China's Health Insurance Explained: 职工医保 vs 居民医保, Reimbursement, and Cross-Province Care
China's basic medical insurance (基本医疗保险) covers over 95% of the population, but the system has two very different tracks, city-by-city rules, and a reimbursement logic that surprises newcomers. This guide covers who pays, what gets reimbursed, and how to use it outside your home city.
The Two Tracks
职工医保 (Employee insurance) — mandatory for formally employed workers. Employer and employee contribute monthly (typical rates: employer around 6–10%, employee around 2% of salary — exact rates vary by city). It comes with an individual account (个人账户) you can spend on outpatient care and pharmacy purchases, plus a pooled fund for hospitalization.
居民医保 (Resident insurance) — for everyone else: freelancers, students, children, the elderly, the unemployed. You pay an annual flat premium (a few hundred yuan per year; the national floor was ¥400 in 2024 and rises gradually), and the government subsidizes the rest.
Employee insurance reimburses at higher rates and covers more. If you're employed in China, you're on 职工医保 — that's the good track.
What Gets Reimbursed (and How Much)
Only items inside the official catalogs are covered: the drug list (药品目录), medical services list (诊疗项目目录), and consumables list (医用耗材目录). Off-catalog drugs, tests, and imported materials are fully self-pay.
Reimbursement follows: (total bill − self-pay items − deductible 起付线) × reimbursement ratio. National 2025 figures from the National Healthcare Security Administration: employee insurance paid 84.1% of in-catalogue hospitalization costs (83.1% at tertiary hospitals, 87.0% secondary, 89.7% primary); resident insurance paid 66.0% (61.7% tertiary, 71.8% secondary, 79.4% primary). Lower-tier hospitals reimburse better — another reason not to crowd tertiary hospitals for minor issues.
Deductibles (起付线) and caps (封顶线) differ by city: a few hundred yuan deductible per hospitalization is typical, with annual caps in the hundreds of thousands.
Outpatient Coverage: 门诊统筹
Since the 2021 outpatient pooling reform (门诊共济保障机制), employee insurance covers ordinary outpatient costs too — not just hospitalization. Typical structure: an annual deductible of a few hundred yuan, then 50–70% reimbursement at primary hospitals, lower at tertiary ones, up to an annual cap. Resident insurance outpatient benefits are thinner but improving. Check your city's exact numbers — they change yearly.
大病保险: Catastrophic Coverage
On top of basic insurance, serious illness insurance (大病保险) automatically covers everyone enrolled in basic insurance. When your out-of-pocket spending passes a threshold (often around local average annual income), the catastrophic fund kicks in with additional reimbursement — typically 60–80% of the excess, with some provinces removing the cap entirely. You don't enroll separately; it's funded from the basic insurance pool.
异地就医: Getting Care Outside Your Home City
This is the part newcomers get wrong. The rule is: 先备案,选定点,持卡(码)就医 — file first, pick designated hospitals, use your insurance credential.
- 先备案 (File a record): before seeking non-emergency care in another city/province, file a cross-province record in the 国家医保服务平台 app or the 国家医保局 WeChat mini-program (异地就医备案). It takes minutes and usually takes effect quickly.
- 选定点: use designated cross-province hospitals (the app lists them).
- 持卡就医: pay with your insurance e-code (医保码); the bill settles directly.
Settlement follows 就医地目录,参保地政策,就医地管理 — the treatment city's catalog, your home city's reimbursement policy, the treatment city's administration. Emergency care out-of-town doesn't need advance filing, but file retroactively as soon as you can. Without filing, reimbursement drops sharply (often 10–20 percentage points lower, and some places won't reimburse at all).
Foreigners and Insurance
Foreigners legally employed in China must be enrolled in social insurance including basic medical insurance — it's the employer's legal obligation, same as for Chinese employees. If your employer hasn't enrolled you, that's a compliance problem on their side worth raising. Short-term visitors aren't eligible; get travel insurance instead.
Frequently asked questions
Can I use my Beijing insurance in Shanghai?
Yes, after filing the cross-province record (异地就医备案) and using a designated hospital. Your reimbursement follows Beijing's policy applied to Shanghai's catalog.
Does insurance cover dental, vision, or cosmetic procedures?
Mostly no. Routine dental cleanings, orthodontics, glasses, and anything cosmetic are self-pay (see our dental guide for the partial exceptions).
What happens to my insurance if I change jobs or cities?
Employee insurance pauses when contributions stop; transfer your enrollment to the new city/employer to keep continuous coverage. Resident insurance is annual — re-enroll each year during the enrollment window (usually autumn).
Sources
- National Healthcare Security Administration — 2025 national statistics bulletin: http://www.nhsa.gov.cn/art/2026/7/16/art_7_21451.html
- NHSA on cross-province direct settlement: https://www.nhsa.gov.cn/art/2025/6/7/art_52_16757.html
- National government service platform — cross-province care zone: https://gjzwfw.www.gov.cn/col/col857/index.html