Reform of the Health Insurance Fee Schedule: Shifting from a Test-Centric Approach to a Focus on Regional and Essential Healthcare

Reform Details at a Glance

On June 25, 2026, the government finalized the Health Insurance Fee Structure Reform Plan at a meeting of the Health Insurance Policy Deliberation Committee. This reform is described as the largest-scale fee adjustment since the introduction of the Health Insurance Relative Value Score system in 2001.

The core objective is simple: to reduce the structure where revenue increases with the number of tests performed, and to provide greater compensation for medical services essential to maintaining the healthcare system, such as emergency care, childbirth, pediatrics, inpatient care, and general consultations.

What Are Health Insurance Reimbursement Rates?

Health insurance reimbursement rates are the price list for medical procedures covered by health insurance. When patients receive treatment at a hospital, the amount they pay at the front desk is only a portion of the total reimbursement rate; the National Health Insurance Service covers the remainder.

Health insurance reimbursement rates are typically calculated using the following structure.

• Relative Value Score: A score reflecting the workload, treatment costs, and risk level associated with each medical procedure
• Conversion Index: The unit price per score
• Adjustments (Increases or Decreases): Adjustments applied based on region, night/holiday hours, severity of illness, and the functions of the medical institution

In other words, fee schedule reform is not merely a policy that changes hospital revenue. It is a policy that simultaneously alters how medical institutions allocate personnel and equipment to specific treatments, the extent to which patients can access care, and how health insurance funds are spent.

Why Is This Considered the First Major Reform in 25 Years?

The relative value score—the core of the current health insurance fee-for-service system—was introduced in 2001. At that time, high-cost equipment such as CT and MRI scanners was less widespread than it is today, and it was relatively straightforward to establish a reimbursement system for tests where costs were easy to calculate, such as equipment prices or reagent costs.

Conversely, it was difficult to calculate the cost of consultation fees. This is because the time a doctor spends with a patient, the quality of explanations provided, and the difficulty of comprehensively assessing complex conditions are hard to quantify simply with numbers. As a result, criticism grew over time that while high reimbursement rates were maintained for equipment-based tests, basic and essential medical services—such as consultations, hospitalizations, anesthesia, and emergency treatment—were relatively undervalued.

According to an analysis released by the government, an examination of approximately 6,000 medical health insurance fee codes revealed that laboratory tests, such as blood tests, yielded a return on cost of about 190%, while specialized imaging tests, such as CT and MRI scans, yielded a return of about 194%. In contrast, services such as consultations, hospitalizations, and anesthesia were classified as under-reimbursed areas.

Financial Structure: 2.6 Trillion Won in Savings + 1 Trillion Won in Additional Funding

The financial structure of this reform is broadly divided into two parts.

The government has proposed a strategy that, rather than simply cutting reimbursement rates for laboratory tests, CT scans, and MRIs across the board, will adjust overcompensated items where the return on cost exceeds a certain threshold and link these adjustments to quality control measures for medical tests.

What Will Increase and What Will Decrease

1. Consultation Fees Will Increase

Consultation fees at clinics are scheduled to be adjusted as follows.

The in-depth consultations lasting 15 minutes or longer, which had been piloted at tertiary general hospitals, will be transitioned into a full-scale program, and the number of applicable sessions will be expanded. In-depth consultations at general hospitals and in-depth primary care consultations lasting 10 minutes or longer in certain medical departments will also be introduced.

The significance of this change is that the system will provide greater reimbursement for “care that involves listening carefully and providing thorough explanations” rather than “care that consists of brief consultations and numerous tests.”

2. Hospitalization Fees Will Increase

Reimbursement for hospitalization services will also be strengthened.

The hospitalization fee system will also be revised so that wards requiring more nursing staff receive higher reimbursement. This aims to encourage hospitals to secure more staff for managing inpatients.

