Interim Measures For The Basic Medical Insurance For Urban Residents In Jinan City

Original Language Title: 济南市城镇居民基本医疗保险暂行办法

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(June 27, 2008 in Jinan people's Government promulgated as of August 1, 2008, No. 232) Chapter I General provisions article I to protect the urban resident basic medical care, according to the relevant regulations of the State and province, combined with the city's actual, these measures are formulated.
    The second basic medical insurance system for urban residents adhere to the following principles: (a) the voluntary insurance, Government subsidies, (ii) health care benefits commensurate with the funding levels and (iii) provide inpatient and outpatient medical needs, taking into account the clinic; (d) and basic medical insurance for urban employees, the new rural cooperative medical system link. Article implement territorial management of basic medical insurance for urban residents. Has this city administrative town residents household (still retained contracting to or Homestead of except) of following personnel (following referred to parameter assured), are can participate in town residents basic medical insurance: (a) elementary and middle schools stage of in school students (including vocational high school, and secondary, and mechanic College and special education school students, with), and children and the other 18 age following of town residents; (ii) male years full 60 age, and
    Women 55 years of age and do not belong to the coverage of basic medical insurance for urban workers and elderly residents (hereinafter referred to as older residents), and (iii) 18 years of age, men under 60 years of age and women under 55 years of age, and no occupation, no income and other non-working urban residents do not participate in social security (hereinafter referred to as non-resident practitioners).
    Persons in different places of residence after moving into our city, not part of the coverage of these measures.
    Legal working age of individual industrial and commercial household employers and their workers, flexible employment, shall participate in basic medical insurance system for urban employees, not part of the coverage of these measures. Fourth article of the basic medical insurance for urban residents, the implementation of an integrated policy.
    Lixia flyover district of huaiyin district and Shizhong district, and, and, and licheng and Changqing district (hereinafter referred to as the city's area 6) implement the city-level overall plan. Counties (cities) people's Governments shall, in accordance with this regulation, combined with practical, on the funds of basic medical insurance for urban residents to raise standards, enjoy the treatment standards and management models developed and implemented and reported to the municipality for approval.
    When conditions are ripe and timely incorporated into municipal planning. Fifth of municipal labor and social security administrative departments are the Department of basic medical insurance for urban residents in the city, responsible for organization and implementation of basic medical insurance for urban residents, and supervision and management.
    Regional Labor and social security administrative departments are responsible for the supervision of the medical insurance management and urban residents in the area of insurance organizations, and so on.
    Financial departments are responsible for the basic medical insurance for urban residents that the Government grant funds mobilization, allocation and supervision of fund management.
    Appointed medical institutions of health departments are responsible for helping to strengthen oversight in the implementation of policies for basic medical insurance for urban residents.
    Department of education is responsible for the care of children, school students participating in the Organization of work.
    Development and reform, public security, civil affairs, auditing and statistics, food and drug administration, price, disabled persons ' Federation and other departments, in accordance with their respective responsibilities, in collaboration with the basic medical insurance for urban residents.
    Sixth municipal medical insurance agency responsible for urban resident basic medical insurance fund management, allocation and operational guidance to the health insurance agencies.
    Medical insurance agency is responsible for the basic medical insurance for urban residents in the areas under their jurisdiction is imposed by management, insurance, medical insurance card payment records and cash reimbursement approval for the treatment of paid work.
    Street (town) labor and social security institution specific insured residents registration, information-gathering and policy advocacy work.
    Chapter fund raising section seventh urban resident basic medical insurance fund (hereinafter health insurance fund) include: (a) the urban residents ' basic medical insurance premiums paid by the insured person, (ii) at all levels of government subsidies; (c) the Fund's interest income and (iv) social contribution; (e) funds raised through other channels. Eighth District 6 of the city basic medical insurance for urban residents (hereinafter referred to as medical insurance) raised according to following criteria: (a) school students, children and other residents under 18 years of age in accordance with the standard raise of 100 yuan per person per year. Among them, individuals pay 40 Yuan, the Government subsidizes 60 Yuan (ii) elderly residents in accordance with the standard raise of 500 yuan per person per year. Among them, the individuals to pay 200 Yuan, Government subsidies of 300 yuan, and (iii) other non-working residents in accordance with the standard raise of 500 yuan per person per year.
