Measures for the implementation of basic medical insurance for Jinan residents
Chapter I General Provisions
Article 1 In order to establish and improve the basic medical insurance system for residents and ensure the basic medical care for urban and rural residents, these Measures are formulated in accordance with the relevant provisions of the state and the province and in combination with the actual situation of our city.
Article 2 These Measures shall apply to the participation, service and related supervision and management activities of residents' basic medical insurance within the administrative area of this Municipality.
The term "residents" as mentioned in these Measures refers to the following persons (hereinafter referred to as the insured) outside the basic medical insurance coverage of employees within the administrative area of this Municipality:
(1) Full-time undergraduate students and full-time graduate students (hereinafter referred to as college students) who receive general higher education in all kinds of full-time ordinary institutions of higher learning and research institutes stationed in China;
(two) primary and secondary school students, kindergarten children and other residents under the age of 18 (hereinafter referred to as children) with household registration in this Municipality;
(3) Unemployed urban residents and rural residents (hereinafter referred to as adult residents) who have reached the age of 18 and have household registration in this city. Except for the household registration moved to this city after retirement in different places.
Article 3 The basic medical insurance for residents shall adhere to the following principles:
(a) the combination of individual contributions and government subsidies, the implementation of territorial management;
(two) the income is fixed, the balance of payments is balanced, and there is a slight balance, and the level of protection is commensurate with the level of financing;
(three) municipal planning, hierarchical management, mainly in counties (cities).
Fourth city, county (city) district social insurance administrative department is responsible for the management of basic medical insurance for residents within their respective administrative areas. City, county (city) district social insurance agencies shall be responsible for the management and service of basic medical insurance for residents in this area according to their duties. The financial department is responsible for raising and allocating government subsidy funds for residents' basic medical insurance. Health and family planning, education, public security, civil affairs, auditing, prices, federations and other departments, in accordance with their respective responsibilities to do a good job in the basic medical insurance for residents. Townships (streets) and villages (residential areas) undertake the registration of insured residents, information collection and policy propaganda.
Chapter II Raising of Residents' Basic Medical Insurance Fund
Article 5 The sources of residents' basic medical insurance fund include: residents' basic medical insurance premiums paid by insured individuals, government subsidies at all levels, fund interest income, social donation funds, funds raised by other channels, etc.
Sixth residents' basic medical insurance fund raising standards are:
(1) Individual contributions: college students and children pay 80 yuan every year; The payment standard for adult residents is divided into two grades, one is 300 yuan per person per year, and the other is 100 yuan per person per year, which I choose voluntarily.
(two) government subsidies in accordance with the standards prescribed by the state, borne by all levels of finance in accordance with the provisions of * * *, according to the annual budget, to ensure timely and full disbursement in place.
(III) Persons with severe disabilities, rural five-guarantee recipients, urban and rural minimum living allowances and other difficulties, and rural seven to ten disabled soldiers, survivors of martyrs, survivors of soldiers who died in the line of duty, demobilized soldiers, veterans who returned home sick, and retired people who participated in the war, who do not pay fees, will be fully subsidized by the government (among them, adult residents will be subsidized according to individual payment standards).
Conditional township (street) and village (neighborhood) collectives can provide payment subsidies for residents' insurance, and conditional employers can provide payment subsidies for the immediate family members supported by employees to participate in the basic medical insurance for residents.
Article 7 The basic medical insurance for residents shall be paid annually. The payment period of basic medical insurance for residents in the next medical year is from September 1 day to February 1 day.
After the insured person pays the basic medical insurance premium in full in one lump sum during the payment period, he can enjoy the basic medical insurance benefits for residents according to the medical year.
Newborns can pay the annual basic medical insurance premium for residents in one lump sum after household registration.
Article 8 If the insured person dies within the payment period after payment, or fails to enjoy the basic medical insurance benefits for residents in the next medical year due to reasons such as joining the army, employment, household registration, and transfer from this city, he may apply to the social insurance agency for refund of the fees paid by the individual in that year.
Ninth students, children in the park by the school, child care institutions responsible for organizing the payment of basic medical insurance for residents. Other people who meet the conditions of participating in the basic medical insurance for residents shall go through the formalities of insurance payment at the township (street) and village (neighborhood) where the household registration is located.
Article 10 Those who have participated in social insurance for employees may not participate in basic medical insurance for residents at the same time.
