Shanghai Basic Medical Insurance Scheme

Original Language Title: 上海市职工基本医疗保险办法

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201506/20150600399657.shtml

Shanghai basic medical insurance scheme

    (September 30, 2013 at the 25th Executive meeting of the Municipal Government published by Shanghai Municipal People's Government, the 8th October 14, 2013 December 1, 2013) Chapter I General provisions

Article I (purpose and basis)

    In order to protect workers ' basic medical needs, according to the People's Republic of China Law on social insurance and the Shanghai implementation of the State Council decision on establishing the basic medical insurance system for urban employees, the implementation of the programme, these measures are formulated.

Article II (scope of application)

This approach applies within the administrative area of the city enterprises and institutions, State organs, social organizations, private non-enterprise units and employees of individual businesses (collectively the "employer") and the workers ' basic medical insurance and related administrative activities.

    Workers in these measures, including workers, retirees and other insured persons.

Article III (definition)

Emergency risk standards mentioned in these measures refers to workers at designated medical institutions within a year emergency medical expenses incurred, in accordance with this approach by the staff that year included funds to cover personal medical accounts, and additional health insurance fund (hereinafter "additional funds") before payment, the amount of individual ego.

Standard of paid funds in these measures refers to workers at designated medical institutions within a year hospitalization or emergency room medical expenses for the stay in hospital for observation, according to this approach by the funds before payment, the amount of individual ego.

Funds and additional funds in these measures of payout percentage, refers to the workers within a year in medical costs incurred by the designated medical institution, in accordance with this approach by the funds or additional funding to pay for parts.

    The payment ceiling on funds in these measures refers to employees within a year in medical costs incurred by the designated medical institution, in accordance with this approach by the funds to pay the maximum amount.

The fourth section (management) Municipal human resources and Social Security Bureau is the Administrative Department of the urban basic medical insurance is responsible for the unified management of the urban basic medical insurance.

District and County Office of health insurance (hereinafter "district, County Health Office") is responsible for the basic medical insurance management within their respective jurisdictions.

The municipal development and reform, health and family planning, finance, audit, the food and drug administration, Home Affairs and other departments according to their respective duties, in collaboration with good management of basic medical insurance.

The social insurance agency is responsible for collection and payment of basic medical insurance.

    Municipal medical insurance service management Center (hereinafter "city health care center") is the medical insurance agency, responsible for the medical costs, disbursement of settlement, as well as basic medical insurance individual account (hereinafter "personal health accounts") management.

Fifth (proportion of relevant standards, adjusted) Basic medical insurance payment ratio, outpatient risk standards, funds to pay standards, funds and the additional payout percentage, overall pay ceiling on funds of funds should be based on the level of basic medical insurance and the city's economic and social development level of adaptation, keeping the basic medical insurance treatment gradient and the improving the efficiency of medical resource use sources, timely adjustment.

    Specific adjustment programme, by the municipal human resources and Social Security Bureau, in conjunction with relevant government departments, demonstrate and report to the municipal people's Government announced after the execution.

    Chapter II registration and payment

The sixth section (registration) The employer in accordance with the provisions of the municipal human resources and Social Security Bureau, to specify the social basic medical insurance registration insurance agency procedures.

Among them, the new employer shall, within the established date of 30th, registration procedures for basic medical insurance.

The employer terminate or change of registered particulars of basic medical insurance, should be since the date of 30th in the circumstances, to the original registration agency for cancellation or change of the registration.

    Social insurance agency handling the formalities prescribed in the preceding two paragraphs of this article shall audit the requirements according to the municipal Bureau of human resources and social security, and in accordance with relevant regulations, timely registration, change of employer registration or cancellation of registration notify city health care center.

Seventh (workers ' base pay calculation and payment ratio) Employee contribution base for my previous year's average monthly wage.

My average monthly wage over the previous year previous year's average monthly wage 300% workers in the city, ' portion without contribution base; below the previous year's average monthly wage 60% workers in the city, more than a year for 60% workers monthly salary, base pay. Employees shall, in accordance with the percentage of base 2% to pay basic medical insurance premiums.

    Retirees don't pay basic medical insurance premiums.

Eighth (employer contribution base the calculation and the payment ratio)

The base pay of the employer for employees ' base pay in the sum.

    The employer shall, in accordance with the percentage of base 9% to pay basic medical insurance premiums, and in accordance with the ratio of base 2%, payment of additional health insurance.

