Administrative Measures For The Basic Medical Insurance For Urban Workers In Fushun City

Original Language Title: 抚顺市城镇职工基本医疗保险管理办法

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(On June 8, 2005 Fushun city government 25th times Executive Conference considered through on June 8, 2005 Fushun city government makes 111th, announced since on August 1, 2005 up purposes) first chapter General first article for established sound I city town workers basic medical insurance system, maintenance workers interests, improve health level, according to State on established town workers basic medical insurance system of decided and Liaoning province town workers medical insurance system reform implementation views, combined I city actual,
    These measures are formulated.
    Second basic medical insurance is a Government guarantee the employer and employee interests taken by compulsory social insurance, all employers and their employees must be from the date of implementation of these measures, in accordance with the provisions of the basic medical insurance.
    Third article this approach applies Yu this city administrative within of following employing units and workers: (a) State, and institutions, and social groups and workers; (ii) State-owned enterprise, and town collective enterprise, and company business enterprise, and partnership enterprise, and personal owned enterprise and other town enterprise and workers; (three) in the provincial and the field standing this city of levels organ, and enterprises and workers; (four) foreign investment enterprise and China workers; (five) private non-enterprises and workers;
    (F) according to the way of participating in basic medical insurance insured retirement units in line with national requirements (Professional) staff.
    Fourth basic medical insurance for urban employees uphold the basic medical insurance level and the development of regional productivity principles adhere to basic medical insurance premium by the insured units and workers shared on both sides of the principles adhere to basic medical insurance fund in order to support, balance of principles adhere to the health insurance fund to implement the principle of combining social pool and personal accounts. Five basic Medicare managed at the municipal and county levels.
    City and county administrative departments of labor security is responsible for the implementation of the measures, city and county medical insurance agency at the administrative departments of labor security supervision and management is responsible for undertaking the basic medical insurance business.
    Municipal medical insurance agency is responsible for the operational guidance to county medical insurance agency.
    Sixth Municipal Government to set up health insurance Committee of experts, strengthen the operational guidance and supervision of basic medical insurance. Chapter II collection of basic medical insurance premiums article basic medical insurance premiums from the insurance units and the individual contributions.
    Insured annual salary on the unit on-the-job workers as the base, press 7% to pay workers on my annual salary as a base, by 2% pay from insurance units from withholding in their paychecks.
    Pay basic medical insurance man for 30 years, women under 25 years (before the insured uninterrupted period of contributions in line with national requirements) of retirees, stopped paying the basic medical insurance premiums.
Insurance unit ratio of retirees to workers more than 1:1.8, the insured shall pay the Medicare risk adjustment funds.
    = Medicare risk adjustment funds ={-÷ number of employees the number of retired persons 1.8}x pension X7% =tbl/> eighth employee shall be paid in equal monthly instalments over 300% above average in the city last year, with 300% as the base, below average to average wage as a base.
    Nineth year workers involved in the work or into the city, I actually only months salary as a base; wages are not clear, the above annual wages as a base in the city.
    The tenth insurance units after the change of continue operator must bear the insurance unit and its workers ' basic medical insurance.
    11th insured unit bankrupt according to law, revocation, dissolution, ceases business activities sold or for any other reason, for their employees a one-time paid two years of basic medical insurance premiums, retiree paid the average life expectancy in the basic medical insurance premiums. 12th the insurance unit that is not required to pay basic medical insurance premiums from the month stop paying premiums, suspend the unit covered by basic medical insurance treatment of the persons insured. In 90 days within (containing 90 days) paid began paid of medical premium and the late fees Hou, parameter insurance personnel recovery enjoy medical insurance treatment, on stopped paid premium during parameter insurance personnel in Sentinel medical institutions, and Sentinel pharmacy occurred of medical costs, by parameter insurance units by medical card, and IC card, and receipt and the related records material, by medical insurance handling institutions audit Hou, by about provides handle claims procedures. For more than 90 days of unpaid arrears of payment of health insurance premiums and fines on the insurance units, automatic processing.
    Stop automatically after paying premiums, renewal process, stop insurance premiums where the period of medical expenses shall not be reimbursed. Chapter III Community co-ordinating medical funds and personal medical accounts 13th funds of basic medical insurance by co-ordinating funds and personal accounts pose.
    Individual account form for health insurance IC card (hereinafter referred to as IC card).
    14th article parameter insurance units and workers personal paid of basic medical premium, according to I payment base or pension monthly by following proportion designated into personal account: (a) 45 age (containing 45 age) following by 2.5% designated into; (ii) 46 age to 55 age by 3% designated into; (three) 56 age to 69 age by 4% designated into; (four) 70 age (containing 70 age) above by 4.8% designated into. 15th insurance unit, employees ' basic medical insurance premiums paid by individuals, according to their provisions into individual accounts, the rest into the whole Fund.
    This charging late fees, and other income into the whole Fund. 16th medical insurance agency insurance for staff personal accounts, setting up health insurance number, issuing IC card.
    IC cards are insured medical treatment, purchase and settlement cost of private vouchers.
