Chapter I General Provisions
Article 1 In order to ensure the basic medical care for urban 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 this Municipality.
Article 2 The basic medical insurance system for urban residents adheres to the following principles:
(a) voluntary insurance, government subsidies;
(two) medical insurance benefits and financing level to adapt;
(three) focus on ensuring the medical needs of inpatients and outpatients with serious illness, taking into account the outpatient service;
(four) with the basic medical insurance for urban workers and the new rural cooperative medical system.
Article 3 The basic medical insurance for urban residents shall be subject to territorial management. The following persons (hereinafter referred to as the insured) who have the household registration of urban residents within the administrative area of this Municipality (except contracted land or homestead) may participate in the basic medical insurance for urban residents:
(a) primary and secondary schools (including vocational high schools, technical secondary schools, technical colleges and special education schools, the same below) students, children and other urban residents under the age of 18;
(two) elderly residents who have reached the age of 60 for men and 55 for women and have not been included in the basic medical insurance coverage for urban workers (hereinafter referred to as elderly residents);
(3) Other non-employed urban residents (hereinafter referred to as other non-employed residents) who have reached the age of 18, men under 60 and women under 55, and have no occupation, income and social insurance.
Persons whose household registration moves into this city after retirement in different places do not belong to the insurance coverage of these measures.
Employers of individual industrial and commercial households of legal working age and their employees and flexible employees shall participate in the basic medical insurance for urban workers in accordance with the provisions, which does not belong to the scope of insurance coverage of these measures.
Article 4 The basic medical insurance for urban residents in this Municipality shall implement a unified policy. Lixia District, Shizhong District, Huaiyin District, tianqiao district, Licheng District and Changqing District (hereinafter referred to as the six districts of the city) shall implement the overall municipal planning.
County (city) people's government shall, according to the provisions of these measures, combined with local conditions, formulate the implementation opinions of the basic medical insurance fund raising standards, treatment standards and management models for urban residents, and report them to the municipal government for approval before implementation. When the conditions are ripe, it will be included in the municipal overall planning.
Article 5 The municipal labor security administrative department is the competent department of the basic medical insurance for urban residents in this Municipality, and is responsible for the organization, implementation, supervision and management of the basic medical insurance for urban residents. The district labor and social security administrative department is responsible for the supervision and management of the medical insurance agencies in this district and the insured organizations of urban residents in this area.
The finance department is responsible for raising, allocating, supervising and managing the government subsidy funds for the basic medical insurance for urban residents.
The health department is responsible for assisting in strengthening the supervision over the implementation of the basic medical insurance policy for urban residents by designated medical institutions. The education department is responsible for organizing the participation of kindergarten children and school students. Development and reform, public security, civil affairs, auditing, statistics, food and drug supervision, prices, disabled persons' federations and other departments shall, according to their respective functions and duties, coordinate in the basic medical insurance for urban residents.
Sixth city medical insurance agencies responsible for the management and disbursement of the basic medical insurance fund for urban residents, and provide business guidance to the district medical insurance agencies.
District medical insurance agencies are responsible for the collection of basic medical insurance premiums for urban residents in this area, the handling of medical insurance cards, the payment records of insurance premiums and the issuance of cash reimbursement.
Street (town) labor and social security institutions specifically undertake the registration, information collection and policy propaganda of insured residents.
Chapter II Fund Raising
Seventh sources of the basic medical insurance fund for urban residents (hereinafter referred to as the residents' medical insurance fund) include:
(a) the basic medical insurance for urban residents paid by the insured;
(2) government subsidies at all levels;
(3) Fund interest income;
(4) Funds donated by the society;
(5) Funds raised by other channels.
Article 8 The basic medical insurance premiums for urban residents in six districts of the city (hereinafter referred to as residents' medical insurance premiums) shall be raised according to the following standards:
(a) 18 students, children and other urban residents are raised according to the standard of 100 yuan per person per year. Among them, individuals pay 40 yuan and the government subsidizes 60 yuan;
(two) the elderly residents are raised according to the standard of 500 yuan per person per year. Among them, individuals pay 200 yuan and the government subsidizes 300 yuan;
(three) other non employed residents are raised according to the standard of 500 yuan per person per year. Among them, individuals pay 400 yuan, and the government subsidy is 100 yuan;
(four) to enjoy the minimum living guarantee for the severely disabled and people with difficulties in the city, and to be fully subsidized by the government in accordance with the above-mentioned standards.
