Hefei People's Government Of Hefei City, On Amending The Decision Of The Provisional Regulations On Basic Medical Insurance For Urban Workers

Original Language Title: 合肥市人民政府关于修改《合肥市城镇职工基本医疗保险暂行规定》的决定

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(December 8, 2006 Hefei Government 79th times Executive Conference considered through December 13, 2006 Hefei Government makes 125th, announced since January 1, 2007 up purposes) for strengthening I city basic medical insurance fund of supervision and management, combat illegal take basic medical insurance fund of behavior, promote medical insurance work health development, according to about legal regulations of provides, now decided on Hefei town workers basic medical insurance provisional provides for following modified: a, and
    Adding a paragraph to article 30th, as the second paragraph of "my social security card insured persons shall not be lent to others in hospital, may not be altered or provide false medical receipts and medical instrument".
    34th, paragraph (d) is amended as "decomposed inpatient hospital, false, fake hospital, induced by hanging-bed hospital, hospitalization, reduced admission standards, other than within the basic medical insurance drug list medicines into drugs or other items, such as substance abuse, obtain basic medical insurance fund". Three, and 47th article modified for: "Sentinel medical institutions and staff has violation this provides 34th article case one of of, on units can sentenced 10000 Yuan above 30000 Yuan following of fine, on main head, and directly is responsible for of competent personnel and other directly responsibility personnel can sentenced 1000 Yuan of fine; plot serious of, suspended until canceled Sentinel medical institutions qualification, on Sentinel medical institutions main head by competent sector give corresponding administrative sanctions until downgraded, and dismissed
    ; A contravention of subsection (d) provides, medical insurance agency should also refuse to pay or recover appropriate costs incurred, and 2 to 3 times reduced, reduced amount is deducted from the amount that should be paid in the month, while suspension of basic medical insurance fund ". Four, and 48th article modified for: "Sentinel retail pharmacy and staff has violation this provides 37th article case one of of, medical insurance handling institutions should refused or recovered by occurred of corresponding costs, and at 2 to 3 times times reduced, reduced amount from month should allocated of amount in the deduction, while suspended basic medical insurance fund allocated; on units can sentenced 10000 Yuan above 30000 Yuan following of fine, on main head, and
    Directly in charge of personnel and other persons can be fined 1000 Yuan fine serious circumstances, temporarily suspend or even abolish appointed retail drugstores ".
    Five, add one, as the 50th "30th insured persons in violation of the provisions of the second paragraph of article, medical insurance agency shall recover appropriate costs incurred, and suspended the medical insurance benefits insured persons 3-6 months, during the suspension of medical costs borne by the I constitutes a crime, criminal responsibility shall be investigated according to law."
    Six, add one, as the 57th "for reporting law and retrieving relevant units and individuals of the basic medical insurance fund, the administrative departments of labor security award, funded by financial expenses separately, and the specific measures formulated by the municipal labor and social security administration departments of finance".
    In addition, the order and part of the text of the provision for appropriate adjustments and modifications.
    This decision shall enter into force on January 1, 2007.

    The provisional regulations on basic medical insurance for urban workers in Hefei corresponding amendments shall be made according to this decision, and release it again.
    Attachment: interim provisions on basic medical insurance for urban workers in Hefei city (amended 2006) (released November 14, 2000, people's Government of Hefei city, the 82nd according to Hefei, people's Government of Hefei city, January 10, 2005, to amend regulations on interim provisions on basic medical insurance for urban workers, such decisions under the people's Government of Hefei city, December 13, 2006 to amend the revision of provisional regulations on basic medical insurance for urban workers in Hefei city, the decision of the second amendment) Chapter I General provisions
    First to establish a basic medical insurance system for urban employees, ensure basic medical care, improve the level of workers ' health, promoting healthy development of medical and health services, according to the State Council decision on establishing the basic medical insurance system for urban employees and the reform of the medical insurance system for urban workers in Anhui Province number of observations, such as provision of, combining city actual, these provisions are formulated.
