(Adopted at the 96th ordinary meeting of the Shanghai People's Government, held on 24 January 2011, by Decree No. 60 of 30 January 2011, by the Government of the Shanghai City, on 1 May 2011)

Article 1

In order to guarantee basic medical needs for insured persons, the regulation and strengthening of the basic health insurance supervision management activities, the maintenance of the health insurance fund security, and the development of this approach in accordance with the prevailing circumstances in the city.

Article 2

This approach applies to activities to monitor the management of the basic health insurance provisions in the city (hereinafter referred to as a medical institution), the retail pharmacies for basic health insurance (hereinafter referred to as a pharmacies), personal compliance with the provisions of the basic health insurance in the city.

The basic health insurance described in this approach includes basic health insurance for urban workers, basic health insurance for urban residents and other basic health insurance.

Article 3

The National Human Resources Security Agency is the primary health insurance administration in this city responsible for the management of basic health insurance in the city. The Human Resources Security Bureau of the District (Parliament) is responsible for monitoring the inspection of basic health insurance within the Territory.

The municipal health insurance monitoring inspection is commissioned by the National Human Resources Agency for the specific implementation of administrative enforcement, such as the basic health insurance supervision inspection, and the strengthening of oversight inspection forces, in accordance with regulatory requirements.

Sectors such as development reform, health, food medicine surveillance, business administration, finance, audit, public safety and prices should be aligned with the management of basic health insurance oversight within their respective responsibilities.

Article IV

The National Human Resources Security Agency should establish and improve the system for the management of the medical establishment of the customized medical institutions, as well as the basic health insurance cost-recovery system, and provide real-time regulation of the basic medical insurance costs incurred by the targeted medical institutions and their practitioners in the delivery of medical services, and regulate the medical services of the medical medical practitioners.

The targeted medical institutions and the targeted retail pharmacies should be equipped with the necessary online equipment, in accordance with the requirements of the market's basic health insurance network, to comply with the relevant provisions of the basic health insurance information technology norms and information safety, and to communicate, in a timely and accurate manner, information on the settlement of basic health insurance costs.

Article 5 (In-house management)

The targeted medical institutions and the targeted retail pharmacies should establish a sound basic health insurance management system with the necessary management to inspect compliance with the provisions of the basic health insurance in the city.

Article 6

The targeted medical institutions should implement the relevant provisions of the budget management for the payment of basic health insurance payments in the city, the management of the total prepayments, the basic medical needs of the insured person and regulate the use of health insurance funds.

Article 7

The merger or institutional nature of the targeted medical institutions, the address of the operation, the change in the number of authorized beds, the operation of the targeted retail pharmacies or changes in the scope of the operation should be reorganized to the HOH in accordance with the relevant provisions of this city.

Article 8

The targeted medical institutions should have a reasonable choice of therapeutic projects, in accordance with the provisions of the basic health insurance-related medical treatment projects, medical facilities and prescription management, drug use.

The provision of medical services by targeted medical institutions for insured persons should be subject to the basic health insurance-related medical treatment projects, medical care facilities, the scope of medicines, the payment of standards and the fees set by the value-of-charge sector, and the medical cost-of-living of the insured person.

Article 9

The pharmacies of the pharmacies are not subject to the basic medical insurance coverage, varieties and quantities of non-subsistent medicines provided by the insured person when they are supplied with the services acquired by the insured person.

The targeted retail pharmacies offer medical services for the insured person and should comply with the relevant provisions of price management to provide the insured person with the relevant cost-recovery documents.

Article 10

In the case of a medical institution, a basic medical certificate should be presented on the basis of a pre-supence, inspection, pharmacization, hospitalization, settlement of medical costs or the distribution of medicines at the targeted retail shop.

The insured person shall not transfer the basic health insurance certificate to another person.

The basic health insurance certificate of the insured person should be obtained by the targeted medical institutions and the fixed-point retail pharmacies when they provide medical services to the insured person or provide the medical services.

Article 11

The Human Resources Security Bureau of the District (Parliament), the Urban Health Insurance Monitoring Inspection Unit should enhance the supervision of targeted medical institutions and targeted retail pharmacies.

The basic health insurance coverage costs of targeted medical institutions depart from budgetary indicators or the higher rate of payments, and the Human Resources Management Service of the District (Parea) and the Urban Health Insurance Monitoring Unit should conduct monitoring inspections in a timely manner.

Article 12

The municipal health insurance surveillance inspector should provide a real-time monitoring of the monthly emergency medical treatment of the insured person and the basic health insurance costs incurred. An emergency medical treatment of the insured person is beyond the scope of the provision for the number of medical care and the basic health insurance costs incurred, which can be temporarily altered in the form of the mailing of its emergency medical insurance costs.

In the context of temporary changes in the settlement of the pay for the basic medical insurance expenses, the IMS should inform the insured person and review the medical situation in a timely manner. The review did not identify violations of the basic health insurance provisions and should be carried out on the day when the inspection was completed, and the manner in which the primary medical insurance cost was recovered.

Article 13

The Human Resources Security Bureau of the District (Parliament), the City Medical Insurance Monitoring Inspection Unit, which conducts daily and specialized supervision inspections, should be informed in writing of the specific content and time of the inspection.

The supervisory inspector shall not be less than two persons in the event of a monitoring inspection conducted by the Human Resources Security Bureau of the District (Parliament) and the municipal health insurance supervision inspectorate and shall make an initiative to produce administrative law enforcement documents.

Article 14.

