KRW 2.7 Trillion for Regional, Essential Care... Major Reimbursement System Overhaul in January

Reimbursement rates for major surgeries up 20%; first-visit consultation fees at clinics and inpatient fees at hospitals also rise
Adjustments to laboratory test, CT and MRI reimbursement rates to save KRW 2.6 trillion a year

The government will overhaul the National Health Insurance reimbursement system to strengthen regional and essential medical services. Starting in January 2027, it will prioritize KRW 2.7 trillion a year for regional and essential care, while adjusting reimbursement rates for laboratory tests and computed tomography (CT) and magnetic resonance imaging (MRI) scans, which have faced criticism for excessive compensation, to cut annual spending by KRW 2.6 trillion. It will also raise fees for consultations, which have seen little change in 20 years, and inpatient care, whose rates have remained unchanged for more than a decade.

On October 28, the Ministry of Health and Welfare adopted an implementation plan for its “Health Insurance Reimbursement Structure Innovation Plan” at the 19th meeting of the Health Insurance Policy Deliberation Committee. As a follow-up to the reimbursement structure innovation plan finalized in June, the government will begin implementing key measures in January 2027.

The government has set the implementation schedule for KRW 2.7 trillion of the KRW 3.6 trillion annual investment plan to strengthen regional and essential medical services. It will decide when to implement the remaining KRW 900 billion after further discussions later this year.

To narrow regional gaps in medical care, the government will introduce preferential reimbursement rates that provide additional compensation in areas outside the Seoul metropolitan region and underserved areas within it. The rates will first apply in January 2027 to high-risk deliveries and admissions and treatments in neonatal intensive care units, and will be expanded to surgeries and procedures starting in March.

Reimbursement rates for 2,740 types of surgery and procedures performed at general hospitals and higher-level medical institutions in areas outside the Seoul metropolitan region, as well as in six underserved areas within it—including Uijeongbu, Namyangju, Icheon, and Pocheon in Gyeonggi Province, and the northwestern and central parts of Incheon—will be increased by 10%. The additional reimbursement rate for emergency surgeries for critically ill patients performed at night or on holidays will also rise from a current maximum of 350% to 450%. With the additional preferential regional rate, it can reach up to 470%.

Consultation fees at general hospitals, hospitals, and clinics in 86 cities, counties, and districts designated as population-decline areas will be increased by 5%, while inpatient fees at general hospitals and hospitals will also rise by 5%. The government will also seek to amend relevant laws and regulations to ensure that patients do not pay out of pocket for the additional compensation under the preferential regional rates.

Compensation will also be increased for medical institutions that provide definitive treatment to critically ill and emergency patients. Reimbursement rates for 1,670 types of major surgeries and procedures performed at general hospitals and higher-level medical institutions will rise by 20%. Compensation will also be expanded for general anesthesia, anesthesia accompanying major surgeries, and highly complex specialized anesthesia. The additional reimbursement rate for major surgeries and procedures, and the accompanying anesthesia, performed at night or on public holidays will increase from the current 100% to 150%.

Basic care compensation will also be adjusted. The relative value scores for first consultations at clinics will rise by 6%, and those for follow-up consultations by 4%; at hospitals and higher-level medical institutions, rates for both first and follow-up consultations will increase by 2%. For example, the fee for a first consultation at a clinic, currently 18,840 won, will rise to 21,210 won next year, including both the increase under the reimbursement structure reform and adjustments linked to the conversion factor. The fee for a first consultation at a dental clinic, currently 16,840 won, will rise to 17,590 won.

Basic inpatient rates will increase by 7% for general wards and 10% for intensive care units. Additional rates for medical institutions that assign more nursing staff will also be raised to strengthen compensation based on staffing levels.

The government will also increase compensation for high-risk deliveries and neonatal intensive care, and expand the age range eligible for additional pediatric consultation fees from children under 6 to children under 8. It will also introduce or expand additional compensation for major surgeries on children and treatments in pediatric intensive care units. The role of Dalbit Children's Hospitals, which provide pediatric care at night, will be strengthened, and emergency medical management fees at pediatric emergency medical centers will be raised to twice the current level at regional emergency medical centers.

By contrast, reimbursement rates for tests that are considered excessively compensated will be reduced. Adjusting rates for laboratory tests, including blood tests, is expected to cut annual spending by KRW 1.7 trillion, while abolishing the outsourced testing management fee will save KRW 200 billion. Adjustments to CT and MRI reimbursement rates are also expected to reduce annual spending by KRW 700 billion. However, tests essential for treating serious illnesses and providing emergency care will be excluded from the adjustments.

The government will also reform the system for outsourcing laboratory tests. Starting in January 2027, the National Health Insurance Service will directly pay the referring institution and the testing institution separately for the fees corresponding to each institution's role. Institutions that share test results quickly and accurately and meet requirements for patient management and quality control throughout the testing process will receive conditional, differentiated compensation. The aim is to shift the system away from price-discount competition and toward test quality and patient safety.

The Ministry of Health and Welfare said, “We expect this reform to make the compensation system for outsourced laboratory testing more transparent and improve the quality of testing services provided by referring and testing institutions, enabling patients to receive tests that are timely, accurate, safe, and appropriately provided.”

Meanwhile, at the committee meeting that day, members agreed to launch a pilot program in January 2027 to support treatment for patients with drug addiction. A compensation system will be established for each stage of treatment for people eligible for protective care, from intensive detoxification through recovery and maintenance treatment to connections with community rehabilitation institutions.

In addition, the second-phase pilot program for the designation and operation of pediatric rehabilitation medical institutions, which is due to end at the end of 2026, will be extended by three years and run from 2027 through 2029.

This content was produced with the assistance of AI translation services.