Jinan Urban Workers ' Basic Medical Insurance Scheme

Original Language Title: 济南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/201506/20150600399478.shtml

Jinan urban workers ' basic medical insurance scheme

    (March 22, 2014 the city, Jinan City, 47th Executive will discuss on April 1, 2014, Government order No. 252, published since April 1, 2014) Chapter I General provisions

    First to establish and improve the basic medical insurance system for employees, and ensure basic medical, according to the relevant regulations of the State and province, combined with the city's actual, these measures are formulated.

    Second approach applies within the administrative area of the city workers ' basic medical insurance coverage, services, and regulatory activities.

    Article should stick to the basic medical insurance charge, the principle of balance of payments, slightly, realizing the combination of equity and efficiency, rights and obligations correspond to level of protection commensurate with the level of social development. Fourth, Social Security Administration Department in charge of the urban workers ' basic medical insurance.

Social insurance agencies in charge of workers ' basic medical insurance fund raising, management and audit for the treatment, payment, and so on.

The County (City) Social Security Administration Department in charge of the workers ' basic medical insurance management in the administrative area, belongs to the social insurance agency is responsible for the employee's basic medical insurance fund raising, management and audit for the treatment, payment, and so on.

    Finance, health, food and drug regulation, pricing, audit, civil affairs departments shall, in accordance with their respective responsibilities, common good management of workers ' basic medical insurance.

    Fifth article of the urban workers ' basic medical insurance and social medical assistance, supplementary health insurance, civil service medical benefits, commercial medical insurance combined to form a multi-level medical security system.

    Chapter II basic medical insurance fund raising

    Sixth employee basic medical insurance fund revenues include: employers and trade unions, flexible employment to pay basic medical insurance premiums, interest income, financial subsidies, transfer income, grant from the higher authority, solution on a lower income, other income, and so on.

Seventh employer pursuant to 9% of the workers ' wages last month to the municipal or County (City) social insurance agency pay employees ' medical insurance premiums, workers ' wages last month income (hereinafter referred to as salary) 2% pay monthly withholding pay by his employer.

    Workers ' monthly salary of less than 60% of the last year's average monthly wage of fully employed staff, units and individuals are on the city's annual base pay 60% of monthly average wage of fully employed staff. Article eighth of flexible employment personnel to the base, last year's average monthly wage of fully employed staff, in accordance with the 10% of rates payment and the establishment of personal accounts, or by 5.

    5% rates payment does not establish individual accounts.

Nineth employer termination, revocation, dissolution, bankruptcy according to law shall be in accordance with relevant regulations of the State, province, paid to basic medical insurance premiums.

    Bankrupt enterprises shall, in accordance with the city's annual per capita amount of such medical expenses of retirees, retirees a one-time payment of 10 of the unit's medical insurance.

Tenth employee basic medical insurance fund in accordance with the following provisions of interest:

(A) raising part of the year, according to the Bank's demand deposits carry interest at a rate;

(B) of the previous year's carry-over funds and interest group, according to the Bank's 3-month lump-sum deposit interest rates;

    (C) deposit financial account deposit of social security funds, banks 3-year zero-sum deposit and deposit rates interest, grade of not lower than the level of interest rates.

11th workers ' basic medical insurance fund into gold funds and personal accounts. Funds refers to the employee's basic medical insurance fund, part of revenue into personal accounts. Personal account payment covers the individual contributions and from the part of the income of the Fund into personal accounts.

    Individual account and personal interest. 12th workers ' individual accounts classified according to the following provisions: under 35 years of age according to my monthly salary of 0. 8%, 35 years old and above 45 years of age according to my monthly salary 1%; 45 years according to my monthly salary of 1.

5%.

Workers ' monthly salary is higher than 300%, last year's average monthly wage of fully employed staff, the partial payment of the basic medical insurance premiums, 50% into personal accounts. Flexible employees ' individual accounts classified according to the following provisions: under 35 years of age according to my monthly salary of 2. 8%, 35 years old and above 45 years of age according to my monthly salary 3%; 45 years according to my monthly salary of 3.