3. Regional Preferential Rates Will Be Introduced

Regional preferential fee rates will be applied in principle to non-metropolitan areas and certain underserved areas within the Seoul metropolitan area. Additional reimbursement will be provided for surgeries, procedures, and emergency care in non-metropolitan areas, as well as in the Uijeongbu, Namyangju, Icheon, and Pocheon regions of Gyeonggi Province, and the Northwest and Central regions of Incheon.

The key details are as follows:

• A 10% surcharge on approximately 2,700 surgeries and procedures at general hospitals and higher-level medical institutions
• An additional 10% surcharge for emergency surgeries and procedures performed at night or on holidays
• Regional preferential fee schedules of up to 20% will be applied in certain areas
• A 5% surcharge on consultation fees for medical institutions in 84 cities, counties, and districts experiencing population decline
• An additional 5% payment on hospitalization fees for general hospitals and hospitals in these areas

The purpose of this system is to reflect the costs and challenges involved in maintaining essential medical care in these regions, even for the same medical procedures.

4. Compensation for Critical and Emergency Final Treatment Will Increase

The government will invest 900 billion won annually in critical and emergency final treatment. The plan includes a 20% increase in reimbursement rates for approximately 1,600 of the roughly 2,700 surgeries and procedures performed at general hospitals and higher-level facilities, as well as compensation of up to 5.5 times the standard rate for emergency surgeries performed at night or on holidays.

Reimbursement rates for general anesthesia will also increase by 50% from current levels. This signifies a commitment to compensating not only for the surgery itself but also for the anesthesia, preoperative preparation, and emergency response capabilities that make the surgery possible.

5. Compensation for Childbirth and Pediatric Care Will Be Strengthened

From the perspective of medical institutions, childbirth and pediatric care involve high staffing burdens and risks, yet demand varies significantly by region, making these fields prone to reduced supply. This reform allocates separate funding to these areas.

For example, for the delivery of a preterm infant born before 28 weeks, a surcharge of approximately 4.4 million won may apply at a specialized maternal and child health center, while at maternal and child health centers outside the Seoul metropolitan area, a surcharge of approximately 5.06 million won may apply, reflecting regional preferential rates. The age range for pediatric consultation surcharges will be expanded from under 6 years old to under 8 years old.

How Will CT, MRI, and Laboratory Tests Change?

The government is adjusting reimbursement rates for laboratory tests, CT scans, and MRI scans to reduce excessive spending in the diagnostic testing sector.

However, this does not mean that all CT and MRI scans and all tests will be uniformly reduced. The government stated that it will pursue detailed adjustments to ensure that essential tests required for critically ill or emergency patients, as well as tests with a low risk of overtesting, can maintain their current levels.

The System for Outsourcing Laboratory Tests Is Also Changing

The system for outsourcing laboratory tests has remained largely unchanged since 1999. Under this structure, outsourcing entities—such as neighborhood clinics—request blood and urine tests, and contracted laboratories perform the actual testing.

The government believes that under the existing system, the combination of overcompensated test items and a discount structure for test fees created incentives for unnecessary testing. Accordingly, it has decided to abolish the outsourcing management fee and instead clearly divide the roles of the outsourcing and contracting institutions within the test fee structure.

In the first phase of the reform, the adjusted test fees will be allocated at a ratio of 35% to the referring institution and 65% to the testing facility. Subsequently, a system involving conditional reimbursement based on evaluations of test quality, patient safety, support for testing in underserved areas, prompt notification of critical results, and specimen tracking and management is under consideration.

How Will Patient Out-of-Pocket Costs Change?

From the patient’s perspective, the most important question is, “If the fee schedule increases, will my out-of-pocket medical expenses also rise?” The answer is it depends on the specific medical service and the patient’s copayment rate.

Health insurance fees include both the portion covered by the National Health Insurance Service and the patient’s out-of-pocket copayment. Therefore, if the fee for a service subject to patient copayment increases, the patient’s out-of-pocket costs may also rise slightly. For example, since the statutory copayment rate applies to consultation fees and some hospitalization fees, the actual cost to the patient may change slightly.