The basic medical insurance premium for urban residents in counties (cities) shall be raised according to the standard that the annual income of minor urban residents shall not be lower than that of 80 yuan, other non-employed residents and elderly residents shall not be lower than that of 300 yuan. Among them, the government grants subsidies to underage urban residents, elderly residents and other non-employed residents according to the standards of not less than 40 yuan, 160 yuan and 60 yuan per person per year; The severely disabled and people with difficulties who enjoy the urban minimum living guarantee shall be fully subsidized by the government according to the improved standard.
Government subsidy funds, in addition to financial subsidies at or above the provincial level, the municipal finance will grant subsidies to counties (cities) and districts according to a certain proportion. Among them, the six districts in the city (including high-tech industrial development zones) are subsidized by 50%, Shanghe County by 20%, Pingyin County and Jiyang County by 10%, and Zhangqiu City is fully borne by local finance. Government subsidy funds are included in the fiscal budget on an annual basis, and are directly included in the financial accounts of residents' medical insurance funds by the financial department.
Ninth residents' medical insurance premiums are used to establish residents' medical insurance funds, and no personal accounts are established.
Article 10 The residents' medical insurance fund shall be divided into two lines of revenue and expenditure, which shall be included in the financial special account management, accounted for separately and used for special purposes. No unit or individual may occupy or misappropriate.
Eleventh insured in the payment period of a one-time full payment of medical insurance premiums for residents, according to the medical year to enjoy medical insurance benefits for residents; Those who fail to pay in full and on time during the payment period do not enjoy the medical insurance benefits for residents in this medical year.
Article 12 The payment period of residents' medical insurance is from 65438+ 10/month to 65438+February 3 1 year, and residents can enjoy medical insurance benefits from the following year. If the insured person dies within the payment period after paying the fee, he may apply to the district medical insurance agency for refund of the fees paid in the current year.
Newborns can pay the annual residents' medical insurance fee in one lump sum after household registration, and enjoy the residents' medical insurance benefits from the next month of payment.
Every year from 65438+1 October1to 65438+February 3 1 is a medical year.
Thirteenth residents' medical insurance premiums paid by insured kindergarten children and students in school shall be handled by local kindergartens and schools.
After the implementation of these measures, kindergarten institutions and primary and secondary schools shall handle the insurance procedures for the insured kindergarten children and students in school from the first payment cycle.
Fourteenth people who have participated in the basic medical insurance for urban workers or the new rural cooperative medical system shall not participate in the residents' medical insurance at the same time.
Those who participate in residents' medical insurance and basic medical insurance for urban workers after employment can't reach the minimum payment period of basic medical insurance for urban workers when they retire, and the accumulated payment amount of individual residents' medical insurance can offset the supplementary payment of basic medical insurance for urban workers.
Fifteenth insured persons to participate in the basic medical insurance for urban workers after employment, from the date of enjoying the basic medical insurance for urban workers, the termination of the enjoyment of medical insurance benefits for residents.
In a medical year, the insured person who is unemployed after being transferred to the basic medical insurance for urban workers can continue to enjoy the medical insurance benefits for residents in this medical year.
Article 16 If the insured is not insured or the payment is interrupted after the insured, the part that should be borne by the individual over the years or the payment period is interrupted within the prescribed payment period before the residents can enjoy the medical insurance benefits for the next medical year.
Chapter III Residents' Medical Insurance Benefits
Article 17 The residents' medical insurance fund is used to pay a certain proportion of the medical expenses of the insured for outpatient, inpatient and outpatient diseases (treatment of malignant tumor and leukemia, dialysis treatment of renal failure and anti-rejection treatment of organ transplantation) stipulated in these Measures.
The municipal labor and social security administrative department shall, jointly with the municipal finance department, timely adjust the catalogue of outpatient diseases according to the income and expenditure of residents' medical insurance fund, and announce it to the public.
Article 18 The medical expenses incurred by the insured for hospitalization or outpatient treatment of specified diseases within a medical year shall be borne by individuals below Qifubiaozhun. Qifubiaozhun for inpatient and outpatient diseases is calculated separately.
Qifubiaozhun for hospitalization is determined according to the standards of first-level medical institutions (including community health service institutions) in 200 yuan, second-level medical institutions in 400 yuan and third-level medical institutions in 700 yuan. Within a medical year, the Qifubiaozhun for the second hospitalization is reduced by 20% compared with the last one, and the Qifubiaozhun will no longer be implemented from the third hospitalization. The outpatient service stipulates the Qifubiaozhun for diseases. In a medical year, the insured person can only pay Qifubiaozhun once, and the standard is 200 yuan.