If the insured person participates in employee social insurance after employment and fails to reach the minimum payment period of employee basic medical insurance when he retires, the accumulated individual payment amount of resident basic medical insurance can offset the supplementary payment amount of employee basic medical insurance.
Eleventh the city to establish a general outpatient co-ordination system, outpatient co-ordination funds from the residents' basic medical insurance fund, separate accounting and management. The specific measures shall be formulated separately by the municipal administrative department of social insurance.
Establish a serious illness insurance system for residents, which is connected with the basic medical insurance system for residents.
Chapter III Basic Medical Insurance Benefits for Residents
Twelfth residents' basic medical insurance does not establish individual accounts. The insured person in the city designated medical institutions for medical treatment to implement immediate settlement.
Residents' basic medical insurance fund is used to pay a certain proportion of medical expenses for outpatient, inpatient and outpatient services.
Thirteenth insured persons enjoy treatment according to the medical year. The medical year for adult residents and children is 10 month 1 to February1; The medical year of college students is from September 1 day to August 3 1 day.
Newborns who pay insurance premiums within 3 months from the date of birth enjoy basic medical insurance benefits for residents from the date of birth; Insured for more than 3 months, enjoy the basic medical insurance benefits for residents from the next month of payment.
Article 14 The medical expenses of inpatient and outpatient diseases (including the part borne by individuals according to a certain proportion) incurred by the insured within a medical year that meet the payment scope of the residents' basic medical insurance fund shall be subject to the Qifubiaozhun and the maximum payment limit system. Medical expenses below Qifubiaozhun and above the maximum payment limit shall be borne by individuals.
Qifubiaozhun for college students is: tertiary medical institution 700 yuan, secondary medical institution 400 yuan, primary medical institutions (including community health service institutions, the same below), and township hospitals 200 yuan. Qifubiaozhun for hospitalization of other insured persons is provincial (ministerial) tertiary medical institutions 1.200 yuan, other tertiary medical institutions 1.000 yuan, secondary medical institutions 700 yuan, primary medical institutions and township hospitals 400 yuan. Within a medical year, the Qifubiaozhun for the second hospitalization will be reduced by 20% accordingly, and the Qifubiaozhun will not be implemented from the third hospitalization.
The outpatient service stipulates that the disease Qifubiaozhun is 200 yuan, and the insured person only undertakes it once in a medical year.
The maximum compensation limit is 200,000 yuan.
Fifteenth insured in a medical year in line with the basic medical insurance fund to pay the scope of hospitalization or outpatient medical expenses, paid by the basic medical insurance fund and individuals in accordance with the following standards:
(a) college students in tertiary medical institutions, 60% paid by the residents' basic medical insurance fund, 40% personal burden; For medical treatment in secondary medical institutions, 70% is paid by the residents' basic medical insurance fund, and 30% is borne by individuals; In the first-class medical institutions, township hospitals for medical treatment, the basic medical insurance fund for residents to pay 80%, personal burden of 20%.
(two) children and adult residents pay according to a standard, in the province (Ministry) three medical institutions, 40% paid by the residents' basic medical insurance fund, 60% personal burden; In other tertiary medical institutions, 55% is paid by the residents' basic medical insurance fund, and the personal burden is 45%; Secondary medical institutions, residents' basic medical insurance fund to pay 65%, personal burden of 35%; In the first-class medical institutions, 80% is paid by the residents' basic medical insurance fund, and the personal burden is 20%; For medical treatment in township hospitals, 90% is paid by the residents' basic medical insurance fund, and the personal burden is 10%.
(three) according to the second standard payment of adult residents, in the province (Ministry) three medical institutions, 30% paid by the residents' basic medical insurance fund, 70% borne by the individual; Other tertiary medical institutions, residents' basic medical insurance fund to pay 45%, personal burden 55%; For medical treatment in secondary medical institutions, 60% is paid by the residents' basic medical insurance fund, and the personal burden is 40%; In the first-class medical institutions, 80% is paid by the residents' basic medical insurance fund, and the personal burden is 20%; For medical treatment in township hospitals, 90% is paid by the residents' basic medical insurance fund, and the personal burden is 10%.
Article 16 If the insured person dies after being rescued in the outpatient department, the emergency expenses that meet the scope of payment by the residents' basic medical insurance fund shall be paid by the residents' basic medical insurance fund in accordance with the relevant provisions of hospitalization, and the Qifubiaozhun will no longer be implemented. Seventeenth insured people need to be transferred to other places for hospitalization, must meet the following conditions:
(1) Difficult and serious diseases that cannot be diagnosed and treated by designated medical institutions in this Municipality;
(two) without the city's designated medical institutions or designated medical institutions at or above the municipal level to make a diagnosis;
(three) the level of diagnosis and treatment of medical institutions is higher than that of this Municipality, and it must be a tertiary medical institution.