    Provisions of this article apply to the following employers and their personnel in the administrative area of Hefei: (a) the State organs, institutions and their staff, (ii) social groups, private non-enterprise units and their employees; (c) according to the basic medical insurance the employer comply with State retirees.
    Owners of individual economic organizations and their employees in township enterprises and their employees, towns, not participating in basic medical insurance.
    Article III standing fat Central and provincial organs, enterprises and institutions and their staff and Hefei the same policy, block operations; Central and provincial enterprise of Hefei city, have joined pension insurance, included in the scope of Hefei city basic medical insurance.
    Changfeng, feidong County, three counties in feixi County into these units.
    Fourth administrative departments of labor security in the city, Hefei Department of basic medical insurance for urban workers, medical insurance agency has specific responsibility for basic medical insurance.
    Health, medicine, finance, tax, pricing, auditing Department cooperate closely in accordance with their respective responsibilities, do a basic medical insurance.
    Fifth article town workers basic medical insurance insisted following principles: basic medical insurance of level and this city productivity development level phase adapted of principles; town all employing units and workers are to participate in basic medical insurance, implemented territorial management of principles; basic medical premium by employing units and workers both common burden of principles; basic medical insurance fund implemented social and manpower and personal account phase combined of principles; established on medical patient both restricted mechanism of principles.
    Sixth units and individuals must fulfill the obligation to pay basic medical insurance, basic medical insurance treatment of insured persons enjoy rights.
    Chapter II basic medical insurance premiums article collecting basic medical insurance premiums by the employer and workers ' monthly contributions.
    This unit all workers ' wages last month as employers pay the health insurance contribution base for the month, at a ratio of 8% to pay employees more than the annual average monthly wage income as when I run over July 1 to the end of June the health insurance contribution base, by the 2% to pay. Average monthly payment lower than the province's average monthly wage of employees 60% for the last year, according to 60% determine the contribution base; higher than the province's average monthly wage of employees 300% for the last year, according to 300% determine the contribution base.
    Employee personal monthly income lower than the province's average monthly wage of employees 60% for the last year, according to 60% determine the contribution base; higher than the province's average monthly wage of employees 300% for the last year, according to 300% determine the contribution base.
    Statistic calculation of workers ' wages in accordance with State regulations.
    New flats to employees in this area last year when the insured monthly salary multiplied by the number of employees as the unit base, individual workers ' monthly salary of the previous year as a base in the region.
    Entered reemployment service centers in State-owned enterprises laid off workers in the Center during the basic medical insurance premiums (including fees and workers ' individual contributions) are made by the re-employment service center areas 60% as the base pay of the workers ' monthly salary of the previous year. Eighth article parameter insurance units paid of basic medical premium, its sources by original supply channel not variable, by following provides expenditures: (a) organ, and social groups units from regular spending of social security fee in the expenditures; (ii) institutions from career spending of social security fee in the expenditures; (three) enterprise from workers Welfare fee in the expenditures; (four) workers personal paid of basic medical premium from workers I wage in the spending; (five) into re-employment service center of State-owned enterprise laid off workers of basic medical premium,
    From reemployment service centers of workers ' basic living expenditures of funds. Nineth employee basic medical insurance premiums paid by individuals, by the insurance unit from income withholding in their paychecks.
    Retirees don't pay basic medical insurance premiums.
    Insurance institutions shall be declared to the tax authorities shall pay on a monthly amount of health insurance premiums, after approved by the local tax Department, direct collection.
    Tenth employer coverage should be the social insurance registration certificate holders, medical insurance agencies go through the following formalities: (a) fill in Hefei area employers ' participation in basic medical insurance application form and the name list, wage statements and (ii) basic medical insurance agreement signed, and (iii) receive a social security card.
    11th article employing units in handle basic medical insurance business process in the, shall not has following behavior: (a) will not belongs to basic medical insurance of personnel included basic medical insurance range; (ii) less reported payroll; (three) will with disease, and not meet parameter insurance conditions of personnel recruitment to units work, for its handle basic medical insurance; (four) to medical insurance handling institutions provides false voucher, caused basic medical insurance fund loss.