Conversely, for services where fees are reduced—such as CT and MRI scans or laboratory tests—the patient’s out-of-pocket costs may decrease. Additionally, the government explained that for a significant number of items covered by the expanded essential medical care compensation—such as regionally preferential rates, childbirth, and hospitalization fees for children under 2 years of age—patient out-of-pocket costs will either be eliminated or kept low.

To summarize:

What Does This Mean for Healthcare Facilities?

This reform is a policy that changes the revenue structure of healthcare facilities. Revenue models that relied on the turnover rate of diagnostic equipment will decline, while facilities that maintain outpatient care, inpatient care, emergency care, childbirth services, pediatric care, and essential regional medical services will receive additional compensation.

In particular, hospitals outside the Seoul metropolitan area may have a greater incentive to maintain essential care through regionally preferential fee schedules. However, the actual effectiveness must be evaluated in conjunction with factors such as securing medical personnel, bed management, the emergency medical delivery system, resident training environments, and regional demographic structures. It is difficult to assume that regional essential healthcare issues will be fully resolved by fee schedules alone.

Policy Implications of This Reform

The core of this fee-for-service reform is not to “spend more” on the National Health Insurance budget, but to “spend it differently.” It reduces the relatively high-reimbursement structure centered on diagnostic tests and shifts funds to essential areas where public access would deteriorate significantly if the healthcare system were to collapse.

From a policy perspective, this has the following implications:

1. Reform to Reduce Reimbursement Distortions: Adjusting high-reimbursement, cost-intensive diagnostic testing areas while increasing reimbursement for under-reimbursed essential care.
2. Reform Reflecting Regional Disparities: Granting additional reimbursement for essential care provided in underserved areas, even for the same medical procedures.
3. Reform to Enhance the Value of Consultations: The system will shift toward rewarding thorough consultations and explanations rather than brief visits.
4. Improving the Efficiency of Health Insurance Finances: Incentives for unnecessary tests will be reduced, and funds will be allocated to high-priority areas such as severe cases, emergencies, childbirth, and pediatrics.
5. Transition to a Continuous Adjustment System: The current relative value revision cycle, which runs every 5 to 7 years, will be shortened to an adjustment system occurring within two years to more quickly reflect changes in medical technology and costs.

Key Issues to Monitor Going Forward

This announcement establishes the broad direction, and the actual impact on healthcare settings and patient out-of-pocket costs will be further clarified through detailed regulations and the implementation process. In particular, the following issues require ongoing monitoring:

• Will the adjustment of CT and MRI fees reduce access to these necessary tests?
• Will the increase in consultation fees lead to an actual increase in consultation time?
• Are regional preferential fees sufficient to secure essential medical personnel outside the Seoul metropolitan area?
• Will enhanced compensation for obstetrics and pediatrics actually improve the sustainability of hospital operations?
• Does the reform of the diagnostic testing outsourcing system improve test quality and patient safety?
• How will patient copayments change for each service item?

Summary

The government’s reform of the National Health Insurance fee-for-service system is a policy aimed at reducing the test-centric reimbursement structure and reallocating funds toward regional and essential healthcare. It aims to save 2.6 trillion won annually from laboratory tests, CT scans, and MRIs, and, by adding 1 trillion won from the National Health Insurance budget, invest a total of 3.6 trillion won annually in outpatient care, hospitalization, emergency care, obstetrics, pediatrics, and post-acute care.

Patients may experience different effects depending on the specific medical services they receive. While consultation fees and some hospitalization fees may rise slightly, the financial burden may decrease for services where testing fees are reduced. Although the government maintains that the reform is designed to prevent an overall increase in out-of-pocket costs, the actual impact will vary depending on the detailed implementation guidelines and each individual’s specific treatment.