5%. Retirees personal account gold in accordance with my monthly basic pension (pensions) 4% included, imposed minimum caps. Which, 60 age following months remit account amount below 50 Yuan of by 50 Yuan designated into, highest not over 170 Yuan; 60 age above 70 age following months remit account amount below 60 Yuan of by 60 Yuan designated into, highest not over 190 Yuan; 70 age above 80 age following months remit account amount below 70 Yuan of by 70 Yuan designated into, highest not over 220 Yuan; 80 age above 90 age following months remit account amount below 80 yuan of by 80 Yuan designated into, highest not over 220 Yuan

    ; Remit account less than 90 yuan per month of more than 90 years classified by 90 Yuan, up to 220 Yuan. 13th article of the city, including through establishing workers ' individual account adjusted GOP co-ordinate system.

    Specific measures shall be formulated separately by the Municipal Department of the social security administration.

    Chapter III basic medical insurance

14th insured pay standards above, below the maximum limit under inpatient, outpatient disease and general outpatient clinic of medical costs paid by the funds in accordance with the regulations.

    Insured in accordance with provisions under basic medical insurance of hospitalization, outpatient disease and GOP should be borne by the individual's medical expenses and fixed-point retail pharmacy drug purchase costs may be paid from the personal account.

15th payment standard in these measures refers to a health care during the year prescribed by the personal burden on Inpatient, outpatient disease and general outpatient medical facility.

Inpatient, outpatient provides disease and pay standards for general outpatient clinic to the city's annual average wage of fully employed staff as the base, according to the three-level medical institutions is not higher than 6%, secondary medical institutions is not higher than 4%, and other medical institutions does not exceed 3% standards are determined. Inpatient, outpatient provides disease and pay standards for general outpatient clinics were calculated.

    During the year under a medical, second hospitalization of the insured to pay a standard lower than the last 20%, from the hospital for the third time are no longer standard; clinic provides patients and GP paying accumulated standards respectively, burden only once. 16th highest limit in these measures refers to a range of health annual internal co-ordination among insurers to pay medical expenses maximum amount.

Inpatient and outpatient disease under the maximum payment limit standards for the city's annual average wage of fully employed staff 6 times, pay ceiling for the GOP standard prescribed separately by the Municipal Department of the social security administration.

    Medical expenses exceeds the maximum limit, resolved by the large medical expenses assistance, specific measures shall be formulated separately by the Municipal Department of the social security administration.

17th article from January 1 to December 31 of each year for a medical.

    Each year of medical standards and maximum payment limit, social security administration, by adjusting the release.

Article 18th insured (excluding pensioners) in a health care co-ordination within the scope of the Fund within the annual inpatient and outpatient fee for provision of medical treatment, burden in accordance with the following provisions: 1.

Payment standards above, 10000 Yuan the following section, coordinating Fund 85%, born 15%; 2.

More than 10000 part to a maximum limit, and fund 88%, born 12%. Retirement fund than the preceding paragraph for personnel and manpower burden increase 3%, 3% reduce the personal burden.

Before the founding of the old workers ' co-ordinating fund raise less the burden on retirees 5%, 5% reduce the personal burden.

Insured by the fixed-point tertiary general hospitals or city-level hospitals agree to transfer to the field hospital, temporary in the field suffering from acute inpatient treatment, relocation or long record of personnel in the field by the long-term hospital transfer to another hospital, coordinating Fund lower 10%, 10% increase the personal burden.

    An insured person in a medical general outpatient medical expenses for the year, pooling Fund and individual burden from the urban social insurance administrations separate.

    19th basic medical insurance requirements of class b drugs, pay part of the cost of treatment programs and health care services project, after the first paid by the insured in accordance with the regulations, respectively in accordance with article 18th of this approach by pooling Fund and individual burden.

Article 20th since employers pay basic medical insurance of employees of the month covered by basic medical insurance treatment. Flexible employees pay basic medical insurance of the 7th straight month, enjoy basic health insurance benefits.

    The original employer, have completed 6 months of continuous pay basic medical insurance, rescission, termination of labor relations or of receiving unemployment insurance compensation in flexible employment capacity, within 3 months after the expiry of the basic medical insurance, payment of the month covered by basic medical insurance treatment.