    12th the insurance unit's name, bank account number, and address of the legal representative and personnel, salary changes must be in the 5th of the next month to the medical insurance agency truthfully, go through the change procedures.
    13th insurance unit should be specified (and) staff actively with health insurance agencies to do the basic medical insurance management work.
    Chapter III article 14th insurance pooling Fund and individual accounts and basic medical insurance premiums paid by individuals to form the basic medical insurance fund into funds of basic medical insurance funds and personal accounts, pooling Fund and individual accounts should be accounted for separately managed separately shall not be diverted.
    15th article personal account by following provides monthly designated into: (a) parameter insurance personnel personal paid of basic medical premium all remember into personal account; (ii) parameter insurance units paid of basic medical premium points age paragraph by different proportion by months designated into personal account, 45 age following by workers I payment wage of 1% meter into, 45 age (containing 45 age) above by workers I payment wage of 1.5% meter into, retired personnel by this area Shang annual workers months average of 4% meter into. 16th all principal and interest into his own personal account, dedicated to my medical expenses and shall not be appropriated for other purposes may be carried forward for use and inheritance.

    When the insured people across integrated areas, personal account balance along with the transfer from the unit to transfer medical insurance medical insurance.
    17th personal accounts should be determined by the health insurance agencies banks, uniformly made the Hefei urban workers ' basic medical insurance individual account card, used to record personal medical insurance accounts in the income and expenditure of funds, kept by the insured person and in accordance with the regulations.
    18th overall Fund include: (I) to co-ordinate all the insurance companies pay deducted the total amount credited to the individual account and the remainder of the (ii) subsidies, (iii) social contributions (iv) bank interest; (v) late fee; (vi).
    19th insurance unit withdrawn, mergers, acquisitions, transfer, pooling, leasing, Contracting when receiver or continue the operator must assume the staff (including retirees) health insurance, pay employees ' medical insurance premiums on time.
    Fourth chapter of basic medical insurance treatment 20th insurance personnel from units and individuals to meet their financial obligations, from next month on basic medical insurance treatment not required payment unit, its treatment of insured persons not covered by the basic medical insurance.
    21st insurance personnel in my social security card can be used at any of the designated medical institutions in the city clinics, purchase or in accordance with the regulations to the designated retail pharmacy drug purchase.
    Outpatient medical treatment, purchase of medicines, medical expenses and hospitalization costs out-of-Pocket partly paid from the personal account, not enough to pay for part of themselves.
    22nd insured persons with my social security card, can be eligible for the designated hospital in the city hospital. Article 23rd persons insured hospital, medical costs are mainly paid by the funds. In one level and below, level II, and level III hospitals, standard of paying funds annual average wage of workers in this area, respectively 8%, 10%, 12%.
    Hospitalized multiple times within the same year, standard in turn 2%, was 5%. Below the standard of paying funds for medical expenses paid by the individual.
    Above the standard of paying over funds, insurance funds and personal "calculated and accumulated pay" approach to pay.
    Funds in a health care annual maximum limit for annual average wage of workers in this area 4 times.
    Insured persons in hospital, she must pay a certain amount of deposit to the hospital to pay out-of-Pocket medical expenses.
    24th insurance unit participating in basic medical insurance at the same time, staff (including retirees) to participate in the medical insurance, annual medical aid premiums paid in one lump sum for each insured person, payment standards for about 6 Yuan per person per month, in the "fixed income, balance" principle, yearly adjustments.
    Medical assistance fund administered by the health insurance agencies, earmarked funds to pay above the maximum payment limit section, specific measures separately.
    25th when the insured person is in hospital use Group a list of medicines prescribed by the basic medical insurance for expenses incurred to pay; b directory medicine projects and pay part of the costs of basic medical insurance diagnosis and treatment facilities, medical services, first by the insured person pays a certain percentage, as provided for in the basic medical insurance to pay the rest. Article 26th insured persons in local and offsite (excluding relocation officer) non-fixed income hospital emergency public medical institutions for observation and treatment of medical expenses that occur together, the press 1 hospital stay.