Nineth (medical insurance premiums paid channels)

    Employer paid medical insurance, as stipulated by the financial department expenditures.

Tenth (collection management)

    Employer and employee contributions calculation, payment procedures, and collection and payment disputes, in accordance with the relevant provisions of the management of the collection and payment of social insurance.

    Chapter III basic medical insurance funds and additional funds

11th (basic medical insurance fund)

The basic medical insurance fund, formed by pooling Fund and individual medical accounts.

    Basic medical insurance premiums paid by employers, inter alia in accordance with article 13th of this approach to personal health accounts, inclusion and manpower fund the rest.

12th (the establishment of personal medical account)

    City health care center in employer registration procedures for the basic medical insurance and paid according to the regulations after the medical insurance premium, should establish personal medical accounts for workers.

13th (personal health account funding included)

Basic medical insurance premiums paid by employees, and all included individual medical accounts.

About 30% of the basic medical insurance premiums paid by employers to personal medical accounts.

Basic medical insurance premiums paid by the employer into an individual medical account criteria differ according to different ages.

Staff ages are divided into:

(A) under 34 years of age;

(B) aged 35 to 44 years of age;

(C) over the age of 45.

Age of retirees is divided into:

(A) retirement to 74 years of age;

(B) over the age of 75.

    Basic medical insurance premiums paid by the employer into an individual medical account specific criteria and adjustment, by Bureau of human resources and social security, in conjunction with relevant departments, demonstrate and report to the municipal people's Government announced after the execution.

14th (the cessation of personal medical accounts included)

    Workers should be paid and unpaid health insurance premiums or interrupt access to basic old-age insurance benefits, stop accounted for in the Fund in accordance with article 13th of this approach.

15th (the use of personal medical account Fund and interest)

Personal medical accounts owned by individuals, can span more than closing and inherited according to law.

Personal medical accounts into that year included funding and the balance of the calendar year.

    End of personal medical accounts funds in accordance with the relevant provisions of interest, and to personal medical accounts.

16th (personal medical accounts queries)

    Employees can query individual medical account fund credited and expenditure, municipal health centre staff queries should be facilitated.

17th (additional funds)

    Place additional health insurance premiums paid by employer, included all the additional funds.

    Fourth chapter staff for medical care and the provision of medical services

18th (the definition of designated medical institutions and appointed retail drugstores)

Designated medical institutions in these measures refers to licensing and approval by the health and family planning made after examination by the City Department of human resources and social security, allowed the establishment of basic health insurance settlement of medical institutions.

    Of appointed retail drugstores in these measures refers to approval by the food and Drug Administration business qualification and after examination by the City Department of human resources and social security, allowed the establishment of basic medical insurance billing retail drug enterprise.

19th (service requirements for designated medical institutions and appointed retail drugstores)

    Designated medical institutions, appointed retail drugstores should provide employees with services, and basic medical insurance diagnosis and treatment project, the scope of medical services and drugs as well as standards, applications for medical billing.

20th (diagnosis and treatment project, the scope of medical services, drugs and pay standards)

    The city basic medical insurance diagnosis and treatment project, the scope of medical services and drugs as well as the provisions of the standard, by the municipal human resources and Social Security Bureau in conjunction with the departments concerned in accordance with national regulations.

21st (medical and pharmaceutical workers)

Employees can go to the designated medical institution within the city limits.

Workers at designated medical institutions dispensing, can also be provided to the designated retail pharmacy dispensing.

    Workers ' employment or residence in the outer provinces and cities, as well as provincial and municipal emergency, you can go to local hospitals for medical treatment.

22nd (medical certificate)

Workers at designated medical institutions in the city for medical treatment, to the designated retail pharmacy prescription, shall produce their medical insurance documents.

Designated medical institutions or appointed retail drugstores should be on the workers ' medical insurance certificate for verification.

    No person shall use, counterfeit, altered, lend proof of medical insurance.

    Fifth chapter medical payments

23rd (workers ' basic medical insurance treatment of condition)

Employers and their workers to pay health insurance premiums as stipulated, payment of health insurance premiums starting next month, employees covered by basic medical insurance treatment; failure to pay health insurance premiums, workers not covered by the basic medical insurance benefits.

Employer health insurance tax in accordance with the relevant provisions, in approving the holdover period, workers enjoy basic medical insurance benefits shall not be suspended.

