Tianjin's Basic Medical Insurance

Original Language Title: 天津市基本医疗保险规定

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201205/20120500368197.shtml

Tianjin's basic medical insurance

    (January 14, 2012 82nd meeting of the people's Government of Tianjin by February 3, 2012, Tianjin Municipal People's Government, the 49th release as of March 5, 2012) Chapter I General provisions

    First in order to regulate the relations of basic medical insurance, basic medical insurance for citizens to participate in and enjoy basic medical insurance treatment of legitimate rights and interests of, in accordance with the People's Republic of China social security law and relevant regulations of the State, considering the actual situation in the city, these provisions are formulated.

    Article adhere to basic medical insurance system wide coverage, basic, multi-level and sustainable approach, in accordance with the level of protection commensurate with the level of economic and social development in principle, according to the financial status, the employer and the capacity of individual economies to determine funding criteria, in urban and rural areas, and the city's co-ordination and the gradual transformation of basic medical insurance system for employees and residents. Third unit within the administrative area of the city and its employees and retirees, and shall, in accordance with the provisions of the basic medical insurance for urban and rural residents.

Basic medical insurance including workers ' basic medical insurance and basic medical insurance.

State organs, organizations, enterprises, institutions, private non-enterprise units, other organizations and individual businesses have workers (collectively employer) and its employees and retirees should be participating in basic medical insurance.

Students, children, unemployed rural and urban residents should be participating in basic medical insurance.

    No employees self-employed, not employers ' participation in the part-time employee's basic medical insurance in China and other flexible employment personnel, you can choose to participate in an employee's basic medical insurance and basic medical insurance.

Article fourth basic medical insurance for city and county governments should be incorporated into the national economic and social development plan, to give the necessary financial support.

    Within the administrative area of the county people's Governments shall arrange the employer and residents to participate in basic medical insurance. Fifth of municipal human resources and social security administrative departments are responsible for the city's medical insurance management.

    Finance, health, education, prices, the food and drug administration, audit, civil affairs, industry and commerce, public security and other departments, within the scope of their respective duties and responsibilities relating to the work of basic medical insurance.

    Sixth municipal medical insurance agency is responsible for the basic medical insurance registration record, collection and payment of insurance, personal interests, insurance payments and so on, to designated medical institutions, drugstores and other health care institutions to provide handling operational guidance.

    Seventh article of the city establish a multi-level medical security system, encouraging the development of complementary medical insurance, the Government support for the enterprises to establish supplementary medical insurance.

Eighth municipal human resources and social security administrative departments employ employer representatives, representatives of insured persons, the relevant experts as a supervisor of social medical insurance, medical insurance management and services departments and staff in charge, designated medical institutions, drugstores and doctors, pharmacists, employers and insured persons abide by the basic medical insurance laws and regulations and monitoring implementation of Community regulations.

    Basic medical insurance for any organization or individual has the right to violate laws, regulations, reports, complaints and regulatory actions.

    Nineth medical insurance agency shall be announced to the public on a regular basis to have health insurance as well as medical insurance funds, income, expenses, balance and earnings.

    Chapter II basic medical insurance premiums raised

    Tenth employing units and employees, retirees, resident shall be paid in accordance with the provisions of the standard basic medical insurance premiums.

11th employee in accordance with my annual salary not less than 2% monthly payment of basic medical insurance, the employer is not lower than the individual contribution base and 10% monthly payment of basic medical insurance premiums. Individual employees pay basic health insurance for all and compliance from the employer classified as part of the basic medical insurance premiums paid into individual accounts.

    All principal and interest into his own personal account, personal account interest rates refer to Bank the savings deposit interest rate. 12th my last year's average monthly wage of employees is higher than the city's average monthly wage of employees 300% for the last year, annual average monthly wage of workers in this city of more than 300% to pay basic medical insurance in the base.

My last year's average monthly wage of employees is lower than the city's average monthly wage of employees 60% for the last year, annual average monthly wage of workers in this city of more than 60% to pay basic medical insurance in the base.

    My last year's average monthly wage of employees cannot be determined, above the annual workers ' monthly salaries to pay basic medical insurance base.

