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

Original Language Title: 哈尔滨市城镇居民基本医疗保险暂行办法

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(September 21, 2007 Harbin city government 13th times Executive Conference considered through November 1, 2007 Harbin City Government makes 176th, announced since announced of day up purposes) first chapter General first article for further perfect medical insurance system, established cover town all residents of medical guarantees system, guarantees town residents of basic medical needs, according to State on carried out town residents basic medical insurance pilot of guide views of related provides, combined I city actual, developed this approach. Second article where in this city urban has town household, and not into town workers basic medical insurance range of following personnel (not containing in school students), are can according to this approach participate in town residents basic medical insurance: (a) 18 age above (containing 18 age) of non-practitioners residents (following referred to adult residents); (ii) not full 18 age town residents, including infant (not containing was born 28 days within of newborn), and school-age Qian children, and elementary and middle schools stage students (including secondary school, and mechanic school, and
    Secondary vocational and technical schools, special school pupils) (hereinafter students).
    Article these measures implemented by the municipal administrative departments of labor security.
    Municipal medical insurance agency in accordance with the regulations, specifically responsible for the undertaking of basic medical insurance for urban residents insurance eligibility, fee collection, medical expenses, medical management, and so on.
    Administrative departments of labor security and health insurance institutions, neighborhood offices, community labor service institutions specifically responsible for the basic medical insurance for urban residents registered, information changes, and policy advisory work.
    City development and reform, public finance, health, home, education, drug supervision, public security and the CDPF sectors, shall, in accordance with their respective functions, basic medical insurance for urban residents. Fourth article town residents basic medical insurance system insisted following principles: (a) low started, reasonable determine funding level and guarantees standard, focus guarantees town non-practitioners residents of big disease medical needs; (ii) parameter insurance town residents right and obligations phase corresponds to, guarantees treatment and funding level phase adapted; (three) medical premium by family, and Government common bear; (four) Fund of using insisted to received set support, and balance, and slightly has balances; (five) implemented territorial management, city level and manpower.
    Basic medical insurance for urban residents of basic policy, standards and management measures such as dovetailed with the basic medical insurance system for urban workers, gradually establish funding levels, payment mechanism linked to the age and level of treatment; (f) to encourage working-age urban residents with the ability to work within, through a variety of jobs, participating in basic medical insurance for urban workers.
    Article fifth Government grant funds of basic medical insurance for urban residents into local budgets.
    Article is mainly used for basic medical insurance fund insured urban residents in hospital and special diseases outpatient spending, not to set up personal accounts, a health insurance card management.
    Seventh point of the basic medical insurance system for urban residents care, referral for medical management. Chapter II fees and subsidies article eighth basic medical insurance for urban residents by the family, the Government shared responsibility: (a) the funding criteria for adult residents of 330 Yuan per person per year.
    Among them, the Government subsidizes 60 Yuan, individuals pay 270 Yuan.
    For basic living allowances and the seriously disabled persons 60 years of age or older and low-income families, 265 government subsidy, individuals pay 65 Yuan. (B) the student funding criteria to 90 yuan per person per year for children.
    Among them, the Government subsidizes 60 Yuan, the family paid 30 yuan.
    Belonging to basic living allowances or students with severe disabilities of children, the Government subsidizes 80 yuan per person per year, households pay 10 Yuan.
    Article new insured urban residents should be held from September 1 to December 20 of each year accounts, the original ID card and its copy, fax a recent 2-inch color photos to area communities as the household labor and social security services for the insured procedures.
    Subsistence allowances target low-income families and people over 60 years of age, shall provide the subsistence allowances for urban residents in Harbin city certificate and proof of low income; severely disabled persons should be provided with the People's Republic of China disabled permit.
    Students from the schools or nurseries insurance, health insurance agencies, to handle registration and payment. Newborns in 28 days after birth by parents holding relevant material to the household registration area community labor and social security services for the insured procedures.
    Enjoy basic medical insurance benefits payment next month.
    Article tenth insured urban residents registered insured, within the prescribed payment period to the banks at once fully paid medical insurance premiums payable for the current period, collected by the Bank.
    Community labor service agencies on claims data audit is correct, the basic information into a computer, and uploaded in real time to the municipal medical insurance agency.
    Making medical insurance agency insurance for urban residents of Harbin city basic medical insurance for urban residents, referred to the community labor service organizations.
    11th system of basic medical insurance for urban residents on annual basis in advance, every year from September 1 to December 20 for basic medical insurance for urban residents to pay next year payment period.
    12th insured urban residents to go abroad for settlement, the army, education (universities), household moving out, death, termination of the insurance relationship itself, the fee will not be returned.
    13th after insurance of urban residents in accordance with the regulations to the urban workers ' basic medical insurance or other forms of health care by the Government, no longer enjoy the benefits of basic medical insurance for urban residents, the fee will not be returned.
    Article 14th municipal medical insurance agency on an annual basis, 1 basic medical insurance for urban residents that the Government program, and report to the municipal finance department. Chapter III basic medical insurance treatment 15th adult residents who are insured and to pay basic medical insurance premiums, the payment on January 1 the following year covered by basic medical insurance treatment.