If the insured person needs to be transferred to other places for hospitalization, the experts from the city's tertiary designated medical institutions or municipal specialized designated medical institutions shall put forward their opinions and report to the social insurance agencies in the county (city) district for the record, and the residents' basic medical insurance fund shall be paid according to the standards of the provincial (ministerial) tertiary designated medical institutions.
Eighteenth insured in the field of undocumented medical expenses, residents' basic medical insurance fund in accordance with the provisions of article fifteenth of the standard payment.
Article 19 The medical expenses incurred by the insured for the drugs listed in the Class B drug list stipulated in the basic medical insurance for residents in this Municipality, as well as the medical treatment items and medical service facilities that pay part of the expenses shall be paid by the insured according to the prescribed proportion, and then implemented according to the provisions of Article 15.
Twentieth college students, children's outpatient emergency medical expenses due to accidental injuries, in the residents' basic medical insurance fund to pay more than 200 yuan, the residents' basic medical insurance fund to pay 80%, in a medical year, the maximum payment limit is 2000 yuan (including a certain proportion of personal burden).
Article 21 For the insured who meet the national family planning policy, the maternity medical expenses incurred due to hospital delivery shall be included in the payment scope of the residents' basic medical insurance fund, and the fixed lump sum payment shall be implemented: natural delivery in 800 yuan, vaginal delivery 1.000 yuan, cesarean section 1.900 yuan.
The insured person as the spouse of the male worker insured by maternity insurance has enjoyed the maternity insurance in maternity grants, and the residents' basic medical insurance fund will no longer pay.
Article 22 The insured is out of the city due to reasons such as joining the army, household registration or student status. The basic medical insurance benefits for its residents shall be terminated immediately.
If the insured participates in the basic medical insurance for employees after employment within a medical year, the basic medical insurance benefits for residents shall be terminated from the date of enjoying the basic medical insurance benefits for employees; In a medical year, people who are unemployed after participating in the basic medical insurance for employees and no longer enjoy the basic medical insurance benefits for employees can continue to enjoy the basic medical insurance benefits for residents in this medical year.
Twenty-third insured medical expenses in the following circumstances, residents' basic medical insurance fund will not pay:
(1) Being injured or injured due to violation of relevant laws and regulations;
(two) suicide (except mental illness) or drunkenness caused casualties;
(3) Plastic surgery, cosmetology and corrective treatment;
(four) due to induced labor, abortion and family planning operations;
(5) Occurred outside China;
(six) there is a third party liability compensation;
(seven) other provisions do not meet the basic medical insurance for residents.
Twenty-fourth insured persons shall not have the following acts of defrauding residents' basic medical insurance benefits:
(1) Illegally using or forging the identity of the insured or the relevant certificates of basic medical insurance for residents to seek medical treatment in designated medical institutions;
(2) defrauding residents of basic medical insurance benefits through repeated medical visits or forging, altering or tampering with medical records, prescriptions, reimbursement vouchers, documents or related certification materials;
(3) Lending the personal basic medical insurance certificate of residents to others for use, or settling the basic medical insurance expenses of residents through paid transfer of medical certificates and settlement documents;
(four) the sale of drugs or medical materials obtained by using the residents' basic medical insurance fund;
(five) other acts of defrauding residents of basic medical insurance benefits.
Chapter IV Management and Supervision
Twenty-fifth residents' basic medical insurance shall implement a unified drug list, diagnosis and treatment items and medical service facilities.
Twenty-sixth social insurance departments to establish a unified basic medical insurance information network system for urban residents.
Social insurance agencies adopt a compound settlement method of total prepayment, payment by disease type, fixed settlement and quality assessment to effectively control the cost level. The settlement process with designated medical institutions shall be formulated separately by the municipal social insurance agency.
Twenty-seventh the establishment of the basic medical insurance fund for residents municipal swap payment system, and gradually transition to the city's unified revenue and expenditure. Measures for the administration of transfer funds shall be formulated separately.
Twenty-eighth residents' basic medical insurance is managed by designated medical institutions. The scope and management of designated medical institutions shall refer to the relevant provisions of the basic medical insurance for employees, and eligible township hospitals and village clinics shall be included in the designated scope.