Should be paid and unpaid health insurance premiums for employers and their workers pay in full after the medical insurance premium, workers can continue to enjoy basic medical insurance treatment. The age limit for employers and their workers to pay health insurance premiums (including as payment years) more than 15 years, you can enjoy basic medical insurance benefits after retirement. Considered as a period of contributions, calculated separately by the municipal Bureau of human resources social security provisions.
After the workers reached the statutory retirement age, retirement formalities, be entitled to a pension in the month, basic medical insurance premiums paid by the employer into their personal medical accounts part, in accordance with his last month in Office in the standard into account; the payment of medical expenses, according to retiree medical insurance regulations.

    Before the implementation of these measures in accordance with the relevant regulations of the basic medical insurance benefits for retirees, and not be limited by the provisions of this article.

24th (employees outpatient medical expenses) Employees within a year of outpatient treatment or to the designated retail pharmacy dispensing of what these measures are in addition to the 26th, 27th article other than costs, first by his own accounts included funds to cover that year.

Short part paid by the individual to the risk criteria of outpatient 1500 Yuan, the portion paid in accordance with the following provisions (not including what happened to the designated retail pharmacy dispensing fee):

(A) persons under 44, at the outpatient level medical institutions, by additional fund 65%; at the outpatient level II medical institutions, by additional fund 60%; in three-level outpatient emergency, additional funds to pay 50%. (B) persons over the age of 45, at the outpatient level medical institutions, by additional fund 75%; at the outpatient level II medical institutions, by additional fund 70%; in three-level outpatient emergency, additional funds to pay 60%.

Among them, was born December 31, 1955, before December 31, 2000, to participate in the work of more than ego standard part of medical expenses of outpatient, outpatient medical institutions, by additional fund 75%; in two outpatient emergency, additional funds to pay 70%.

Employees own standard part of outpatient medical expenses in accordance with this part provides that the additional funds remaining after the payment of medical expenses, personal medical accounts with Li year surplus funds, paid for by the balance of the calendar year, is still not enough to pay for, by employee risk.

    Employees what is happening to the designated retail pharmacy dispensing fees may be paid by an individual medical account over the balance of the funds.

25th (outpatient medical expenses of retirees) Retirees within a year. Clinical emergency medical treatment or to the designated retail pharmacy dispensing of what these measures are in addition to the 26th, except as provided in article 28th of the costs, from his own account when included in the funds.

Short part paid by the individual to the risk standard in outpatient period of 700 Yuan, the portion paid in accordance with the following provisions (not including what happened to the designated retail pharmacy dispensing fee): (A) persons under 69, at the outpatient level medical institutions, by additional fund 80%; at the outpatient level II medical institutions, by additional fund 75%; in three-level outpatient emergency, additional funds to pay 70%.

Among them, were born before December 31, 1955, on December 31, 2000, the former personnel participating in work and retirement formalities after January 1, 2001, more than ego standard part of medical expenses of outpatient, outpatient level medical institutions, by additional fund 85%; at the outpatient level II medical institutions, by additional fund 80%; in three-level outpatient emergency, additional funds to pay 75%.

(B) persons over the age of 70, at the outpatient level medical institutions, by additional fund 85%; at the outpatient level II medical institutions, by additional fund 80%; in three-level outpatient emergency, additional funds to pay 75%. Before December 31, 2000 dealing with retirement formalities, within a year of outpatient medical care or to designated retail pharmacy dispensing of what these measures are in addition to the 26th, except as provided in article 28th of the costs, from his own account when included in the funds.

Insufficient part by personal paid to door emergency conceit paragraph standard meter 300 yuan, over part according to following provides paid (not containing to Sentinel retail pharmacy dispensing by occurred of costs): in level medical institutions outpatient emergency of, by additional Fund paid 90%; in II level medical institutions outpatient emergency of, by additional Fund paid 85%; in three level medical institutions outpatient emergency of, by additional Fund paid 80%.

Retirees own standard part of outpatient care and in accordance with the provisions of this article by the additional fund to pay medical expenses for the rest of personal medical account of the balance of the calendar year, paid for by the balance of the calendar year, is still not enough to pay for, by retirees risk.

    Retirees to the designated retail pharmacy dispensing of costs incurred, by the personal care account funds to pay the balance of the calendar year.

26th (outpatient and home health care costs) Workers in outpatient for heavy syndrome uremia dialysis, and malignant tumors treatment (chemical treatment, and endocrine specific treatment, and radiation treatment, and isotope treatment, and intervention treatment, and TCM treatment), and part psychiatric disease species treatment (schizophrenia, and in the heavy degrees depression, and mania crazy syndrome, and forced syndrome, and spirit development slow with sent spirit obstacles, and epilepsy with sent spirit obstacles, and paranoid sex psychiatric) (following collectively "outpatient big disease") by occurred of medical costs, on-the-job workers of, by and manpower Fund paid 85%; retired personnel of, Paid from the funds 92%.