21st retirees covered by basic medical insurance treatment of 30 years ' minimum period of contributions for men and women under 25 years.

Does not meet the minimum period of contributions, retirement formalities shall, in accordance with the city last year to base monthly wage of fully employed staff and one months of basic medical insurance premiums make up the difference and enjoy basic medical insurance benefits since next month.

    According to the requirements of workers ' basic old-age insurance payment period, January 2005 basic old-age insurance for urban workers before the actual period of contributions was calculated for the period of contributions. 22nd an employer not paying employees ' medical insurance premiums, starting from next month due to the fees, and Fund suspended payment of its employees ' medical costs, individual account balances can continue to be used.

Since the employer make up for a month due to the fees and late fees, recovery workers enjoy treatment. Flexible employment since months unpaid workers ' basic medical insurance, funds to suspend paying their medical expenses.

Continuous arrears for less than 6 months, make up the arrears and late fees month recovery access to treatment; tuition for more than 6 months in a row since back pay from the 7th month of access to treatment.

    Medical expenses incurred during the insured debt, funds not be paid.
23rd the unemployed during the period of receiving unemployment insurance compensation payment of basic medical insurance premiums paid from the unemployment insurance fund, individuals are no longer paid.

    24th by the judicial authorities or departments concerned found that the insured due to suicide, self-harm or committing the crime incidence of injury, medical expenses, and funds are not paid.

    The fourth chapter of medical services management

25th basic medical healthcare institutions and the management of appointed retail drugstores. The social security administration from eligible medical institutions and retail pharmacies identified in fixed-point units, by the social insurance agency signed an agreement with, specify the rights and obligations of both parties.

    Specific measures shall be formulated separately by the Municipal Department of the social security administration.

Article 26th insured with valid medical documents to the designated medical institution in this city, you can purchase at designated medical institutions can also take the prescription to designated retail pharmacy to buy drugs.

Provisions apply for outpatient treatment, shall be approved by the social insurance agency organizations identified and sent to the clinic provides basic medical insurance of medical treatment permit. Emergency treatment of critical patients, can be close to non-designated medical institutions in the city hospital, it shall, within three working days from the date of hospitalization insurance agency to submit a written report to the community, his condition stabilized, should go to the designated medical institutions for treatment.

    Without due cause fails to report or verify is not of emergency treatment of critical patients, funds not be paid.

27th the employing unit or individual shall not commit the following acts of obtaining basic health insurance benefits:

(A) forge labor relations or fraudulent use of someone's personal information to participate in basic medical insurance;

(B) the fraudulent use, falsification of insured status or basic health insurance vouchers at designated medical institutions and appointed retail drugstores for treatment drugs;

(C) by repeating the visits, counterfeit, altered, altered medical records, prescriptions, expense vouchers, documents or supporting material, obtaining basic health insurance benefits;

(D) basic medical insurance certificate for personal lending to others, or by transfer of medical credentials, the settlement documents, the basic medical insurance costs;

(E) sale of basic medical insurance funds derived from drug use or medical materials;

(Vi) using individual accounts cash;

    (VII) other acts of obtaining basic health insurance benefits.

28th designated medical institutions and appointed retail drugstores and staff should strictly implement the basic medical insurance drug list projects, medical services, medical services and pay standards. Designated medical institutions, designated retail pharmacies shall provide the insured with reasonable and necessary medical, pharmacy services.

    Use the list of basic medical insurance for insured persons outside the scope of medicines, materials or provide services outside the scope of list of basic medical insurance, shall first seek consent of the insured person agrees.