The following measures may be taken in the context of the monitoring inspection activities carried out by the Human Resources Security Bureau of the District (Parliament) and the municipal health insurance supervision inspection.

(i) To collect relevant information and material in an interview, audio, video, photography or reproduction, and to register in the event that the evidence may be lost or transferred;

(ii) To request targeted medical institutions, targeted retail pharmacies or individuals to provide documentation related to monitoring inspections and to explain and clarify them.

The targeted medical institutions, the fixed-point retail store, the participant or other individuals should provide documentation, data and other material related to the supervision of inspection, as required by the Human Resources Security Bureau of the District (Parea), the Urban Health Insurance Monitoring Unit.

Article 15

In monitoring inspection activities carried out by the Human Resources Security Bureau of the District (Parliament), the Urban Health Insurance Monitoring Inspection Unit, brokering agencies and relevant experts may be delegated to audit or verify the use of the health insurance fund for targeted medical institutions, targeted retail stores, and to verify and advise on basic health insurance matters.

Article 16

There are one of the following acts in targeted medical institutions, customary retail stores, and the National Human Resources Security Service should be responsible for revamping, recovering the related basic health insurance costs paid by the Medical Insurance Fund and fines of up to 100,000 dollars; in exceptional circumstances, it may suspend its basic health insurance settlement relationship between 1 and 6 months or remove its basic medical qualifications:

(i) No basic medical insurance costs have been settled for individuals who use basic medical certificates or receive medicines in violation of basic medical insurance certificates, in accordance with the provision of the basic medical insurance certificate;

(ii) The use of repetitive walls for insured persons, repeated or no reference to recruitment, inspection, treatment, separation or non-recruitization of inpatient medical services, or the provision of unnecessary medical services, and the payment of basic medical insurance costs;

(iii) In violation of the relevant provisions of the basic health insurance system, the coverage of the health insurance fund or the medical costs incurred by medical care projects other than the scope of the agreed service, and medical services facilities, shall be settled at the cost of basic health insurance;

(iv) In violation of the scope of essential health insurance or the use of drug-specific provisions to address the cost of basic health insurance by means of ultra-use medicines, repetition of medicines, non-compliance with special restrictions, or by distributing, changing prescriptions, etc.;

(v) The operation of the basic health insurance costs through the repayment, distributing, over-standard collection or self-determined standards;

(vi) No basic medical insurance costs have been incurred in accordance with the proportion of payments under basic health insurance;

(vii) Inadequate access to basic health insurance costs, in accordance with Article 7 of this scheme, for the purpose of re-establishing the accreditation procedures for basic medical insurance.

Article 17

There are one of the following acts in targeted medical institutions, customary retail stores, and the National Human Resources Security Service should be responsible for revamping, recovering the related medical costs paid by the Medical Insurance Fund and fines of up to 3,000 yen; and in the event of a serious nature, it should also suspend its basic health insurance relationship between 1 and 6 months or remove its basic medical qualifications:

(i) To carry out a network of non-scheduled medical institutions or retail pharmacies for basic health insurance costs;

(ii) Conduct basic health insurance costs in the form of a false or altered record of the history of illnesses, prescriptions, accounts, medical bills, top-down data;

(iii) The use of non-pharmacies such as living supplies, health-care feeding products as medicines within the scope of basic health insurance medicines and the payment of basic health insurance costs;

(iv) Other forms of damage to the health insurance fund, which are to be covered by basic health insurance costs.

Article 18

In one of the following acts in connection with medical treatment or the purchase of medicines, the POHR shall be responsible for refunding the relevant basic health insurance costs paid by the Medical Insurance Fund and may be fined by a warning or by a fine of up to US$ 1000,000; in the event of a severe fine of up to 1 million yen in 2000; and may also take measures to change the cost of basic health insurance by 1 to 6 months:

(i) Remove the basic medical insurance certificate from himself to another person or perform the basic medical insurance cost settlement through a reimbursable transfer of a medical certificate, a settlement card;

(ii) To carry out the basic health insurance cost settlement by taking advantage of the basic health insurance certificate or by falsification, conversion of basic medical insurance vouchers;

(iii) The operation of basic health insurance costs, including through the repetitiveness of medical treatment or forfeiture, respiration, retrieval, courier, voucher, medical cost orders;

(iv) Removal of medicines subject to basic medical insurance costs;

(v) Other forms of damage to the health insurance fund, which are subject to basic health insurance costs.

Article 19

In accordance with article 16 of this scheme, a fine was imposed on the medical establishment of the targeted retail pharmacies and the amount of the fine was executed in accordance with the following provisions:

(i) A breach of the amount of up to 10,000 dollars and a fine of up to 300,000 dollars;

(ii) A breach of the amount of more than 300,000 dollars, with a fine of up to 500,000 dollars;

(iii) The amount of more than 300,000 dollars for violations is fined by more than 500,000 dollars.

Article 20

The relevant sections of the targeted medical institutions and the fixed-point retail pharmacies or staff members are in grave breach of the basic health insurance provisions, and the HDI may take measures to suspend payment of their basic health insurance costs.

Article 21

The basic health insurance administration and supervisors should perform the management and inspection duties of the basic health insurance, in accordance with the relevant provisions of the State and the city, without abuse of their duties, favouring private fraud, and saving duties. For those responsible for violations, the National Human Resources Security Service should be administratively disposed of in accordance with the law; the related costs should be recovered as a result of the loss of the health insurance fund. This constitutes an offence and is criminalized by law.

Article 2 (As of implementation)

This approach has been implemented effective 1 May 2011.