Annual outpatient visit cap cut to 300; patients exceeding limit to pay 90% of costs

Starting next year, patients who exceed 300 outpatient visits annually will be required to cover 90 percent of their medical costs out of pocket. Children, pregnant women, and patients with severe or rare diseases will remain exempt from the new limit. A medical records verification system allowing healthcare providers to check patients' treatment histories at the point of care will also be introduced beginning Dec. 24.

The Ministry of Health and Welfare said the amended enforcement decree of the National Health Insurance Act was approved at a Cabinet meeting Tuesday.

Under the revised decree, starting Jan. 1, 2027, patients whose annual outpatient visits exceed 300 will face a 90 percent out-of-pocket cost rate from their 301st visit onward.

Safeguards will remain in place for patients who require frequent outpatient visits for medical reasons. Exemptions apply to children, pregnant women, people with severe disabilities, and patients receiving treatment for severe, rare, or intractable diseases under the special cost-sharing exception program. Even for those who do not qualify for an automatic exemption, the National Health Insurance Service's excessive medical use review committee may grant exceptions after reviewing medical necessity on a case-by-case basis.

The decree also establishes the legal basis for building and operating a benefits utilization verification system, which will allow healthcare providers to check a patient's national health insurance usage history during treatment. The Health Insurance Review and Assessment Service will be entrusted with building and operating the system, and the items and methods subject to verification will be determined through deliberation by a medical appropriateness review committee to be set up within the agency.

The system is expected to reduce patient safety risks associated with repetitive or excessive medical use by enabling providers to review relevant treatment histories at the time of diagnosis and prescription.

CT scans and MRI examinations will be covered first when the system goes live on Dec. 24, with other items to be added in phases.

The threshold for applying to pay additional insurance premiums — such as those arising from year-end settlements for workplace subscribers — in installments will also be significantly relaxed.

Under the current rules, installment payments of up to 12 times are available only when the additional premium owed equals or exceeds the subscriber's own share of one month's salary-based premium.

From Oct. 1, the threshold will drop to the minimum salary-based premium floor. Based on the 2026 subscriber contribution rate, anyone owing 10,080 won ($8) or more will be eligible to split the payment into up to 12 installments.

The deadline for workplaces to report data needed for year-end insurance premium settlements to the National Health Insurance Service will also be extended from March 10 to March 31 each year. The extension will allow National Tax Service data to be reflected in settlements first, with workplaces then having until the end of March to review and supplement the information. As a result, more employees will be eligible for settlement using tax agency data, reducing the reporting burden on workplaces, while the existing April premium settlement schedule will remain unchanged.

The decree also establishes grounds for the government to proactively review and adjust the coverage status of medical procedures and treatment materials already designated as covered or non-covered benefits, when their safety, efficacy, cost-effectiveness, or coverage appropriateness changes.

Specifically, the health minister may adjust the coverage status of a procedure or treatment material when reclassification is needed, when its cost-effectiveness or coverage appropriateness has changed, or when a reassessment of a new medical technology raises safety concerns or finds that its clinical efficacy has changed.

The decree also explicitly states in law that drugs approved or registered for marketing but not yet designated as covered benefits are classified as non-covered, resolving ambiguities in the interpretation of regulations governing the reporting and disclosure of non-covered medical costs.

Yoo Ju-heon, director general of the Ministry of Health and Welfare's national health insurance policy bureau, said the amendments were designed "to ensure that medically necessary care is fully covered while reducing patient safety risks from repetitive and excessive medical use, and to support the public in using healthcare services more appropriately." He added that the ministry would "prepare thoroughly so that the public can feel the changes in practice, as the amendments also ease the burden of lump-sum premium payments during settlement and reduce the reporting burden on workplaces."