[Reasons for Proposal]

Following the revision of the National Health Insurance Act (Act No. 21235, Promulgated on Dec. 23, 2025, Effective on Dec. 24, 2026) aimed at preventing risks to patient safety and burdens on National Health Insurance finances caused by excessive medical use, this amendment stipulates the tasks necessary for establishing and operating the Real-Time Medical Benefit Details Verification System and the scope of its consignment. To promote the efficiency of the system's operation and ease the burden of premium payments for subscribers, it extends the notification deadline for matters necessary for calculating the monthly remuneration of employee insured persons from March 10 to March 31, and relaxes the criteria for installment payments of settled premiums. Furthermore, to prevent excessive outpatient use, it strengthens the criteria for out-of-pocket payments of the total outpatient medical benefit costs, thereby inducing rational medical use and improving and supplementing some deficiencies found in the operation of the current system.

[Main Contents]

A. Stipulates the tasks necessary for establishing and operating the Real-Time Medical Benefit Details Verification System and the scope of its consignment (Draft Article 18-5)

B. Extends the notification deadline for matters necessary for calculating the monthly remuneration of employee insured persons from March 10 to March 31 (Draft Article 35, Paragraph 1)

C. Relaxes the application criteria for installment payments of additional premiums due to year-end tax settlements, etc., to the level of the "lower limit of the monthly remuneration premium for employee insured persons" (Draft Article 39, Paragraph 4)

D. Strengthens the criteria requiring individuals to pay 90 percent of the total outpatient medical benefit costs from exceeding 365 annual outpatient visits to exceeding 300 visits (Draft Attached Table 2)

E. Establishes grounds for the National Health Insurance Service to request data regarding the Medical Benefit Details Verification System from the Health Insurance Review & Assessment Service (Draft Attached Table 4-3)

F. Revises the calculation formula to clarify the order of operations in the formula for the unfair ratio (Draft Attached Table 5)