Article 2 The basic medical insurance for urban residents in the whole city shall be managed at the municipal level as a whole and at different levels. Provincial (city, district) Labor and Social Security Bureau is responsible for supervision, management and implementation.
Third county (city, district) basic medical insurance agencies responsible for the basic medical insurance for urban residents, the main responsibilities are:
(a) to be responsible for the collection, management and payment of the basic medical insurance fund for urban residents;
(two) the preparation of urban residents' basic medical insurance fund budget and final accounts, reported to urban residents.
Various financial and statistical statements of basic medical insurance;
(three) to be responsible for the preliminary examination of the application and related certification materials of the designated medical institutions for urban residents' basic medical insurance, report to the municipal labor and social security department for approval and confirmation, and announce it to the public.
Article 4 The financial departments of counties (cities, districts) shall allocate handling fees to communities and other agencies according to the number of insured persons approved by medical insurance agencies, and the handling fees shall be included in the fiscal budget at the same level.
Article 5 The municipal medical insurance agency shall withdraw 3% of the basic medical insurance for urban residents every year to establish an adjustment fund, but it will not be withdrawn after the total amount reaches 15% of the annual income of the overall fund this year, which is specially used to prevent major risks arising from the operation of the basic medical insurance for urban residents.
Article 6 These Rules shall apply to students and children of primary and secondary schools (including vocational high schools, technical secondary schools and technical schools) that do not belong to the basic medical insurance system for urban workers (hereinafter referred to as children of residents); Elderly residents over 60 years old; Other non-employed urban residents: rural residents who are not included in the municipal area of the new rural cooperative medical system.
The full-time age of all kinds of personnel shall be determined on the date of 1+0 every year.
Article 7 Urban residents take their families as units, hold valid certificates such as household registration books and resident identity cards, and non-local registered students take schools as units to go through the insurance registration procedures at the labor security agencies in the streets (towns) where their household registration is located.
Article 8 The starting period of basic medical insurance for urban residents: Hecheng District is from 2007 1 October 1 to March 3, 2008, and other counties (cities, districts) are from 20081October1to June 30. The basic medical insurance premium shall be paid regularly, and every year from June 65438+1 October1to February 30th is a natural year.
If the basic medical insurance for urban residents is insured within the prescribed time limit in the year of start-up, they will enjoy the basic medical insurance for urban residents from the next month of payment. Belong to the urban medical insurance object but not within the prescribed time limit, enjoy the basic medical insurance benefits for urban residents from 90 days after the payment date (except newborns and new immigrants).
After the start-up period, those who transfer to the household registration relationship should be insured in the next year. Those who are required to participate in the insurance in that year should pay all the premiums in that year and do not enjoy the medical treatment before the insurance payment.
Babies born after the start-up period, 30 days after birth, have gone through household registration procedures, and both parents have participated in social medical insurance, they can be insured in the same year. When insured, you should pay all the premiums of the current year and do not enjoy the medical treatment before insurance.
If the insured fails to pay the basic medical insurance premium in full and on time, he will stop enjoying the basic medical insurance benefits for urban residents from next month and then ask for insurance. They can only enjoy the treatment after paying off all the fees owed over the years within 90 days of the payment time, and their continuous insurance payment period is recalculated.
The medical insurance premium paid by the insured residents will not be refunded or transferred due to the fact that their household registration is not in the city or death.
Article 9 The basic medical insurance for urban residents consists of two parts: individual contributions and government subsidies. The funding standard is per person per year: 80 yuan, the children of residents, and 200 yuan, other urban residents.
Government subsidies are implemented according to the following standards:
(a) who participated in the basic medical insurance for urban residents, 40 yuan subsidy per person per year.
(2) Children of residents who belong to low-income groups or are disabled at level 2 or above are subsidized annually 10 yuan, and other low-income groups, disabled people at level 2 or above who have lost their ability to work, and elderly people over 60 from low-income families are subsidized annually in 60 yuan.
(three) the "three noes" who have no ability to work, no source of income, and can't decide their dependents or dependents shall be fully subsidized by the finance at the same level.
Article 10 The insured holds the original and photocopy of the household registration book and resident ID card. Non-local household registration students, taking the school as the unit, go through the registration formalities at the agency where the household registration is located, fill in the Registration Form of Personal Information of Basic Medical Insurance for Urban Residents in Huaihua City, and the agency will paste a copy of relevant information on the back of the registration form for review.