The rest paid for by his own account over the balance of the funds is still not enough to pay for, the employees own.

    Employee medical costs incurred by the family bed, by coordinating Fund 80%, and the rest by an individual medical account funds to pay the balance of the calendar year, is still not enough to pay for, the employees own.

27th (employee costs of hospitalization, emergency room care) The staff inpatient hospitalization or emergency room by funds to pay medical expenses for the Observatory, set pay standards.

Standard for 1500 Yuan.

Employees within one year of hospitalization or emergency room medical expenses for the stay in hospital for observation, more than part of the payment standard, paid by the funds 85%.

    Standard of paying workers the following medical expenses as well as from the film fund to pay medical expenses for the rest of, by an individual medical account funds to pay the balance of the calendar year, is still not enough to pay for, by employee risk.

28th (retiree costs of hospitalization, emergency room care) Retiree inpatient hospitalization or emergency room by funds to pay medical expenses for the Observatory, set pay standards.

Retire before December 31, 2000, standard 700 Yuan on January 1, 2001 and retired after, start to pay standard is 1200 Yuan.

Retirees a year hospitalization or emergency room medical expenses for the stay in hospital for observation, more than part of the payment standard, paid by the funds 92%.

    Retirees pay standards the following medical expenses and by co-ordinating Fund to pay medical expenses for the rest of, by an individual medical account funds to pay the balance of the calendar year, is still not enough to pay for, by retirees risk.

29th (funds more than the maximum payout limits and costs) Payment ceiling for the solidarity fund of 340,000 yuan.

Employees within one year in the hospital, emergency room hospital observations of cases above standards of the medical costs, as well as outpatient or home care medical costs, below the maximum limit, by the solidarity fund under this approach the 26th, 27th, 28th, provided payment is paid.

    Payment ceiling on funds over health-care costs, additional funds to pay 80%, remainder staff proud.

30th (some special diseases medical expenses paid)

Workers for a class infectious diseases occurred in accordance with the basic provisions of the health insurance outpatient and hospitalization, emergency room medical expenses for the stay in hospital for observation, all paid by the funds.

    Workers for maternity medical expenses incurred as a result of work injury, occupational disease, maternity insurance fund or the work injury insurance fund according to the State and the city paid the relevant provisions.

31st (not paid)

The following range of medical expenses not covered by the basic medical insurance fund:

(A) shall be paid from the work injury insurance fund;

(B) shall be borne by the third party;

(C) shall be borne by the public health;

(D) overseas for medical treatment. Medical costs that shall be borne by the third party, third party does not pay or cannot determine a third party, paid by the basic medical insurance fund.

    After the advance payment of the basic medical insurance fund, is entitled to recourse to a third person pursuant to the provisions.

    Sixth chapter, medical expenses and settlement

32nd (billing and account deduction of medical expenses)

Employee medical treatment or a prescription that meet the requirements of the basic medical insurance of medical expenses incurred, with employees ' medical insurance certificate in accordance with the following provisions:

(A) belonging to the solidarity fund and additional funds, designated medical institutions shall be truthfully billed;

(B) personal health account funding to pay, designated medical institutions or appointed retail drugstores should buckle from the employee's personal medical accounts, personal health account funding to pay shall be charged to the employee.

    Designated medical institutions, appointed retail drugstores on the workers ' medical care or dispensing what happened does not meet the requirements of the basic medical insurance medical expenses shall be charged to the employee.

33rd (medical cost reporting settlement)

Designated medical institutions, appointed retail drugstores from the individual medical account deduction of medical expenses per month to the designated district or county health care settlement.

Designated medical institutions belonging to the solidarity fund account medical expenses and additional funds to pay per month to the designated district or county health care settlement.

    Trade unions took place according to the provisions of the third paragraph of the article 21st of this approach can be used by the funds, additional funds or personal medical accounts to pay medical expenses, by virtue of their medical insurance documents to the designated district or county health care settlement.

