities from blindly raising treatment standards and maintain the bottom line of system sustainability. At the same time, it leaves room for local governments to fine-tune benefits based on local realities. It is a "basic-guaranteed" institutional arrangement that takes into account the actual national conditions.
Huang Lijun reminded that there is a realistic tension between the sustainability of the fund and the goal of "maintaining basic needs". Subsequent matching rules can be tilted towards severe disability and home care scenarios through differentiated payment ratios.
Keep the "entry gate" of disability assessment in check
In May 2026, the National Medical Insurance Administration reported a long-term care insurance fraud case: a nursing institution in Shanghai colluded with a local assessment center to organize non-disabled elderly people to participate in disability level assessments in batches, instigating the elderly to "deliberately be unable to get out of bed and unable to walk." The assessment indicators were artificially manipulated, and the elderly who should have been rated zero to one were falsely assessed as three to six levels of disability; some elderly people who were assessed as "unable to take care of themselves" not only moved freely, but also traveled many times. The caregivers dispatched by the agency do not provide care services, but housekeeping services such as cleaning.
The Shanghai Municipal Medical Insurance Department initiated a re-evaluation of the disability status of some elderly people and transferred the cases to the public security organs. After re-evaluation, the assessment levels of 234 elderly people were lowered, and 144 of them no longer enjoy long-term care insurance benefits. As of the incident, the two institutions had illegally robbed more than 2 million yuan of funds, and five suspects were arrested.
Huang Lijun introduced that once the collusion to defraud insurance is verified, the relevant entities will face three levels of legal liability: civil, administrative, and criminal. At the civil level, if the institution breaches the contract, the agreement may be suspended or terminated, the fees during the insurance period will not be settled, the benefits of the insured and their families will be cancelled, and the paid fees will be recovered; at the administrative level, the institution will return funds, impose fines, cancel designated qualifications, and manage Insurance managers are prohibited from entering the industry, and insured persons and their families are fined multiples of the amount defrauded and included in the personal credit reporting system; at the criminal level, if an institution conspires with others to defraud insurance, the organizer, planner, and implementation personnel will be punished with the crime of fraud. Although the unit does not constitute the subject of the crime of fraud, the illegal gains should be recovered. Family members who provide medical insurance cards and cooperate with fictitious services constitute accomplices in the crime of fraud.
Disability assessment is the “entrance gate” for long-term care insurance fund expenditures, and distortion in assessment will directly lead to fund losses. For this reason, the "Guiding Opinions" clearly state that for institutions with an abnormally high or abnormally low assessment pass rate, payment will be withheld in proportion until they refuse to pay.
In Huang Lijun's view, there are four main reasons why evaluation fraud can be achieved: first, information asymmetry, home care occurs in a closed private space, and external supervision cannot cover the entire process; second, the evaluation tools are subjective, mainly relying on action observation and oral questions and answers, leaving evaluators with a large space for discretion; third, the re-evaluation mechanism is insufficiently implemented, forming a "only in, not out" benefit lock-in effect; fourth, nursing institutions, evaluation agencies, intermediaries, insured persons and their families have formed a closed-loop community of interests.
Longe also pointed out that disability level assessment relies on on-site observation and interviews, and there is no objective medical record chain in the home setting. It is easy for the assessment agency, nursing station, and family members to form a closed loop of "high assessment level - agency accepting orders and dispatching orders - all parties sharing profits." He believes that the "Guiding Opinions" are compressing the space for fraud from the payment side: payment has shifted from payment by project to payment by person and time, making "multiple projects" unprofitable. Coupled with location check-in, family confirmation, random return visits and cross-verification, it directly reduces the economic benefits of fraud.
Establish unified payment management standards
The Medical Security Law was voted on on August 28, 2026. Article 55 clarifies that “the state shall establish and improve a long-term care insurance system”, and also authorizes the medical insurance administrative department of the State Council to work with relevant departments to formulate supporting specific measures with reference to the provisions of basic medical insurance.
In Huang Lijun’s view, the inclusion of long-term care insurance in the medical security law is a milestone change in the system: long-term care insurance bids farewell to the stage of relying entirely on departmental pilot documents and has been upgraded to a statutory social security system confirmed by law. Financing behaviors and compulsory insurance participation are legally justified, and employers and paying groups have anchored their expectations for the long-term stability of the system.
"However, the Medical Security Law only makes a declaration of principle and does not stipulate specific values for financing rates and benefits, nor does it set up arrangements for a transitional period for the system." Huang Lijun said.
What is the most urgent step in the construction of long-term care insurance payment management system? Experts interviewed pointed out that the focus of the long-term care insurance system at this stage has shifted from "whether to build or not to build" to "how to pay, how to manage, and how to remedy the damage to rights."
Huang Lijun suggested that the payment rules of the "Guiding Opinions" and the authorization of the Medical Security Law be implemented into a three-layer rule system of "administrative regulations + departmental regulations + national unified fixed-point agreement model". The most critical thing is to formulate the "Long-term Care Insurance Regulations" to clarify the annual maximum payment limit, assessment cost sharing, mutual recognition of assessment results and other rules that directly determine benefits.
Huang Lijun further mentioned that rules such as payment ratios and annual limits should be raised to the level of laws and regulations to make benefits predictable and claimable; a full-process remedy of "re-evaluation-objection review-administrative review/administrative litigation" should be constructed to avoid "assessment is the end"; mutual recognition of evaluation results and treatment convergence across coordinating areas should be established to avoid migration interruptions.
"In terms of compliance certainty, it is necessary to unify the agreement template and the quantitative caliber of withholding, clarify the boundaries of the three types of subjects and the connection standards for executions, and unify the application standards of 'medical money and property'." Huang Lijun said.
Longe believes that the identity of an independent fund for long-term care insurance should first be established from the source of the system: independent budgeting, independent accounting, independent auditing, and independent statistics should be achieved, and the long-term care insurance fund should no longer be generally stated as a component of the medical insurance fund. Secondly, it is necessary to open up a queryable and litigable evidence system for the entire chain of "assessment - order dispatch service - settlement and payment - return visit and verification"; simultaneously improve the constituent elements of long-term insurance fraud and industry prohibition rules, refine the liability standards for family members who conspire to participate in insurance fraud, and issue supporting regulations or judicial interpretations.
"Only when the identity of the fund is independent, the chain of evidence is closed, and the boundaries of responsibilities are clear, can the unified national long-term care insurance payment management regulations be truly implemented in every disabled family," Longe said.