The minimum living security objects and "three noes" personnel within the insured scope shall provide the minimum living security certificate for urban residents issued by the civil affairs department for evidence collection; Low-income families over 60 years old (including 60 years old) must also provide low-income certificates issued by civil affairs departments; Persons with disabilities above the second level should also provide low-income certificates issued by the civil affairs departments; Persons with disabilities above Grade II shall also provide the People's Republic of China (PRC) Disabled Persons' Card issued by the Disabled Persons' Federation (provide the original and photocopy of the above materials).
Article 11 Persons enjoying the minimum living allowance, persons with disabilities above the second level, "three noes" and elderly people over 60 years old from low-income families who are included in financial subsidies shall be publicized once a year by the street labor security station where their household registration is located, and the publicity time shall be 7 working days, and the publicity shall be reported to the relevant functional departments for examination and confirmation.
Twelfth agencies check all kinds of materials and input the basic information of the insured into the computer information system; Print payment documents for the insured, and the insured will go through the payment procedures at the designated bank with the payment documents; The agency shall issue the receipt of the social insurance fund with the payment receipt, and determine the time of enrollment with the payment time, and register the payment through the computer information system; Agencies regularly summarize the individual maintenance fees of basic medical insurance for urban residents in Huaihua City, collect payment vouchers and report them to the medical insurance agencies for audit and accounting; Medical insurance agencies after the audit, the issuance of "Huaihua basic medical insurance for urban residents handbook" and ic card.
Article 13: After the payment period is over, the medical insurance agency shall prepare a table of residents' participation in insurance this year, and submit it to the Labor and Social Security Bureau for review and approval by the Finance Bureau. Financial subsidies should be in place before the end of September each year.
Fourteenth medical insurance agencies issued a unified "Huaihua Basic Medical Insurance Handbook for Urban Residents" and an ic card to record personal identity for the insured. The basic medical insurance manual for urban residents in Huaihua City and the ic card shall be properly kept and shall not be lent or altered. If it is lost, it should be reported to the medical insurance agency in time for replacement.
Article 15 When the insured person changes from the basic medical insurance for residents to the basic medical insurance for employees, he must make up the difference between retirement and resignation based on the average social wage of employees in the last year in the overall planning area at the time of transfer.
Sixteenth insured hospitalization expenses due to illness, the basic medical insurance fund for urban residents shall be reimbursed in accordance with the provisions of the standard.
Article 17: the fund stipulates the minimum payment limit for hospitalization. The minimum threshold for hospitalization in a settlement year is: tertiary hospital 600 yuan, secondary hospital 300 yuan, and primary hospital 100 yuan. The maximum payment threshold in a settlement year is 50,000 yuan for residents' children and 25,000 yuan for non-employed residents.
Article 18: The hospitalization expenses of the insured shall be borne by the Fund and the insured according to the following proportions (including the hospitalization expenses of the uninsured party for accidental injury):
(a) the following part of the hospitalization deductible shall be borne by the individual;
(two) above the hospitalization Qifubiaozhun, the highest payment limit is borne by the overall fund and individual * * *:
A hospital (including community health service institutions) fund to pay 65%, 35% personal responsibility;
The secondary hospital fund pays 55% and the individual is responsible for 45%;
The third-level hospital fund pays 40%, and the individual is responsible for 60%.
For the insured who pay the insurance premium continuously, from the second year onwards, the proportion of hospitalization expenses paid by the fund will be increased by 2% every year, with the maximum increase not exceeding 10%.
(three) the part above the maximum payment limit shall be shared by individuals and families.
Article 19 If the outpatient medical expenses of the insured due to six diseases, such as malignant tumor, aplastic anemia, schizophrenia, cerebral palsy, renal failure and organ transplantation, are less than 2,000 yuan in a year, 60% will be paid by the fund, and the excess will be borne by the individual.
Twentieth accidents caused by other responsible persons, in line with the provisions of the outpatient medical expenses, the fund to pay 50%.
Article 21 The medical expenses incurred by the insured under the following circumstances are not covered by the fund:
(a) suicide, self-mutilation, fighting, alcoholism, drug abuse;
(2) Traffic and medical accidents;
(three) the scope of medical rehabilitation and residual insurance payment for work-related injuries and occupational diseases;
(4) Plastic surgery and plastic surgery;
(5) Going abroad or going to Hong Kong, Macao or Taiwan for medical treatment;
(six) without approval in the basic medical insurance for urban residents designated medical institutions for medical treatment;
(seven) beyond the urban residents' medical insurance drug list, diagnosis and treatment project list, medical service facilities and payment standards;
(eight) other illegal acts lead to illness, injury and disability.
Article 22 If the insured person meets the requirements for admission and needs hospitalization, he/she shall go through the hospitalization formalities at the designated medical institution of the basic medical insurance for urban residents with the Handbook of Basic Medical Insurance for Urban Residents, ic card and resident ID card (18 children with household registration book) and pay the full deposit.