    Students by school year pay health insurance premiums, and enjoy basic medical insurance benefits as of the payment month.
    16th insured urban residents hospitalized for drugs established by the implementation of national, provincial directories, medical items, and scope of services provided. 17th insured urban residents should be determined by the municipal labor and Social Security Department of the appointed medical institution of basic medical insurance for urban residents (hereafter "designated medical institutions"). Medical expenses incurred in the payment standard, paid by the individual.
    Pay according to the following provisions: (a) the adult residents in the community health service hospital, 200; level medical institutions in hospital, 240; in the second Hospital of medical institutions, 480; third level medical institutions in hospital, to 720 Yuan.
    (B) students in community health service institutions for children in hospital, is 150 Yuan; level medical institutions in hospital, 200; in secondary care institutions hospital, 300; third level medical institutions in hospital, 400 Yuan.
    A natural year in 2nd in-patient, standard 10%, standard of paying 2nd in-patient in hospital several times. 18th disposable hospital refers patients once admitted, the discharge process. Emergency treatment and hospitalization is not continuous, as disposable hospital. 5th diagnosed infectious disease specialist hospital inpatients, approved may be regarded as disposable hospital, do high class standard of paying hospitals.
    Straddling the disposable hospital process, by timing the end of treatment.
    Article 19th insured urban residents hospitalized in contracted medical institutions shall be made to the designated medical institutions to pay a certain amount of advance payment, to cover the cost should be borne by the individual parts of the.
    Article 20th hospitalized psychiatric patients in specialized medical institutions without paying standard, in line with the scope of the solidarity fund to pay medical expenses borne by individual 25%.
    21st insurance of urban residents in the designated medical institution hospital medical expenses over funds paid over standard, high limit section below, according to medical institutions by funds and individuals as ratios of the respective share.
    Adult residents occurred of hospital medical costs by following proportion share: (a) in community health service institutions Hospital of, and manpower Fund paid 65%, personal burden 35%; (ii) in level medical institutions Hospital of, and manpower Fund paid 60%, personal burden 40%; (three) in two level medical institutions Hospital of, and manpower Fund paid 55%, personal burden 45%; (four) in three level medical institutions (not containing this city part provincial referral hospital) Hospital of, and manpower Fund paid 50%, personal burden 50%.
    Student funds and pay children's hospital medical 70%, born 30%. Basic medical insurance for urban residents in some provincial hospitals identified as referral hospitals. Necessary, approved by the municipal medical insurance agency transferred some provincial medical institutions in treatment, the burden of medical costs incurred by individuals increased 5%.
    Referral health care agencies, health insurance agencies, by according to the health insurance fund shall be separately identified. 22nd insured urban residents in a natural pool Fund annual medical expenses maximum payment limit, maximum limit of 35,000 yuan.
    Students according to academic year settlement. 23rd special diseases outpatient treatment of urban residents paid inclusion and manpower Fund range.
    In a natural year in outpatient and inpatient medical fee payment ceiling on funds, funds to adult residents pay no more than 5,000 yuan; for students ' children's funds to pay up to 25,000 yuan. Specific disease refers to chemotherapy of malignant tumor, uremia (peritoneum) dialysis and kidney transplant anti-rejection treatments.
    Students special diseases in children in addition to the disease, but also including haemophilia, aplastic anemia and Systemic Lupus Erythematosus. Special diseases of urban residents carry out medical management of insured.
    Special diseases diseases of funds payment standard shall be separately formulated by the municipal labor and Social Security Department. 24th occurs in accordance with the following conditions pay range of inpatient medical advances made from the individual, after the end of treatment, related materials, health insurance agencies, to reimbursement in accordance with the provisions of:

    (A) parameter insurance town residents in field (not containing outside) visits, and tourism, meet town basic medical insurance provides range of emergency one-time hospital, or meet town basic medical insurance provides range, in this city non-town residents Sentinel medical institutions emergency rescue, in admitted Hou 5 a days within told City medical insurance handling institutions of; (ii) for illness need, by city labor guarantees administrative sector approved turned to offsite medical institutions treatment of; (three) parameter insurance town residents with standing field of, male years full 60 age,
    Women over the age of 55, to the municipal medical insurance agencies for the remote medical procedures, and a selection of designated medical institutions in the local hospital.
    The preceding paragraph of this section (a), (b) the provision of the staff health insurance fund pay standards and personal burden of increased 20%. 25th insured urban residents are not required to pay insurance premiums make up the arrears within 3 months, since to pay arrears for 2 months before they can enjoy medical insurance benefits. More than 3 months, and in the following year insured under insurance formalities within the payment period.
    Interruption took place during the payment of medical expenses health insurance fund shall not be paid.
    26th insured urban residents have one of the following circumstances, medical expenses health insurance fund not be paid: (a) in the treatment of foreign countries or Hong Kong, Macao and Taiwan areas, (ii) fights, alcohol abuse, self-harm, suicide, drug abuse and criminal injury disease; (c) caused by traffic accidents, accidental injury, medical malpractice and other injury.
    27th insured urban residents are not allowed to any of the following acts: (a) forged documents such as vouchers, altered prescriptions, costs, (ii) to provide medical documents, an impostor doctor.