    17th personal accounts of the principal and interest on insured persons all, for my medical expenses (including personal burden), can be carried forward to the next year, transfer and inheritance. 18th insured personnel transferred out of the city, should be required for transfer of personal accounts and IC card cancellation procedures, accompanying the transfer of funds in his individual account balances. Cannot be transferred, as approved by the health insurance agencies, either in its own.
    Into the city's personnel in the field, should go through the medical insurance procedures and the establishment of personal accounts and the balance transferred to the personal account. 19th when the insured person dies, their individual accounts and IC card should be cancelled in the 30th.
    Individual account balances of funds were paid to heirs.
    Fourth chapter of basic medical insurance treatment in the 20th after 30th ' employer paid medical insurance, insured persons began to receive basic medical insurance benefits.
    21st insurance staff in designated outpatient treatment and drugstores in purchase of medical expenses paid by the individual accounts, excess borne by the individual. 22nd persons insured in-patient medical expenses incurred, paid for by funds, individuals must afford to pay standard costs. Insured persons hospitalized for the first time the burden of paying standard fees, according to three hospitals, tertiary hospitals, municipal hospitals, secondary hospitals, community hospitals, respectively set at 700 Yuan/person, 600 Yuan/person, 500 yuan/person/person, 200 Yuan, 300 yuan/person.
    During the year, each hospital reduced by 100 Yuan, subject to a minimum of not less than 200 yuan/person.
    23rd insured persons on three general hospitals, municipal hospitals (including secondary general hospitals), community hospitals (including a-level General Hospital) hospital treatment expenses, personal burdens, respectively: workers born 15%, 12%, 10%, retiree burden, and 10%, and 6%.
    24th article parameter insurance personnel does for illness need, by sentinel medical institutions agreed, and by medical insurance handling institutions approved, out city hospital treatment by occurred of medical, personal burden up pay standard costs for 1000 Yuan/passengers, personal burden proportion for: on-the-job workers burden 35%, retired personnel burden 25%, and Yu treatment end Hou, holding effective voucher to turned out of Sentinel medical institutions audit settlement.
    Article 25th offsite location of the medical personnel must be insured selected fixed-point medical institutions of medical treatment, for medical expenses that occur with valid credentials to the local medical insurance authority audit settlement.
    Article 26th temporary out-patient insured persons close to the acute disease medical treatment, for medical expenses that occur with valid credentials to the local medical insurance authority audit settlement. 27th this year, insurance funds to pay basic medical expenses (including inpatient and outpatient medical treatment of chronic diseases) capped 4 times times the city's average wage of staff and for the last year, more than 4 times the medical expenses paid by large supplementary medical insurance.
    All employers and workers participating in basic medical insurance to participate in large supplementary medical insurance. 28th insurance unit participating in basic medical insurance and large supplementary medical insurance on the basis of establishing enterprise supplementary medical insurance.
    Enterprise complementary medical insurance premium in wages within 4% of the parts, from employee benefits, fees were charged, inadequate welfare expenditures part, after they have been approved by the finance and taxation departments at the same level in cost.
    29th the medical expenses of the insured person in accordance with the basic medical insurance drug list in Liaoning province Fushun city, and the urban workers ' basic medical insurance diagnosis and treatment project (Amendment) and the basic medical insurance for urban workers in Fushun city medical services scope and payment provisions of the interim measures for the management of audit settlement.
    The fifth chapter of basic medical insurance management and services of the 30th the employing unit shall be approved within 30th of the Medicare medical insurance registration insurance agency procedures.
    31st insurance medical insurance registration unit is changed or terminated according to law shall be from the date of modification or termination in the 30th, health insurance agencies go through the modification or cancellation of registration of medical insurance. 32nd basic fixed-point medical institutions and healthcare management of drugstores.
    Appointed medical institutions of insured persons to choose a doctor and drugstores to buy drugs, prescription medications are prescription to designated medical institutions or drugstores to buy drugs. Article 33rd opening within the administrative area of the city according to law of medical institutions and pharmacies, to the municipal administrative departments of labor security may apply to take up the basic medical insurance service, by the municipal labor and social security administrative departments of health administration, United the examination and approval of drug supervision departments, issuing fixed-point medical institutions or drugstores qualification certificates.
    Health insurance agencies according to the traditional Chinese and Western medicine simultaneously, grass-roots, both specialist and general medical institutions, the principles of treatment of employees, purchase of medicines, is responsible for the identification of designated medical institutions and drugstores.
    Article 34th medical insurance agency with designated medical institutions, drugstores basic medical insurance service agreements signed, specify the responsibilities, rights and obligations of both parties.
    Medical insurance agency in accordance with the basic medical insurance policy provided with designated medical institutions, drugstores and signed agreements with designated medical institutions, drugstores and settlement expenses on time. 35th medical institutions and drugstores should strengthen medical staff technical training and education for staff and operations, to develop and improve the necessary systems, guaranteeing medical and pharmaceutical quality, adhere to disease treatment, scientific diagnosis and rational drug use, effective treatment.