    Among them, to pay 400 Yuan, the Government subsidizes 100 Yuan (iv) severe disability and enjoyed by the financial difficulties in the urban minimum living standard security personnel in accordance with the raised standard full subvention. The County (City) of basic medical insurance for urban residents, according to a minor not less than 80 yuan per person per year for urban residents and other non-working residents and elderly residents of standard raise of no less than 300 yuan per person per year.
    Government for young urban residents and elderly residents and other non-working residents per person per year not less than 40 Yuan and 160 Yuan, 60 standard grant; severe disabilities and difficulties in enjoying the urban minimum living standard security personnel according to raise standards for fully subsidized by the Government. Government grant money, apart from the provincial financial aid section above, and municipal finance in a certain proportion of County (municipality), district subsidies. Among them, the local District 6 (high) 50%, subventions shanghe 20%, subventions, jiyang grant 10%, pingyin, zhangqiu city by the full financial burden.
    Government subsidies included in the budgets on an annual basis, directly into the health insurance fund by the financial sector financial account.
    Nineth residents ' medical insurance premium for establishing medical insurance fund, does not establish individual accounts. Tenth residents ' health insurance fund revenue and expenditure line, into the financial account management, separate accounts, earmarking.
    No unit or individual is allowed to occupy, use.
    11th insured articles annually during the payment period after the one-time paid medical insurance premiums, may enjoy medical insurance medical treatment did not pay in full and on time during the payment period, do not enjoy the health care medical insurance benefits for the year. 12th from October 1 to December 31 every year to pay for medical insurance premiums, payment on January 1 of next year to enjoy medical insurance benefits.
    The insured died during the pay period after the payment, may apply to the district health insurance agencies returned that year to pay.
    Residents can pay a one-off annual after registration of newborn health insurance payment the month to enjoy medical insurance benefits.
    From January 1 to December 31 of each year for a medical.
    13th insured nursery school children, student medical insurance premium payments, the nurseries, schools are responsible for processing.
    After kindergarten, primary and secondary schools shall, on the implementation of this approach, since the beginning of the first pay period for insured nursery children and students for the insured procedures.
    Article 14th participation in urban workers ' basic medical insurance and new rural cooperative medical system, not at the same time to have medical insurance.
    Participate in the medical insurance, employment after participating in basic medical insurance for urban employees, upon retirement, not up to the minimum period of contributions of basic medical insurance for urban workers, individuals whose medical insurance contributions accumulated allowance for urban workers ' basic medical insurance premiums to pay for.
    15th insured employment to participate in the basic medical insurance for urban workers, enjoy the urban workers ' basic medical insurance treatment date, end enjoying medical insurance benefits.
    Insured persons in a health care during the year to participate in urban workers ' basic medical insurance and unemployment may continue to enjoy the benefits of medical residents, the health insurance.
    16th in line with conditions of insured not insured or after the payment of insured, shall, within the prescribed payment period will be over or under interrupt capture individuals should bear part after the completion, can enjoy the next medical medical insurance benefits.
    Chapter III treatment 17th residents ' medical insurance medical insurance fund to cover the insured person provides outpatient, inpatient and outpatient regulations diseases (treatment of cancer and leukemia, renal failure, dialysis treatment, the anti-rejection treatment for organ transplants) a certain proportion of medical costs.
    Administrative departments of labor security in conjunction with the Municipal Finance Department, according to the health insurance fund balance, adjusting the clinic provides list of diseases and to the public. 18th insured in a year of medical, hospital or clinic provides medical expenses for the treatment of diseases, standards borne by the individual.
    Inpatient and outpatient disease criteria laid down respectively. Hospital payment standards, in accordance with the level of medical institutions (including community health service institutions) 200 Yuan, and secondary medical institutions 400 700 standard, three-level medical institutions.