    Fourth chapter fund management article 28th of basic medical insurance for urban residents from: (a) insurance of urban residents to pay basic medical insurance and Government medical subsidies for urban residents; (b) interest on funds of basic medical insurance and value added income.
    Article 29th urban resident basic medical insurance funds into the accounts of the social security fund management, separate account, earmarks, no unit or individual is allowed to occupy, use.
    The fifth chapter of medical service supervision and management, health insurance agencies, 30th signed an agreement with designated medical institutions for urban residents, specify the responsibilities, rights and obligations of both parties.
    31st designated medical institutions for urban residents shall because of illness and treatment, reasonable examination, rational drug use and in accordance with the regulations and the hospital insured urban residents hospital signed an agreement, timely list one day and cost details.
    32nd of municipal labor and social security administrative departments responsible for urban fixed-point medical institutions of basic medical insurance for urban residents policies, regulations, and supervise and inspect the implementation and administration of conditions, designated medical institutions shall cooperate with.
    33rd article Sentinel medical institutions no has following behavior: (a) charges project not price; (ii) using not qualified of dedicated prescription, and documents and account table; (three) admitted impostor personnel Hospital; (four) SWOP disease species or will not belongs to clinic project, and drug directory and service facilities range and paid standard of disease, and drug and service, included medical insurance and manpower Fund paid range; (five) beyond patients illness need for check, and treatment, and medication;
    (F) work on behalf of the insured urban residents of open medicine.
    34th article town residents basic medical insurance management staff no has following behavior: (a) not by provides will medical premium included medical insurance and manpower Fund account; (ii) corruption, and misappropriated basic medical insurance; (three) violation basic medical insurance management provides, caused Fund loss; (four) unauthorized reduction, and from or increased personal payment base; (five) unauthorized change medical insurance treatment; (six) engages in, and bribes bribery.
    Sixth chapter legal responsibility 35th article on violation this approach provides of, by city labor guarantees administrative sector ordered deadline corrected, late not corrected of, by following provides processing; constitute crime of, law held criminal: (a) violation this approach 27th article provides of, recovered has paid of medical, sentenced 500 Yuan above 1000 Yuan following fine; (ii) violation this approach 31st article provides of, not paid medical insurance and manpower Fund paid of medical costs;
    (C) in violation of this article 33rd (b) provision, a fine of 200 Yuan and 500 Yuan fines; (d) violation of this article 33rd (iii), (iv), (v), (vi) regulations, illegal and fined a maximum of amount 3 times more than 5 times; consequences, you can cancel the designated qualification.
    36th article violates this article 33rd (a) the provision, by the commodity price departments in accordance with the relevant provisions.
    37th in violation of the provisions of article 34th, cadre management authority administrative sanctions constitute a crime, criminal liability shall be investigated for their. Article 38th insured urban residents and designated medical institutions, between medical insurance agency when there is a controversy concerning the basic medical insurance for urban residents by the disputing parties through consultation; consultation could not agree, according to the arbitration or dealt with by the administrative departments of labor security.
    Not satisfied with the handling comments by the administrative departments of labor security, you can file an administrative lawsuit. Seventh chapter schedule 39th article has participate in town workers basic medical insurance and and Enterprise lifted labor relationship of personnel, due to health status cannot employment or economic difficult unable to handle medical insurance continued received of, can by this approach provides participate in town residents basic medical insurance, reached statutory retired age Shi, above annual urban on-the-job workers average for base, by 9.5% or 5% of payment proportion handle town workers basic medical insurance continued received procedures, once complement 15 by poor total years of medical premium.
    Change the month, enjoy the corresponding retiree health insurance benefits.
    40th in line with coverage of these measures has been participating in basic medical insurance for urban residents in accordance with the relevant provisions, may continue to be insured in accordance with original, do not enjoy government subsidy; also in accordance with the means to participate in the basic medical insurance for urban residents, and on November 30, 2007, health insurance agencies, to deal with the change.
    In accordance with these rules shall apply the change, the original payment of medical expenses for the health insurance premiums are not returned to pay medical insurance premiums; health care costs less than paying medical insurance premiums, returned the remainder of medical insurance premiums.
    41st funding standards for basic medical insurance for urban residents, Government subsidies, funds to pay standards, the highest percentage payment amount and payment adjustments, by the administrative departments of labor security according to the health insurance fund for the last year level and runs in time to propose adjustments, submitted to the municipal people's Government for approval before implementation. 42nd Hulan district, a district in the financial system transition period, will not enjoy municipal financial assistance policies, at the Central, provincial grants on the basis of, Hulan, Acheng financial grant for urban residents in the area, at the city level and manpower.
    After the reunification of the financial system, and then enjoy the corresponding municipal financial assistance policies.
    Article 43rd conditional employer fee subsidies for families of employees can be insured.
    Personnel participating in basic medical insurance for urban residents, while participation of commercial supplementary medical insurance.
    Bidding commercial insurance programmes and specific measures for urban residents by the municipal labor and social security departments and reported to the municipality for approval.
              44th these measures shall come into force on November 1, 2007.