Nineteenth insured in a medical year, hospitalization and outpatient treatment of diseases in line with the scope of medical expenses paid by the residents' medical insurance fund (including the part borne by individuals according to a certain proportion), the implementation of the maximum payment limit system, the standard is 60 thousand yuan.
Article 20 The medical expenses incurred by the insured for hospitalization or outpatient treatment of diseases that meet the payment scope of the residents' medical insurance fund within a medical year shall be shared by the residents' medical insurance fund and individuals according to the level of medical institutions and the following standards:
(a) in medical institutions (including community health service institutions) in hospital, 70% paid by the residents' medical insurance fund, 30% personal burden;
(two) medical treatment in secondary medical institutions, 60% paid by the residents' medical insurance fund, 40% personal burden;
(three) medical treatment in tertiary medical institutions, 50% paid by the residents' medical insurance fund, 50% personal burden.
If the insured person continuously pays fees, from the second medical year onwards, the payment proportion of the residents' medical insurance fund will increase by 1 percentage point every year according to the provisions of the preceding paragraph, with a total of no more than 5 percentage points.
Twenty-first in a medical year, the insured in the designated community health service institutions in line with the provisions of the residents' medical insurance fund to pay the scope of outpatient medical expenses, of which the cumulative part does not exceed 200 yuan, by the residents' medical insurance fund in accordance with the standard of 20% payment.
Twenty-second students, children and other insured persons under the age of 18 due to accidental injuries, 80% of the emergency medical expenses shall be paid by the residents' medical insurance fund, and the maximum payment limit is 2000 yuan (including the part borne by individuals according to a certain proportion).
Article 23 If a critically ill patient dies after being rescued by an outpatient clinic, the emergency expenses that meet the payment scope of the residents' medical insurance fund shall be paid by the residents' medical insurance fund in accordance with the relevant provisions of hospitalization, and the Qifubiaozhun will no longer be implemented.
If the insured person is transferred from emergency observation to hospitalization in the same designated medical institution due to illness, the medical expenses incurred in emergency observation shall be merged into the unified settlement of hospitalization expenses.
Twenty-fourth insured persons need to be transferred to other places (limited to Beijing, Shanghai, Tianjin) for hospitalization, the city's third-class and first-class designated medical institutions or specialized hospitals above the municipal level shall put forward expert opinions and report them to the district medical insurance agencies for the record.
If the patient is transferred to a different place for hospitalization after filing, the proportion of personal burden of medical expenses will be correspondingly increased by 10 percentage point; The residents' medical insurance fund will not pay the medical expenses incurred in transferring to other hospitals without filing.
Article 25 The medical expenses incurred by the insured in using the drugs listed in the Category B drug list stipulated by the residents' medical insurance in this Municipality, paying part of the expenses for the medical treatment items and medical service facilities shall be paid by the insured in accordance with the prescribed proportion, and then borne by the residents' medical insurance fund and individuals respectively in accordance with the provisions of Article 20.
Twenty-sixth insured because of joining the army, entering a higher school (junior college), household registration to move out of the city, the residents' medical insurance benefits immediately terminated.
Twenty-seventh insured medical expenses in the following circumstances, residents' medical insurance fund will not pay:
(1) Violating relevant laws and regulations and causing injury;
(two) suicide (except mental illness) or drunkenness caused casualties;
(3) fertility and related operations;
(four) plastic surgery, beauty, correction and other treatments;
(5) Rehabilitation treatment;
(six) there is a third party liability compensation;
(seven) other provisions do not meet the scope of payment of medical insurance for residents.
Chapter IV Management and Supervision
Twenty-eighth residents of medical insurance coverage, diagnosis and treatment projects and service facilities with reference to the relevant provisions of the basic medical insurance for urban workers in this city.
The scope of the catalogue and the payment standard that children need to increase shall be implemented in accordance with the relevant provisions of the state and province.
Twenty-ninth residents' medical insurance fund settlement management, adhere to the principle of "fixed income and expenditure, balance of payments, and guarantee basic medical care", and adopt a settlement method combining total control, fixed settlement and quality assessment. Specific settlement management measures shall be formulated by the municipal labor security administrative department in conjunction with the municipal finance department.