Article 29th point appointed retail drugstores and medical institutions shall not be any of the following acts:

(A) in violation of routine disease diagnosis and treatment, technical operations, beyond the treatment necessary to limit excessive checks, medication, treatment, and other irregularities, and resulted in the waste of medical resources and loss of basic medical insurance funds;

(B) falsification of medical records hanging bed inpatient hospital, false or forged, altered documents and other illegal means to obtain basic medical insurance funds;

(Iii) using non-insured funds of basic medical insurance to pay my medical expenses, or provide billing information system of basic medical insurance for non-contracted medical institutions or retail pharmacies;

(D) would be inconsistent with the admission or transfer patients out of the hospital or of standard movements decomposition in hospital or deliberate prolongation of hospitalization time, resulting in loss of basic medical insurance funds;

(E) without justifiable reason to deny medical services to insured persons, belonging to turn basic medical insurance funds to pay medical expenses paid by the insured person;

(Vi) not by external prescription, the case of medicines, medical items, medical material or outside the scope of the basic medical insurance fund medical costs are covered by the basic medical insurance fund;

(VII) use the insured individual account cash;

    (VIII) other obtaining basic medical insurance fund or cause a loss of basic medical insurance fund.

    Supervision and administration of the fifth chapter

    30th of municipal or County (City) Government set up composed of representatives of relevant government departments, employers, medical institutions, representatives of trade unions, the relevant experts to participate in the basic medical insurance fund supervision organization, strengthen the supervision of basic medical insurance fund.

    31st basic medical insurance fund into the financial accounts management, earmarks, no unit or individual is allowed to occupy and use. Article 32nd social security administration and financial departments should strengthen the supervision and management of the basic medical insurance fund.

    Audit departments shall regularly Fund payments to social insurance agencies and management audit.

    33rd social security administrative departments and agencies should strengthen the designated medical institutions, supervision and inspection of appointed retail drugstores, inspected organizations and personnel shall actively cooperate with, truthfully provide information about files, medical records and data.

    Article 34th price departments shall be announced to the public in a timely manner the basic medical insurance and drug prices, medical items, medical services and facilities standards.

    35th social security administrative departments should set up basic health insurance supervision and telephone hotlines and complaint box, and receive reports from the society's complaints in a timely manner.

    The sixth chapter legal liability

    36th the employer fails to pay health insurance premiums, collected by the social insurance institutions ordered to pay or make up, and from the date of default of payment, plus five out of 10,000 late fee on a daily basis.

    37th the employer is not required to pay basic medical insurance premiums, insured medical expenses incurred during this period by the employer be paid according to the standards of the regulations affecting basic medical payment age limit for insured person calculated its loss, losses in part by the standards prescribed by the employer in accordance with the means to pay.

    38th the employing unit or individual in violation of the provisions of article 27th, by the social security administration ordered returned to defraud funds of basic medical insurance and fined a maximum of the amount defrauded more than twice times five times.

    39th medical institutions, appointed retail drugstores in violation of these regulations provided for in article 28th, causing economic losses to the insured, by the designated medical institution, appointed retail drugstores liability.

    40th designated medical institutions and appointed retail drugstores violate the provisions of article 29th of this approach, social insurance institutions arising from their breach of medical expenses not paid has been paid shall be recovered, and depending on the situation and its moratorium on settlement or disarmament agreements; by the social security administration the amount defrauded more than twice times five times for its fine; the circumstances are serious, cancel targeted qualifications.

    41st, social insurance agencies and their staff in basic medical insurance fund collection, management and monitoring activities, abuse of power, dereliction of duty or engages in acts, by the Social Security Administration Department of correction for supervisors and direct responsibility for administrative sanctions constitutes a crime, criminal responsibility shall be investigated according to law.

    The seventh chapter by-laws

    42nd flexible employment in these measures refers to no employees self-employed, not employers ' participation in the part-time employee's basic medical insurance in China as well as other flexible employment.

43rd Government according to the basic medical insurance fund revenue and expenditure and the level of medical services, timely adjustment of units, staff and flexible employment contribution rate and the proportion of funds to pay.

    Municipal social security Administrative Department in accordance with the city's economic and social development level, adjust the gold into the provisions of individual accounts, personal accounts range, GOP provisions and manpower funding criteria and outpatient disease directory, and announced to the public in a timely manner. 44th these measures come into force on April 1, 2014. Released on October 14, 2002, the interim measures of basic medical insurance for urban workers in Jinan (Government order No. 201) repealed simultaneously.