When leaving the hospital, the insured or relatives can sign the list of hospitalization expenses and settle the medical expenses borne by the individual before going through the discharge formalities.
Medical insurance agencies shall, in accordance with the relevant provisions, strictly examine and identify the hospitalization notice and hospitalization expenses list of the insured, and settle accounts with designated medical institutions on a regular basis.
Twenty-third insured admission and discharge standards in accordance with the relevant provisions of the state. If the patient should be discharged from the hospital according to his illness, and refuses to leave the hospital without justifiable reasons after being notified by the hospital, all expenses shall be paid by himself from the second day after being notified by the hospital; Should be discharged from the hospital and the hospital did not inform him to leave the hospital, the expenses shall be borne by the hospital.
Article 24 If the insured is discharged from the hospital and needs consolidation treatment under special circumstances, the dosage standard shall not exceed 5 days and the variety shall not exceed 4.
Twenty-fifth basic medical insurance for urban residents, the scope of payment and the scope of items that will not be reimbursed, drug list, diagnosis and treatment items, medical service facilities and payment standards shall be implemented in accordance with the relevant provisions formulated by the superior.
Article 26 If it is really necessary for the insured to be transferred to hospital for treatment after hospitalization, the designated medical institution shall issue referral procedures and report to the basic medical insurance agency for approval before being transferred to hospital for treatment. The medical expenses for unauthorized referral shall be borne by the individual.
Emergency rescue of critically ill patients can go directly to the nearest medical institution for treatment and hospitalization, but their families should go through the referral registration formalities at the medical insurance agency with the emergency hospitalization certificate and related materials within 3 working days.
Twenty-seventh approved medical expenses incurred by resettlement personnel in different places shall be settled in a lump sum in the medical insurance agency before 65438+2 months every year with hospitalization invoices, expense lists, disease diagnosis documents and hospitalization medical records.
Twenty-eighth basic medical insurance for urban residents to implement the hospitalization system of designated medical institutions. Medical institutions that have obtained the designated qualification of basic medical insurance for urban residents may be designated medical institutions for basic medical insurance for urban residents as determined by medical insurance agencies.
Designated medical institutions shall be fixed for one year. If it is necessary to change, the change formalities shall be handled at the beginning of the next settlement year.
Twenty-ninth medical insurance agencies should sign agreements with designated medical institutions on medical service personnel, service scope, service content, service quality, medical expenses settlement methods, medical expenses payment standards, medical expenses audit and control. , so as to clarify the responsibilities, rights and interests of both parties.
Designated medical institutions that have passed the annual examination and approval can renew the medical service agreement, and those who fail to pass the annual examination and approval will cancel the designated qualification of basic medical insurance for urban residents.
Designated medical institutions shall be announced to the public once a year.
Thirtieth designated medical institutions to implement the annual examination system for high, new and advanced inspection items, and the inspection standards are based on the detailed rules for the implementation of the evaluation standards for secondary and tertiary hospitals in Hunan Province (for Trial Implementation) formulated by the Health Department of Hunan Province. If the positive rate of annual inspection items is lower than the prescribed standard, the designated medical institutions shall bear 60% of the negative part of the expenses.
Thirty-first insured medical treatment, the relevant personnel of designated medical institutions must carefully check. If the witness card does not match, medical services shall not be provided.
Article 32 Designated medical institutions shall abide by medical ethics, treat diseases, conduct reasonable examinations and use drugs rationally. Medication, examination and treatment in violation of the basic medical regulations shall be borne by the medical institutions themselves, and the medical insurance fund shall not pay.
The medical and drug prices of residents' basic medical insurance shall comply with the relevant state pricing regulations, and the part that violates the regulations shall be borne by the designated medical and drug stores themselves, and the residents' medical insurance fund shall not pay.
Article 33 When providing basic medical services for the insured, designated medical institutions must use unified medical vouchers such as special diagnosis and treatment prescriptions, examination and approval forms for special diagnosis and treatment items, examination and approval forms for referral and referral, hospitalization expense statement, hospitalization expense list, and list of out-of-pocket medical expenses of the insured.
Thirty-fourth medical expenses caused by medical accidents shall be borne by medical institutions and directly responsible persons, and the basic medical insurance fund for urban residents shall not be paid.
Thirty-fifth medical insurance agencies should establish a system of letters and visits from group leaders, and set up and publish complaint telephones and report boxes.
Article 36 These Rules shall come into force as of the date of promulgation.
Article 37 The Huaihua Municipal Bureau of Labor and Social Security shall be responsible for the interpretation of these Rules.