    In the context of basic medical insurance, medical expenses that occur in the city, compared with standard settlement in secondary hospital; medical expenses that occur in different places, individual pays the first 10%, the remainder settled by this tertiary hospital standards.
    Insured persons in the city and different non-designated emergency public medical institutions should be in the 3rd (holiday postponed) informed the medical insurance agency, otherwise the Fund does not pay for medical expenses and manpower.
    27th insured persons suffering from coronary heart disease, third phase of hypertension, diabetes, cancer, mental illness, hepatic cirrhosis, renal dialysis, 8 disease after Renal Transplantation (tentatively) in one of the groups identified by medical experts, handling of the special diseases outpatient medical card. Special sickness insured persons can choose the nearest in medical year 1 1 designated hospitals for outpatient treatment. Hospitals can be taken in real time or at regular intervals in patients with insurance settlement costs.
    Other medical diseases occurring during hospitalization, inpatient medical expenses with the above diseases medical expenses, 1 health funds within the annual cumulative amount paid shall not exceed the overall maximum amount of funds. 28th insured persons suffering from diseases to the tertiary hospitals (or hospital) is difficult to diagnosis or the diagnosis is clear, without treatment, can apply for transfer to remote diagnosis and treatment.
    Medical expenses necessitated by an individual or unit advance medical ends within 1 month from patients (or their families) and the health insurance agencies clearing, individual pays the first 10%, the remainder settled by this tertiary hospital standards.
    Article 29th after his retirement to his place of origin, or with spouses, children live in 1 or more people, relocating retirees medical insurance, Hefei, fill out the registration form and after confirmation by the original unit or street, to apply to the medical insurance agency.
    Relocation of retirees should be in their place of residence to determine 3 appointed medical institutions of different levels, as the designated hospital and special diseases outpatient hospital and medical insurance filings. Relocation of retirees in different places to determine when the hospital, in the 3rd (holiday postponed) notifies the health insurance agencies. The medical advances made from the individual or unit, within 1 month after discharge, and medical insurance agency settlement.
    Where basic medical insurance of medical expenses, settlement in accordance with Sentinel hospitals in the city.
    Relocation of retirees with the city's health care policy within the scope of special diseases, identified by medical experts in the city group, handling of the special diseases outpatient medical card.
    Relocation of retirees in different places to determine special disease treated in hospitals, basic health insurance outpatient fees in July of that year and the following year in January, the provisions apply mutatis mutandis to designated hospitals in the city hospital and medical insurance agency settlement.
    Article 30th insured medical expenses for the personnel in the following cases, the funds not be paid: (I) incurred (labour) injured, fertility of women employees, (ii) to go abroad, in Hong Kong, Macao and Taiwan regions to visit relatives during the lecture, study, continuing education, and (iii) crime, brawls, alcohol abuse, self-harm, suicide, traffic accidents, medical accidents, etc.
    My social security card insured persons shall not be lent to others in hospital, may not be altered or provide false medical receipts and medical instruments.
    Fifth chapter management of basic medical insurance service article 31st basic medical healthcare institutions and the management of appointed retail drugstores.
    Article 32nd in the administrative area of the city approved by the health Administrative Department and obtain the practicing certificate for medical institution of medical institutions, and military departments, and health administration departments are entitled to carry out military medical institutions of the foreign service, to the administrative departments of labor security may apply to take up the basic medical insurance service, approved by the review, designated medical institutions issued qualification certificates.