13th employing units in accordance with the provisions of article 11th payment difficulties, adopted by the Conference of the representatives of the employees or employee, you can reduce payment ratio in accordance with the relevant provisions, not to set up personal accounts.

    Self-employed with no employees, not employers insured part-time employees and other flexible employment personnel, in accordance with the relevant provisions of the basic medical insurance premiums, does not establish individual accounts. Article 14th differential residents participating in the basic medical insurance payment system. Students, children and adult residents according to the standards set to pay basic medical insurance premiums. Adult residents pay standard setting different grades, which I voluntarily choose to pay.

Standards for individual payment due pursuant to the provisions of the Government subsidy.

Severe disability, to enjoy the low treatment and special hardship case families grade personnel in accordance with the provisions of the insurance, individuals do not pay, fully subsidized by the Government.

    Residents shall be paid at the end of September to December each year a one-time basic medical insurance premiums for next year.

    15th residents participating in basic medical insurance subsidy by the municipal and district people's Government share the responsibility. 16th municipal people's Government in accordance with economic and social development level, standards and Government subsidies on basic medical insurance payment standard is adjusted accordingly.

    Municipal human resources and social security, administrative, financial and other relevant departments to develop, in conjunction with adjustment programmes, submitted to the municipal people's Government for approval before implementation.

    Chapter III basic medical insurance benefits Article 17th fee month enjoy basic medical insurance benefits for employees.

Workers reached statutory retired age Shi, cumulative paid basic medical premium years male full 25 years, and female full 20 years, and actual payment years full 5 years of, retired Hou no longer paid basic medical premium, continues to enjoy basic medical insurance treatment; insufficient above years of, can in handle retired Shi by when payment standard one-time complement employing units and personal should paid of basic medical premium Hou, enjoy basic medical insurance treatment.

Self-employed with no employees, not employers insured part-time employees and other flexible employment personnel, from the expiration of 6 months from the payment covered by basic medical insurance treatment.

    Entrance kindergarten students, children enjoy the term for payment of the basic medical insurance benefits from September of that year to August of the following year, other residents covered by basic medical insurance payment period for treatment from January to December of the following year.

    18th persons insured hospital, doors (emergency) diagnostic and other medical expenses, State and city basic medical insurance drug list scope, diagnosis and treatment project directory and list of medical services (collectively, the coverage), and paid in accordance with the provisions in the basic medical insurance fund. Article 19th insured hospital treatment expenses that occur within the scope of health care costs, payment criteria determined in accordance with hospital grade and number.

    Insured persons hospitalized more than 2 times in 1 year, starting from his second hospitalization, which belongs to the employees, retirees, and standards according to the 30% Executive, belongs to the residents, is no longer set pay standards.

    20th employee basic medical insurance in hospital reimbursement rate applicable to take care of retirees and other groups, residents ' basic medical insurance in hospital reimbursement according to rank and pay level of hospital settings. 21st basic medical insurance in hospital the highest standard in accordance with national regulations.

    Workers and retirees in hospitals at all levels to implement the same maximum payment standards, residents of maximum payment standards in hospital grades and levels of payment in hospital settings. 22nd employee and retiree expenses that occur within the scope of (emergency) diagnosis of common diseases medical expenses reimbursement rate determined according to the hospital.

    Residents in the hospitals (including community health service center) door (emergency) diagnostic medical reimbursement rate determined according to the payment level.

Article 23rd insured persons suffering from within disease due to high age and mobility, you can apply for in home care treatment, hospital medical expenses medical expenses reimbursement policy.

    Provided they out-the insured persons suffering from specific diseases and basic medical insurance treatment standards are beyond the door (emergency) diagnosis of common diseases standards. Article 24th of insured persons with a class infectious diseases medical expenses paid by the basic medical insurance fund.

    Giving proper care to other patients with infectious diseases. 25th of municipal people's Government in accordance with economic and social development levels and affordability of the basic medical insurance fund, on the level of basic medical insurance benefits adjusted accordingly.