After the insured person pays the residents' basic medical insurance premium in full for the first time, the social insurance agency will handle the medical insurance card for him. The insured person shall go to the designated medical institution for medical treatment with his medical insurance card and other valid documents.
The insured person who applies for outpatient treatment of specific diseases shall be identified and confirmed by the social insurance agency, and a medical certificate for outpatient treatment of specific diseases shall be issued.
Twenty-ninth designated medical institutions and their staff should strictly implement the basic medical insurance drug list, diagnosis and treatment items, medical service facilities and payment standards.
Designated medical institutions shall provide reasonable and necessary medical and pharmaceutical services for the insured. When using drugs and materials outside the scope of the basic medical insurance catalogue or providing services outside the scope of the basic medical insurance catalogue for the insured, the consent of the insured shall be obtained in advance.
Thirtieth designated medical institutions shall not have the following acts:
(a) in violation of the routine and technical operation procedures of disease diagnosis and treatment, there are excessive inspection, medication, treatment and other irregularities beyond the scope of necessary diagnosis and treatment, resulting in waste of medical resources and loss of residents' basic medical insurance fund;
(two) take forged medical records hanging bed hospitalization, false hospitalization or by forging or altering documents and other illegal means to defraud the residents' basic medical insurance fund;
(3) using the residents' basic medical insurance fund to pay the medical expenses of non-insured persons, or providing the residents' basic medical insurance settlement information system to non-designated medical institutions or retail pharmacies;
(4) arranging patients who do not meet the criteria for hospitalization or transfer, decomposing the number of hospitalized patients or deliberately extending the hospitalization time of patients, resulting in the loss of residents' basic medical insurance fund;
(five) refusing to provide medical services for the insured without justifiable reasons, and transferring the medical expenses paid by the residents' basic medical insurance fund to the insured individuals;
(six) using the residents' basic medical insurance fund to exchange drugs, diagnosis and treatment items, medical materials or pay medical expenses beyond the scope of the residents' basic medical insurance fund;
(seven) other acts of defrauding residents' basic medical insurance fund or causing losses to residents' basic medical insurance fund.
Thirty-first social insurance administrative departments and social insurance agencies shall strengthen the supervision and inspection of designated medical institutions, and the units and personnel under inspection shall actively cooperate and truthfully provide medical files, medical records and related materials.
The administrative department of social insurance shall set up a telephone number for supervision and reporting and a complaint mailbox to accept social complaints in a timely manner.
Article 32 The residents' basic medical insurance fund shall have two lines of revenue and expenditure, which shall be incorporated into the management of special financial accounts, and a unified system of social insurance fund budget and final accounts, financial accounting and internal audit shall be implemented, and separate accounts shall be established for special purposes, and no unit or individual may misappropriate them.
Thirty-third counties (cities) should establish and improve the basic medical insurance network for residents according to the needs of work, and enrich the handling staff. County (city) District allocates 2 yuan funds for residents' basic medical insurance every year according to the number of insured persons in this area, and it is included in the fiscal budget at the same level. It is necessary to strengthen the professional training of handling teams, continuously improve the quality of handling personnel and the level of handling services, and ensure the basic medical insurance needs of residents.
Thirty-fourth social insurance agencies should establish and improve the internal management system, strengthen the management of residents' basic medical insurance fund income and expenditure, and accept the supervision and inspection of social insurance, finance, auditing and other administrative departments.
Thirty-fifth social insurance agencies, towns (streets), villages (residential) and their staff, as well as designated medical institutions and insured persons in violation of these measures, in accordance with the relevant provisions of the "People's Republic of China (PRC) Social Insurance Law".
Chapter V Supplementary Provisions
Article 36 The municipal social insurance administrative department shall, jointly with the municipal finance department, timely adjust the fund-raising standard, treatment payment standard, Qifubiaozhun, maximum payment limit and outpatient disease list of the basic medical insurance fund for residents in this Municipality according to the relevant national and provincial policies and regulations, as well as the income and expenditure situation of the basic medical insurance fund for residents and the level of medical consumption, and announce them to the public.
Thirty-seventh residents' medical expenses due to major epidemics, disasters and emergencies shall be arranged separately by governments at all levels.
Article 38 These Measures shall come into force as of 2065438+ 1 year1October 65438, 2005, with a validity period of 5 years. The relevant provisions of the original basic medical insurance for urban residents and the new rural cooperative medical system in our city are inconsistent with these measures, which shall prevail.