    Designated medical institutions must work with medical insurance agency signed an agreement defining their duties, rights and obligations. 33rd article Sentinel medical institutions must comply with following provides: (a) established specifically of medical insurance management sector, and specifically of medical insurance window; (ii) using has unified medical insurance logo of prescription, and records, and settlement single; (three) implemented registered, and clinic, and pricing, and remember account, and pay, and take drug one-stop service and medical day settlement system; (four) implementation basic medical insurance drug directory, and clinic project, and medical service facilities range and paid standard; (five) insisted for disease Shi rule, and reasonable check, and reasonable medication, and
    Reasonable fees; (vi) implementation of separate accounting of expenditure on medical and management respectively. 34th article Sentinel medical institutions and staff in provides basic medical service process in the, shall not has following behavior: (a) refused to parameter insurance personnel select Sentinel; (ii) refused to this medical institutions admitted range within of parameter insurance personnel outpatient medical and hospital; (three) not insisted for disease Shi rule, deduction and manpower medical costs; (four) take decomposition hospital, and false hospital, and fake hospital, and hanging bed hospital, and induced hospital, and reduced admitted standard, and will basic medical insurance medication directory within of drug into yiwai drug or other items, and
    Drug abuse, such as retrieving of basic medical insurance fund.
    Article 35th of the drug business and the business license, made Pharmaceuticals supervision and Management Department of medicine quality control norms issued by the certification certificate, willing to take on basic medical insurance for urban employees retail pharmacy of location based services, to the administrative departments of labor security may apply to take up the basic medical insurance service, after examination and approval and issue the certificate of qualification of appointed retail drugstores.
    Must appointed retail drugstores and medical insurance agency signed an agreement defining their duties, rights and obligations.
    36th appointed retail drugstores must use unified health insurance flag, with (and) level managers.
    Designated retail pharmacies to ensure the variety and quality of basic medical insurance treatment, control drug costs, purchase insurance personnel.
    37th appointed retail drugstores and their staff in the course of providing basic medical services, and shall not be any of the following acts: (a) no prescription doses dispensed, (ii) within the employee's basic medical insurance drug list medicines outside into drugs or other items.
    Article 38th of labour and social security administrative departments publicize was eligible for designated medical institutions and retail pharmacy and by the medical insurance agency marketing point signs.
    39th administrative departments of labor security of designated medical institutions and appointed retail drugstores to introduce annual examination system, in violation of provisions of designated medical institutions and appointed retail pharmacies to order rectification. The sixth chapter of basic medical insurance fund management and supervision

    40th special account of the basic medical insurance fund, the Social Security Fund, the two lines of income and expenditure management, earmarks, no unit or individual shall misappropriate.
    41st basic medical insurance fund, administered by the health insurance agencies, health insurance agencies and designated medical institutions in the spirit "in order to balance" principle, costs of settlement.
    42nd to establish comprehensive health insurance fund budget system, accounting and internal audit systems implementation of solidarity fund cost overruns early warning reporting system, when funds appear extraordinary expenses, health insurance agencies in time to the labour and social security administrative departments and local government reports, while carefully analyze the causes and propose preventive measures.
    Article 43rd year raising funds of basic medical insurance, according to the current deposit interest rate interest; the previous year's carry-over funds and repay the lump-sum deposit at 3-month interest rate; financial account deposit funds into medical insurance, compared with 3-year installment savings deposit interest rate interest, grade of not lower than the level of interest rates.
    44th labor Security Administration Department and Finance Department is responsible for the supervision of basic medical insurance fund, auditing Department responsible for medical insurance agency fund revenue and expenditure and management of audits.
    Set up by government departments, the employer representatives, representatives of medical organizations, trade union representatives, workers ' representatives and experts to participate in the medical insurance funds Supervision Organization, strengthen the supervision of basic medical insurance fund.
    Insurance unit announced to the staff health insurance every six months to pay, accept supervision of employees.
    Medical insurance agency announced to the public on a regular basis medical insurance premium collection and use of the health insurance fund, subject to public supervision.
    Seventh chapter legal liability article 45th employers not complying with the provisions of the basic medical insurance registration not complying with the provisions of modification and cancellation procedures, or not complying with the obligation to declare the basic medical insurance premiums to be paid amounts, rectification and punishment according to the interim regulations on the collection and payment of social insurance.