Thirtieth medical insurance institutions shall apply for medical insurance cards for the insured after they have paid the residents' medical insurance premiums in full for the first time. The insured person shall go to the designated medical institution for medical treatment with his medical insurance card and other valid documents. The scope and management of designated medical institutions shall refer to the relevant provisions of the basic medical insurance for urban workers.
Emergency rescue of critically ill patients can be hospitalized in non-designated medical institutions nearby. However, it shall report to the district medical insurance agency within 3 days from the date of hospitalization. After the condition permits, it should be transferred to designated medical institutions for treatment; Residents' medical insurance fund will not pay if it fails to report or is not a critically ill patient after verification without justifiable reasons.
Thirty-first insured persons to apply for outpatient treatment of diseases, confirmed by the medical insurance agency, issued a medical certificate of outpatient disease.
Article 32 The insured shall not forge or alter prescriptions or expense documents to defraud medical treatment, and shall not lend medical certificates to others for use.
Thirty-third designated medical institutions should carefully examine the medical certificates of the insured, and strictly implement the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and the charging standards approved by the price department. Not by forging or altering accounts, materials, prescriptions, medical bills and other improper means to defraud the residents' medical insurance fund; Shall not violate the relevant provisions of the management of designated medical institutions.
Thirty-fourth price departments shall promptly announce to the public the prices of residents' medical insurance drugs, diagnosis and treatment items and charging standards for medical service facilities, and designated medical institutions shall strictly implement them.
Thirty-fifth administrative departments of labor security and medical 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 labor and social security shall set up a telephone number and complaint mailbox for residents' medical insurance supervision and reporting, and reward those who report meritorious service.
Thirty-sixth residents medical insurance fund to implement a unified social insurance fund budget and final accounts system, financial accounting system and internal audit system. The business expenses of the medical insurance agency shall be solved by the financial department from the budget and shall not be extracted from the fund.
Thirty-seventh medical insurance agencies should establish and improve the internal management system, strengthen the management of residents' medical insurance fund income and expenditure, and accept the supervision and inspection of labor security, finance, auditing and other administrative departments.
Chapter V Legal Liability
Article 38 If the insured violates the provisions of Article 32 of these measures and defrauds the eligibility for treatment, the municipal and county (city) labor and social security administrative department shall order him to return the defrauded residents' medical insurance fund and impose a fine of 1 times and less than 3 times; If the circumstances are serious, the medical insurance agency shall order it to stop enjoying the residents' medical insurance benefits in this medical year.
Thirty-ninth designated medical institutions and their staff in violation of the provisions of article thirty-third, the city and county (city) administrative department of labor and social security to recover the paid medical expenses, and impose a fine of 5000 yuan to 30000 yuan on the designated medical institutions. If the circumstances are serious, the medical insurance agency shall order it to suspend settlement; If the circumstances are particularly serious, its fixed-point qualification shall be cancelled.
Fortieth in violation of the provisions of article thirty-second and article thirty-third of these measures, which constitutes a violation of public security management, shall be punished by the public security organs according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
Forty-first medical insurance agencies, street (town) labor and social security institutions and their staff have one of the following acts, the administrative department of labor and social security shall order it to make corrections within a time limit; Refuses to correct, the main person in charge and the person directly responsible shall be given administrative sanctions; If the case constitutes a crime, criminal responsibility shall be investigated according to law:
(1) Failing to collect residents' medical insurance premiums as required;
(2) Failing to register, change or confirm the insurance information for the insured;
(three) interception, misappropriation of basic medical insurance premiums;
(four) dereliction of duty caused by the loss of residents' medical insurance fund;
(five) the use of authority to ask for bribes and seek personal gain;
(6) delaying payment or underpaying or refusing to pay medical expenses without justifiable reasons.
Chapter VI Supplementary Provisions
Article 42 The municipal government shall, according to the income and expenditure of residents' medical insurance fund and the level of medical consumption, timely adjust the raising standard, treatment payment standard, minimum payment standard and maximum payment limit of residents' medical insurance fund in this Municipality, and announce it to the public.
Forty-third kindergarten children and students who have no permanent residence in this Municipality may participate in residents' medical insurance with reference to the relevant provisions of these Measures.
The medical expenses of full-time college students are still implemented according to the existing regulations.
Forty-fourth due to major epidemics, disasters and emergencies, the hospitalization expenses of group urban residents shall be arranged separately by governments at all levels.
Forty-fifth municipal labor and social security administrative departments shall, in accordance with the provisions of these measures, formulate detailed rules for implementation in conjunction with relevant departments.
Article 46 These Measures shall come into force as of August 6, 2008.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.