    In a health care during the year, the second hospital standards lower than the last 20%, standard of pay from the hospital and is no longer performed for the third time.
    Clinic provides patients pay standards, annual reference in a medical insurer is only executed once, standard of 200 Yuan.
    Article 19th of an insured person during the year under a medical inpatient and outpatient disease treatment provided meet the prescribed range of paid medical insurance funds for medical expenses (individuals according to a certain proportion of the burden-bearing part) the highest payment ceiling system, standard for 60,000 yuan.
    20th article parameter assured in a medical annual within hospital or outpatient provides disease species treatment occurred of meet residents medical insurance fund paid range provides of medical costs, by residents medical insurance fund and personal according to medical institutions grade according to following standard share: (a) in level medical institutions (containing community health service institutions) medical of, by residents medical insurance fund paid 70%, personal burden 30%; (ii) in two level medical institutions medical of, by residents medical insurance fund paid 60%, personal burden 40%;
    (C) in a three-level medical care by the medical institution, paid for by the health insurance fund 50%, born 50%. Continuous payment of insured, medical insurance payments from the second medical annually mutatis mutandis to the preceding paragraph, beginning of the year 1%, not exceeding in the aggregate 5%.

    A medical article 21st year, insured persons in designated community health service institutions meet the prescribed range of paid medical insurance funds for out-patient medical expenses, the cumulative portion of less than 200 Yuan, paid for by medical insurance fund in accordance with 20% standards.
    22nd school students, children and other insured persons under 18 years of age for outpatient medical expenses resulting from accidental injury, residents within the health insurance fund to pay more than more than 200 parts, paid for by the health insurance fund 80%, a health care annual maximum limit for 2000 (containing individuals according to a certain proportion of the burden).
    Article 23rd died in critically ill patients in the clinic, which meet the prescribed scope of medical insurance fund to pay for emergency costs paid for by medical insurance fund in accordance with the relevant provisions of the hospital, not executive pay standards.
    Insured's condition requires, in the same designated medical institutions by the emergency transfer to hospital after treatment, emergency medical expenses, incorporated into the hospital cost clearing.
    24th the insured require referral to the field (limited to Beijing, Shanghai and Tianjin) hospital treatment from the municipal-level medical institutions or upon expert advice from city-level hospitals, reported to the district health insurance agency records.
    Record transferred to the field hospital, medical expense with a corresponding increase in the proportion of burden 10% without filing their own referral medical costs, medical insurance fund not be paid.
    25th insured to the medical insurance for urban residents that b list of drugs included medicines, pay part of the cost of treatment programs and health services project of health care costs, paid by the insured in accordance with the provisions, as stipulated in the article 20th respectively by the medical insurance funds and personal burden.
    Article 26th insured by the army, entering (attending college), household moving out of the city, its medical insurance benefits terminated.
    27th article parameter assured following situation occurred of medical costs, residents medical insurance fund not paid: (a) for violation about legal provides due to hurt of; (ii) suicide self-mutilation (psychiatric except) or drunk led to casualties of; (three) birth and the related surgery; (four) plastic, and beauty, and correction, treatment; (five) rehabilitation sex treatment of; (six) has third party responsibility compensation of; (seven) other not meet residents medical insurance provides paid range of.
    The fourth chapter management and supervision article 28th scope of drugs, diagnosis and treatment of medical insurance project range of facilities and services in the light of the provisions of basic medical insurance for urban workers.
    Directory of children's need to increase the scope and standards of payment in accordance with the relevant provisions of the State, province. 29th medical insurance funds, settlement management, "to the charge, balance of payments, guarantees basic medical" principle, take total control, flat rate payment and quality combined with the settlement.
    Specific management measures for the municipal labor and social security administration departments, financial departments. 30th medical insurance institutions shall be insured in full for the first time after paying medical insurance premiums for medical insurance card.
    Insured person shall hold a medical insurance card, valid documents to designated medical institutions for treatment.
    The scope of designated medical institutions and management, reference to the relevant regulations of the basic medical insurance for urban workers. Emergency rescue in critically ill patients, hospitalized nearby in a non-contracted medical institutions. But from the date of hospitalization within 3rd shall report to the health insurance agencies.