34th (medical approval and disbursement)

District and County Health Office to apply for settlement of medical expenses shall, within 10 business days from the settlement date of receipt of the application at first instance and preliminary review opinions submitted to the municipal human resources and Social Security Bureau. Municipal human resources and Social Security Bureau shall be received in district and county health care comments within 10 working days from the date of first instance, to grant payments, suspension of pay or not to pay for examination and decision. After the municipal human resources and Social Security Bureau in defer payment decisions shall, within 90 days to approve the pay or not to pay decisions and inform the relevant units.
Medical costs approved by the municipal human resources and Social Security Bureau, city care centre shall, within 7 working days from the date of approval, from the health insurance fund shall be disbursed; approved by the municipal Bureau of human resources and social security does not pay health-care costs, by contracted medical institutions, appointed retail drugstores or workers at their own expense.

35th (settlement of medical expenses)

    Total municipal human resources and Social Security Bureau can take advance settlement, settlement services billing, service units or in other ways, with designated medical institutions settle medical expenses beyond the medical costs of the accounting standards, shared with designated medical institutions in accordance with the provisions of the health insurance fund.

Article 36th (application fee settlement prohibited acts)

    Designated medical institutions, appointed retail drugstores or individual shall not be counterfeit or change accounts, information documents, outpatient prescriptions, medical expenses and other improper means, settle medical expenses.

    The seventh chapter legal liability

37th (supervision)

    Designated medical institutions, appointed retail drugstores and insurance personnel supervise and inspect compliance with the provisions of the basic medical insurance, according to the Shanghai Municipal measures on the supervision and implementation of the relevant provisions of the basic medical insurance.

38th (designated medical institutions, appointed retail drugstores liability, insured persons violations)

    Designated medical institutions, appointed retail drugstores and insurance personnel who violate these rules, resulting in loss of medical insurance fund, in accordance with the relevant provisions of the State and this municipality.

39th (health-care liability management violations)

Human resources social security administrative sector and city Medicare Center of staff has following behavior one of of, by city human resources Social Security Council ordered corrected; to medical insurance fund, and employing units or personal caused loss of, law bear compensation responsibility, and on has directly responsibility of competent personnel and other directly responsibility personnel give warning, and demerit or remember than disposition; plot more heavy of, give downgraded or dismissed disposition; plot serious of, give fired disposition:

(A) fails to perform statutory duties of social insurance;

(B) has not been deposited on account of the health insurance fund;

(Iii) deducted or refusing to pay health insurance benefits;

(D) the lost or altered payment records, enjoying medical insurance records and record medical data, personal interests;

    (E) other acts in violation of the laws and regulations on social security.

    The eighth chapter supplementary articles

40th (management and oversight of the health insurance fund) Overall management and supervision of activities of the Fund and additional funds, in accordance with relevant provisions of the national social insurance fund, and the city.

Funds and additional funds into the accounts of the Social Security Fund, the unified management, accounting alone, earmarks, and shall be subject to municipal people's Government the establishment of a social insurance fund supervision organization, as well as the supervision of the finance and auditing Department.

    Overall annual budget and final accounts of the Fund and additional funds by the municipal human resources and Social Security Bureau together with the City Department of finance prepared and submitted to the municipal people's Government for approval before implementation.

41st (flexible employment personnel's basic medical insurance) City workers self-employed, not employers ' participation in the part-time employee's basic medical insurance in China and other flexible employment personnel's participation in employee basic medical insurance, you can set access to health insurance waiting period.

After the expiration of the waiting period, persons insured in accordance with this regulation, enjoy basic medical insurance benefits.

    Specific measures for the setting of the waiting period, developed separately by the municipal Bureau of human resources and social security.

42nd (other people's basic medical insurance)

Participate in the non-urban employee's basic medical insurance in China registered permanent residence outside pay basic medical insurance and basic medical insurance benefits, in accordance with the relevant provisions of this municipality.

    The unemployed during the period of receiving unemployment insurance compensation, paid by the unemployment insurance fund in accordance with the provisions of the basic medical insurance premiums, enjoy basic medical insurance benefits.

43rd (extension of the working personnel of the special provisions)

    Reached the statutory retirement age, according to state regulations, not retired personnel procedures, to work longer, in accordance with the staff regulations of basic medical insurance; retired after the procedure, according to basic medical insurance for retirees with age shall apply.

44th (execution date) These measures shall take effect on December 1, 2013. On October 20, 2000, the Shanghai Municipal People's Government, the 92nd release, March 28, 2008 148 pieces such as the Shanghai Municipal People's Government to amend the Municipal Government decided to amend and republish the regulations of urban employee basic medical insurance in Shanghai at the same time abolish.