    Municipal human resources and social security, administrative, financial and other relevant departments to develop, in conjunction with adjustment programmes, submitted to the municipal people's Government for approval before implementation.

    The fourth chapter is imposed by the basic medical insurance premiums and settlements Article 26th is imposed by the basic medical insurance premiums to implement the city's unification.

    Health insurance agencies are responsible for basic medical insurance premiums levied on specific tasks.

Classification register article 27th residents participating in the basic medical insurance, in accordance with the following provisions, respectively, register with the health insurance agencies:

(A) the level and type of school, kindergarten students, children, school, kindergarten is responsible to conduct medical insurance agency insurance registration;

(B) personnel, special hardship case families enjoy the low treatment staff and allowances by the Home Department identified and referred the personnel detailed medical insurance institutions, registered by the health insurance agencies to handle the insurance;

(C) severely disabled persons confirmed by the disabled persons ' Federation, identity, and referred the personnel detailed medical insurance institutions, registered by the health insurance agencies to handle the insurance;

(D) the retired spouses and widows by the veteran administration identified and referred the personnel detailed medical insurance institutions, registered by the health insurance agencies to handle the insurance;
(E) rural residential village units, respectively, in families of other residents to town, street labor and social security services to handle the insurance register.

    Article 28th of administering entry students, children of basic medical insurance premiums paid by the school, kindergarten to collect payment.

    By the villagers ' Committee of rural residents collect payment.

    Article 29th medical insurance agency in accordance with the advance, the total payment, project billing, head paying or negotiating pay, on time and in full to the designated medical institutions, drugstores or insured persons meet the requirements of the basic medical insurance to pay medical costs. Article 30th insurance medical treatment, buying drugs through health insurance information payment system settlement expenses only to a designated medical institution or drugstores paid individuals should be part of the burden, other costs are covered by medical insurance agencies with designated medical institutions, drugstores monthly.

    National and special provisions for the first advance in this city, from its provisions.

    The fifth chapter of basic medical insurance service management

31st medical insurance agencies shall establish a sound business, financial, security, and risk management systems.

Medical insurance agency business to operate, the survey collected data, relevant units and individuals shall faithfully and promptly provided.

    Street, town, labor and social security services and their communities, labor and social security bodies responsible for the Organization of work of the village residents join resource investigations, approved for registration and pay the medical expenses of insured work such as collecting.

    Article 32nd medical insurance agency under the management services needs, signed a service agreement with designated medical institutions, drugstores, to standardize medical service behavior.

    Article 33rd designated medical institutions, drugstores should clarify health insurance agencies to determine the basic medical insurance (and) staff, this unit is responsible for the basic medical insurance management and services. Article 34th designated medical institutions should be given priority in the provision of basic medical insurance drug list, clinic project directory, list of medical services within the medical services to insured persons.

    Provided to insured patients at their own expense of medicines, medical supplies, medical items, shall first seek consent of the insured patients agree, and medical cost breakdown should be provided.

    35th drugstores should establish management systems in conformity with basic health insurance; ensure the quality and variety of basic medical insurance treatment, provision of rational medicine consultation service for insurance.

Article 36th municipal human resources and social security administrative departments together with the municipal health and food and drug supervision departments establish and improve basic health care services, such as doctors, pharmacists directory management system for service physicians and apothecaries to supervise and check the implementation of basic medical insurance policy.

    Basic medical insurance service directory of physicians and apothecaries to specific measures for the administration of the municipal human resources and social security administrative departments, sectors such as health, food and Drug Administration separately.

    37th medical insurance agencies with designated medical institutions, drugstores for performance, change the service agreement dispute, can apply to the medical insurance billing disputes mediation mediation process, or you can initiate litigation to the people's Court.

Article 38th municipal human resources and social security administrative departments improve the basic medical insurance system, realize the insurance network registration fees, treatment network payments, real-time network monitoring and other functions.

Health insurance agencies use information system of basic medical insurance to pay insurance benefits, shall ensure and designated medical institutions, drugstores around the clock, no holidays Internet settlement.

Designated medical institutions shall establish and improve the information management system of the unit to achieve (urgent) diagnosis, hospitalization and medical insurance agency networking, settlement and information sharing in real time.