    46th article refused paid, and arrears or less paid, delay paid basic medical premium of, by labor guarantees administrative sector to parameter insurance units issued payment notice, parameter insurance units in notice served of day up 15th within must paid clear basic medical premium; late still not paid of, from owes paid of day up by day added received owes paid amount 2 ‰ of late fees, and on directly is responsible for of competent personnel and other responsibility personnel according to social security fee levy paid interim regulations punishment. 47th article Sentinel medical institutions and staff has violation this provides 34th article case one of of, on units can sentenced 10000 Yuan above 30000 Yuan following of fine, on main head, and directly is responsible for of competent personnel and other directly responsibility personnel can sentenced 1000 Yuan of fine; plot serious of, suspended until canceled Sentinel medical institutions qualification, on Sentinel medical institutions main head by competent sector give corresponding administrative sanctions until downgraded, and dismissed; has violation subsection (four) items provides case of,
    Medical insurance agency should also refuse to pay or recover appropriate costs incurred, and 2 to 3 times reduced, reduced amount is deducted from the amount that should be paid in the month, while suspension of basic medical insurance fund. 48th article Sentinel retail pharmacy and staff has violation this provides 37th article case one of of, medical insurance handling institutions should refused or recovered by occurred of corresponding costs, and at 2 to 3 times times reduced, reduced amount from month should allocated of amount in the deduction, while suspended basic medical insurance fund allocated; on units can sentenced 10000 Yuan above 30000 Yuan following of fine, on main head, and directly is responsible for of competent personnel and other directly responsibility personnel can sentenced 1000 Yuan of fine
    In serious cases, temporarily suspend or even cancel the qualification of appointed retail drugstores. 49th employer any of the provisions of this article 11th circumstances, resulting in loss of basic medical insurance fund, recovery of economic loss.
    Directly responsible for the charge and the other persons can be fined 500 Yuan more than 1000 Yuan fine.
    50th insured person has violated the provisions article 30th situations, medical insurance agency shall recover appropriate costs incurred, and suspended the medical insurance benefits insured persons 3-6 months, during the suspension of medical costs borne by the I constitutes a crime, criminal responsibility shall be investigated according to law.
    51st article medical insurance handling institutions and staff in work in the engages in, and misappropriating public funds should be, or using terms and work of will bribes bribery, seek self-interest, and work dereliction of caused basic medical insurance fund loss of, recovered economic loss, on directly is responsible for of competent personnel and directly responsibility people give administrative sanctions, and can sentenced 500 Yuan above 1000 Yuan following of fine; constitute crime of, law held criminal.
    52nd administrative penalties stipulated in this article, the administrative departments of labor security. 53rd party not satisfied with the administrative penalty may apply for administrative reconsideration or bring an administrative lawsuit in accordance with law.
    If no application for administrative reconsideration or bring an administrative suit, nor the execution of the penalty decision, where the administrative departments of labor security person to be punished the people's Court for compulsory execution.
    Eighth chapter supplementary articles article 54th retired personnel, army, second class b unchanged above disabled revolutionary medical treatment, medical management approach according to the relevant provisions of the province.
    College students, provide for immediate family members of workers not participating in basic medical insurance, and their medical expenses under the existing provisions to solve.
    55th on the basis of the basic medical insurance to allow qualified enterprises to establish supplementary medical insurance, supplementary health insurance in the 4% part of its wage bill, expenses from the employee benefits expenses, inadequate welfare expenditures section, approved by the financial sector included in the cost.
    56th medical insurance agency funds, included in the budget resolution shall not be extracted from the health insurance fund.
    57th report illegal cash funds of basic medical insurance for units and individuals, the labor Security Administration Department granting of appropriate incentives, funded by financial expenses separately, and the specific measures formulated by the municipal labor and social security administration departments of finance.
    58th article of the specific problems in the application of the municipal labor and social security administrative departments are responsible for the interpretation.
                                                                                                  59th article of the regulations as of the date of promulgation.