    After illness allowed, shall be transferred to the designated medical institutions for treatment; without due cause fails to report or verify is not of critical patients, medical insurance fund not be paid.
    31st insured apply to enjoy clinic provides treatment of diseases, after confirmation by the health insurance agencies, issuance of clinic provides medical documents.
    Article 32nd of an insured person shall not be forged, altered prescriptions, Bill, obtaining medical treatment, may not be medical documents lent to others. Article 33rd designated medical institutions should carefully examine the insured medical documents, and strict implementation of basic medical insurance drug list, diagnosis and treatment projects, medical service charges approved by the standards and prices.
    Shall not be counterfeit or change accounts, information, prescriptions, medical bill and other improper means, obtaining medical insurance fund must not violate the relevant provisions of designated medical institutions management.
    Article 34th price departments shall be announced to the public in a timely manner medical insurance and drug prices, medical items, medical services standards, designated medical institutions should be strictly enforced.
    Article 35th of labour and social security administrative departments and medical insurance agencies should strengthen supervision and inspection of designated medical institutions, inspected organizations and personnel shall actively cooperate with and provide medical records, medical records and related data, and so on.
    Administrative departments of labor security medical insurance supervision and telephone hotlines and complaint box to report workers who rewarded. 36th medical insurance fund implementation of the unified Social Security Fund budget system, accounting and internal audit systems.
    Medical insurance funds by the financial sector from the budget resolved, shall not be withdrawn from the Fund.
    37th medical insurance agency shall establish an internal management system, strengthen the management of medical insurance fund, and accept, financial, audit and other administrative departments of labor security supervision and inspection.
    Fifth chapter legal responsibility 38th article parameter assured violation this approach 32nd article provides or cheat qualification enjoy treatment of, by city, and County (City) labor guarantees administrative sector ordered its returned cheat of residents medical insurance fund, and at cheat amount 1 time times above 3 times times following of fine; plot serious of, ordered medical insurance handling institutions stop its enjoy this medical annual of residents medical insurance treatment. 39th designated medical institutions and their staff members in violation of the provisions of article 33rd, city and County (City) recovery of medical expenses to be paid by labor and social security administration departments, and more than 5000 Yuan for designated medical institutions fined a maximum of 30000 Yuan.
    The plot of, ordering medical insurance agency to suspend its settlement the circumstances are especially serious, cancel the targeted qualifications.
    40th article violates this approach set forth in 32nd, 33rd, activities contravening public security management, shall be legally punished by public security organs constitutes a crime, criminal responsibility shall be investigated according to law.
    41st article medical insurance handling institutions, and street (town) labor guarantees work institutions and staff has following behavior one of of, by labor guarantees administrative sector ordered deadline corrected; refused to corrected of, on main head and directly responsibility people give administrative sanctions; constitute crime of, law held criminal: (a) not by provides levy residents medical premium of; (ii) not by provides for parameter assured handle parameter insurance information registration, and change or information confirmed of; (three) interception, and misappropriated basic medical premium of;
    (Iv) negligence resulting in loss of medical insurance fund (v) using bribes, personal gain, and (vi) unjustified delay payment or underpayment, refuse to pay medical expenses.
    Sixth chapter supplementary articles article 42nd city under medical insurance fund revenue and expenditure and the level of medical services, timely adjustment of city residents, the health insurance fund to raise standards, payment standards, standards of treatment and maximum payment limit, and to the public.
    43rd does not have a permanent residence in this city of nursery school children and college students can refer to the relevant provisions of this approach to have medical insurance.
    Full-time students from universities in health-care costs, in accordance with the current regulations.
    44th due to major epidemics, disasters and emergencies, such as the Group of hospital medical expenses for urban residents, arranged by all levels of government funding.
    45th of municipal administrative departments of labor security in accordance with the implementing rules for the regulations in conjunction with the departments concerned.
                                                                                                                  46th these measures shall come into force on August 1, 2008.

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