    Drugstores should establish and improve the information management system for the unit to realize real-time settlement medical insurance agency networking and information sharing.

39th insured persons shall take my social security card medical drugs.

    Insured persons under special circumstances not to designated medical institutions or drugstores to buy medicine, commissioned on behalf of the insured person's social security card holders to purchase, the trustee shall show proof of identity. 40th personnel can choose the range of insured fixed-point medical institutions of medical treatment, drugs or prescriptions to drugstores to buy medicine.

    Medical institutions shall provide options to drugstores to buy outsources prescription drug coverage provided.

    41st of municipal human resources and social security administration authorities and the relevant administrative departments to establish a basic medical insurance system.

    Sixth chapter the basic medical insurance fund

42nd basic medical insurance fund, administered by the following funds:

(A) the employer and the basic medical insurance premiums paid by insured persons;

(B) Government subsidies;

(C) the social contributions;

(D) late fees;

(V) interest;

    (Vi) other funds.

    Article 43rd year to raise part of the basic medical insurance fund, according to the Bank's demand deposits carry interest at a rate; the previous year's carry-over funds and repay in a 3 month lump-sum bank deposits carry interest at a rate; deposit financial account deposit of social security funds, compared with 3-year installment savings deposit interest rate interest.

44th implement the city's overall plan of basic medical insurance, basic medical insurance fund into the financial accounts management, deposited in banks responsible for medical insurance business.

    Basic medical insurance including workers ' basic medical insurance funds and the basic medical insurance fund, respectively, establish accounts, income accounts, implementation of the national unified accounting system.

    45th medical insurance fund budget and final accounts of the municipal medical insurance agency is responsible for preparing the draft, reviewed by the municipal human resources and social security administrative departments, municipal finance department review, submitted to the municipal people's Government for approval before implementation.

Article 46th district people's Government and the designated medical institutions, drugstores charge units shall strengthen the designated medical institutions, drugstores pharmaceutical cost management oversight to ensure legitimate medical needs, maintaining safe operation of the basic medical insurance fund.

    Designated medical institutions, drugstores should enhance their physicians, pharmacists and staff management, standardized diagnosis and treatment behavior, providing reasonable and necessary medical services for insured patients.

    47th human resources and social security administrative departments should strengthen the health insurance agencies and monitor the income and expenditure of basic medical insurance fund, establish and improve the basic medical insurance fund's budget system, accounting and internal audit systems; financial sector is responsible for the financial account of the basic medical insurance fund management; audit supervision through auditing in accordance with the basic medical insurance fund.

    The seventh chapter legal liability

48th human resources and social security administrative departments should strengthen the compliance with basic health insurance laws, regulations, and regulatory oversight.

Municipal human resources and social security administrative departments may delegate specific implementation of basic medical insurance medical insurance supervision and inspection agencies administrative law enforcement supervision and inspection work.

    Human resources and social security, health, food and Drug Administration to establish a violation of basic medical insurance found, investigation, finds that communication and coordination and information-sharing mechanisms.

49th article Sentinel medical institutions has following behavior one of, cheat basic medical insurance fund spending of, by human resources and social security administrative sector ordered returned cheat of medical insurance, at cheat amount twice times above 5 times times following of fine; by medical insurance handling institutions lifted service agreement; directly is responsible for of competent personnel and other directly responsibility personnel has practice industry qualification of, by health, and food drug regulatory sector law revoked its practice industry qualification: (a) forged, and variable made parameter insurance personnel visits records of;

(B) not eligible for hospital insurance payroll hospitalization or intentionally extended period of hospitalization, to handle false and fake hospital inpatients;

(C) it would be inconsistent with the outpatient registration of specific disease conditions of the insured person, by fake or altered identification by means of registration for the clinic and treatment of particular diseases;

(D) forging, altering, falsely, the sale, transfer or not complying with the time limit save basic medical insurance-specific instruments;

(V) lend basic medical insurance cost credit card machines, rental clinic departments to implement treatment activities, or apply for the record on behalf of the physicians and pharmacists reporting medical costs;

(F) the fraudulent use of social security card, the convergence to save others in obtaining basic medical insurance funds;

(G) the fees, charges for decomposition.