    Drug prices must be implementing national, provincial and municipal pricing administrative departments to develop standards of medical service fees, accept the municipal labor and social security administration departments, price control administration of inspection and supervision in the community. Article 36th when hospitalization insurance personnel, contracted medical institutions according to the insured person's condition need to be examined and treated.
    Designated medical institutions according to the insured person's condition requires examination and treatment, medical insurance agencies shall not refuse to pay the costs incurred.
    37th insured persons medical treatment, contracted medical institutions should check their health insurance card found forgery, fraudulent use or falsification of health insurance card, should be detained for health insurance card, and report the health insurance agencies.
    38th article Sentinel medical institutions and staff in provides basic medical insurance service process in the, ban following behavior: (a) will non-Sentinel medical institutions of medical costs, and non-basic medical insurance fund paid range of medical with included basic medical insurance fund paid and not by provides settlement medical costs; (ii) not nuclear inspection medical insurance card, and IC card, will non-parameter insurance personnel of medical with into basic medical insurance fund paid;
    (Three) refused to admitted this medical institutions admitted range within of patients or refused to using medical insurance IC card settlement medical costs; (four) not insisted for disease Shi rule, deliberately limit prescription amount and hospital costs; (five) take hanging bed, and decomposition hospital and reduced hospital standard, not due of approach, take basic medical insurance fund; (six) not implementation provides of medical service charges standard and drug price, and violation price management about provides charges, caused basic medical insurance fund loss.
    39th drugstores and their staff in the course of providing basic medical insurance service, prohibit the following acts: (a) not complying with the prescribed doses of drugs; (b) sale of basic medical insurance drug list medicines or other items; (c) violation of drug price control stipulations resulting in loss of the basic medical insurance fund.
    40th insured persons in the medical treatment, the process of purchase and settlement costs, prohibit the following acts: (a) my health insurance card, IC card lent others; (b) forging, altering a prescription or medical bills documentation documents, making false claim medical expenses.
    41st units, persons insured, insured fixed-point medical institutions, and drugstores, between medical insurance agency when there is a controversy concerning the basic medical insurance by the disputing parties settled through consultation, may apply to the administrative departments of labor security decisions or a people's Court according to law.
    Sixth chapter the basic medical insurance fund management and unified supervision 42nd basic medical insurance fund collection, centralized management, unified payment. 43rd basic medical insurance funds into the accounts of the Social Security Fund, the two lines of income and expenditure management, to ensure basic medical insurance fund used to safeguard personnel, no unit or individual is allowed to occupy or divert, also should not be used to balance the budget. Municipal finance, labour and social security administrative departments are responsible for the management and oversight of the basic medical insurance fund.
    Audit Department is responsible for the basic medical insurance fund and management of audits.
    44th medical insurance agencies should establish and improve the basic medical insurance fund budget and final accounts examination and approval system, financial accounting and internal audit systems, and within the stipulated period of time, to the municipal labor and Social Security Administration Department and Finance Department to submit relevant reports.
    45th medical insurance agency Office was funded by financial full, shall occupy or misappropriation of funds of basic medical insurance.
    Article 46th insurance units and the insured persons have the right to medical insurance institutes of basic medical insurance premiums paid and the individual account balances. 47th administrative departments of labor security has the right to audit the insurance units, medical institutions, drugstores the accounts, report to verify the total base number of insured, payment of wages and pensions.
    Medical insurance agency entrusted by the administrative departments of labor security and insurance units, designated medical institutions and drugstores and medical insurance business matters related to inspection and investigation work. 48th insurance unit and designated medical institutions, drugstores must specify a unit of part-time staff to do the basic medical insurance management and services.
    Insurance units regularly released to the employee's annual salary and basic medical insurance premiums paid, and accept supervision by the workers.
    Health insurance agencies should regularly publish the annual usage of the health insurance fund, and accept supervision by the insured and insured persons.
    The seventh chapter penalty provisions article 30th 49th employer is in violation of the measures, the administrative departments of labor security rectification, if the circumstances are serious, the unit in charge and other direct liable persons, fined a maximum of between 5000 and 1000 Yuan.
    50th designated medical institutions, drugstores under the approach set forth in the 38th, 39th, and by the municipal labor and social security administrative departments between 5000 and 1000 Yuan fine; the Fund's losses, in addition to recover their losses, disqualified from point out, more than 5000 Yuan and 10,000 yuan fine; directly responsible for Executive and administrative liability of those directly responsible for the relevant sector.
    51st insured persons violated the provisions of article 40th, give criticism and education by the municipal labor and social security administration departments; the Fund's losses, in addition to recover losses, fines of between 100 Yuan and 500 Yuan.
    52nd medical insurance agency personnel who abuse their power, engage, by its competent authorities giving criticism and sanctions constitutes a crime, shall be investigated for criminal responsibility by judicial organs.
    Eighth chapter supplementary articles article 53rd urban self-employed, Freelancer and employer labor relations can refer to these measures, the relevant provisions shall be separately formulated by the municipal labor and social security administration departments.
    54th from January 1 to December 31 every year for employees ' medical costs. 55th these measures shall come into force on August 1, 2005.
                      The provisional regulations on basic medical insurance for urban workers in Fushun (municipalities, 74th) repealed simultaneously.