Human resources and social security administrative departments of medical institutions to implement the provisions of the preceding paragraph, shall inform the health Administrative Department at the same level.

    Medical insurance agency services agreements with designated medical institutions, shall inform the health Administrative Department at the same level, and will terminate the service agreement of contracted medical institutions to the public in a timely manner.

50th article Sentinel pharmacy has following behavior one of, cheat basic medical insurance fund spending of, by human resources and social security administrative sector ordered returned cheat of medical insurance, at cheat amount twice times above 5 times times following of fine; by medical insurance handling institutions lifted service agreement; directly is responsible for of competent personnel and other directly responsibility personnel has practice industry qualification of, by food drug regulatory sector law revoked its practice industry qualification:

(A) do not purchase prescription clear varieties, specifications, forms, dose of selling drugs, or fabricating, altering purchased prescription;

(B) the basic medical insurance for non-pharmaceutical drugs sold or other items replaced by basic medical insurance, or forged or altered bills and drug cost breakdown insurance-related materials;

(C) fraudulent use of social security card, the convergence to save others in obtaining basic medical insurance funds;

(D) forging, altering, falsely, the sale, transfer or not complying with the time limit save basic medical insurance-specific instruments;

(V) does not match the actual amount and instruments, the declared amount of the drug;

    (F) used for the record on behalf of the pharmacists reporting medical costs or non-drugstores drugstores hire or contract.

51st article Sentinel medical institutions, and Sentinel pharmacy of practice industry physician, and pharmacists has following behavior one of of, by city human resources and social security administrative sector give warning, ordered corrected; plot serious of, by city human resources and social security administrative sector with city health, and food drug regulatory, sector will its from basic medical insurance service physician, and pharmacists directory in the delete, on violation this article provides of physician, and pharmacists and directly is responsible for of competent personnel give informed criticism:
(A) counterfeit or falsified medical documents or medical certificates, or prescription of fake, hoax related material of basic medical insurance;

(B) the basic medical insurance for non-drug or other tampering with drugs for basic medical insurance, or basic medical insurance for non-medical items and services standard tamper for basic medical insurance payment program;

(C) the insured persons treated for prescription of drugs or purchase vouchers, collusion with the insured person does not get the medicine, exchange of cash or marketable securities;

(D) not condition require the use of expensive drugs and large checks and other measures;

    (E) intentionally break down prescription, excessive prescribing, repeat prescriptions.

52nd insured any of the following acts, of obtaining basic medical insurance fund, by human resources and social security Administrative Department in charge shall command returned to defraud Medicare, and fined not more than the amount defrauded more than twice times 5 times:

(A) use another person's social security card to see a doctor to buy drugs, or will my social security card to others to use;

(B) will my social security card to the designated medical institutions or drugstores used; (c) forged or altered claims bills, prescriptions and so on;

    (D) the reselling of basic medical insurance and drug. 52nd 53rd insured persons to the provisions under article, by the municipal human resources and social security administrative departments to adjust medical costs way more than 1 month 1 year or less.

    In the revision of medical fees during settlement, continues to enjoy basic medical care insurance benefits, medical expenses in accordance with the advance reimbursement in full.

    54th article human resource and social security administrations, health insurance agencies and their personnel who abuse their powers, neglect their duties or engages, directly responsible in charge and other direct liable persons shall be given disciplinary actions or personal loss to the employer shall be liable.

    The eighth chapter by-laws

    55th article of the city to take measures for the realization of basic medical insurance for insured persons transferred across the area. 56th establishing workers ' high medical cost assistance system.

    Employees and retirees should be in accordance with the provisions of the standard pay salvage and enjoy the treatment.

    57th to establish additional accidental injury insurance system of basic medical insurance, insured persons medical, disability and death due to accidental injury, attached by a basic medical insurance for accidental injury insurance fund according to the prescribed standards cover the treatment. 58th article this provisions come into force on March 5, 2012.