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Administrative Measures For The Basic Medical Insurance For Urban Workers In Suzhou

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

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(Summit 24th ordinary meeting of the People's Government of Sus State of 23 March 2004 to consider the adoption of the Decree No. 48 of 1 April 2004 of the People's Government Order No. 48 of the State of Sus State of 1 April 2004, which came into force on 1 May 2004)
Chapter I General
In order to adapt to the need to establish a socialist market economic system, the reform of the basic health insurance system for urban workers is further improved and the basic health needs of workers are effectively guaranteed, and this approach is based on the State Department's Decision on the establishment of a basic health insurance system for urban workers, the Zion Regulation of Social Insurance in the province of Giang Sang Province and the implementation of the reform of the health insurance system in the province.
The main task of the reform of the health insurance system is to adapt to the economic system of the socialist market and to establish a social health safety system that guarantees the basic health needs of workers, in accordance with financial, business and personal affordability.
Article 3 establishes the principles of the basic health insurance system for urban workers: the level of basic health insurance is to be adapted to the level of economic and social development; the participation of all urban user units and their employees in basic health insurance, the introduction of territorial management; the co-payment of basic health insurance costs by both user units and workers; and the integration of social integration and personal accounts in the basic health insurance fund.
Article IV is responsible for the development, operation, supervision and management of health insurance policies in the State of Sus State, the Ministry of Labour and Social Security (hereinafter referred to as the labour security sector); the Centre for Social Insurance Fund Management in the State of Sus State (hereinafter referred to as the Social Insurance Fund).
Article 5 The health sector should proactively cooperate with the reform of the health insurance system, synchronize the reform of the pharmaceutical health system, implement the classification of non-profit and profitable medical institutions, implement the management of the two line lines of the hospital's medicine, promote the centralization of the procurement of medicines and medical supplies, strengthen professional ethics education for pharmaceutical practitioners, regulate medical and operational behaviour, and ensure that medical costs are properly controlled owing to sickness treatment, reasonable inspection, reasonable fees.
Article 6 establishes the Social Security Monitoring Committee, which is composed of representatives of financial, auditing, etc., political, trade union representatives, representatives of the insured person, responsible for the harmonization of all-market social safeguards, which is governed by law in the implementation of social security policies, funds management.
Article 7 gives certain incentives to persons reporting violations of health insurance provisions and violations of the interests of insured persons.
Introduction
Article 8. Basic health insurance for urban workers is a mandatory social insurance provided by the State. Its coverage is that all user units within the city's administration, including State (collective) enterprises, shared enterprises, external investment enterprises, private enterprises and other enterprises, State agencies, business units, non-commercial units, social groups, provincial units and field presence units, are involved in basic health insurance in accordance with the principle of territorial management.
All employees (including those working in the user unit and paying their wages) and retirees within the above-mentioned scope of article 9 are the subject of the basic health insurance (hereinafter referred to as participants).
Individual economic organizations and their practitioners, flexibilities such as self-employed persons, should also participate in basic health insurance.
Article 10 Medical costs of the Department of Removal are managed in an integrated manner, in accordance with the relevant provisions of the Provisional Approach to Integrated Management of Medical Costs in the municipality of Sud State.
In line with the provisions of the provisional scheme for the health insurance management of the fraternal fraternal fraternal fraternal fraternals, such as Article 11 (2), the basic health insurance care policy for the urban workers is enjoyed.
Article 12. The State Civil Service enjoys the National Civil Service Health Benefits Policy on the basis of participation in the basic health insurance, in accordance with the relevant provisions of the provisional scheme for medical assistance for the State's civil service in the city of Sud State.
Article 13 provides for the immediate family of the insured person, the university colleges are in school and are not included in the scope of the basic health insurance, and medical costs continue to be implemented in accordance with the original provisions and the funds are addressed by the original channels.
Article 14. Medical expenses incurred by workers for work injury and childbirth are covered by the work injury, maternity insurance fund, and areas where work injury and maternity insurance have not been introduced are still resolved by the source of funds in accordance with the original provisions.
Chapter III Fund mobilization
The Health Insurance Fund includes the Basic Health Insurance Fund, the Integrated Fund for Local Supplementary Health Insurance and the Social Shes Fund for Large Medical Costs.
Article 16 provides that the basic health insurance fee is paid jointly by the user unit and the employee. The unit of the employed person pays the basic health insurance fee by 9 per cent of the total salary of the active employee; the active worker pays the basic health insurance fee at 2 per cent of the total salary, which is paid by the user's unit on a monthly basis from the employee's salary.
Article 17 The cap for the contributory base, which is limited to municipal labour guarantees and the financial sector are published annually after the approval of the municipal government.
The computation of the total salary is carried out in accordance with the provisions of the National Statistics Office for the Total Wage and the Notification on a number of issues related to the reform of the salary system for the staff of the agencies and the utilities.
Article 18
Local sources of the Integrated Fund for Health Insurance are combined with contributions from the user unit, the allocation and financial subsidies for the basic health insurance fund. The unit of the population is rated in accordance with the number of insured persons and is paid on a monthly basis in accordance with 1 per cent of the basic health insurance contributions rate of 1 per cent, to be transferred from the basic health insurance fund in the month to the local supplementary health insurance fund, and the city-level finance increases over the next year, in accordance with the 100-year standard subsidy per retired person.
Local supplemental health insurance payments for flexible employed persons, such as vocational complicity, are paid by 1 per cent of the base paid by individuals in accordance with the basic health insurance fee.
The Integrated Fund for Local Complementary Health Insurance is dedicated to accounting.
The total social cost of Article 19 is financed by a total of $500 per person per month for the insured person and by an in-service and retired person.
Article 20 provides that a conditioned user unit should continue to take a variety of forms to supplement health insurance, in accordance with the provisions of the Provisional Scheme for Supplementary Health Insurance for Enterprises in the Sud State. Complementary health insurance costs are covered by 3 per cent of the total employee's salary, from the cost.
Article 21 lists of funds for health insurance funds: executive organs and business units that are fully financed by financial resources are included in the unit budget and are included in local financial budgetary arrangements; other business units are addressed by the source of funds; and businesses are covered from the employee benefits.
The second article of the Health Insurance Fund is included in the management of the financial exclusive household, with no specific funds being diverted.
Article 23. When the enterprise withdraws, combines and assigns, transfers, leases, contractors, the receiving or continuing contractor shall assume the responsibility for the medical insurance of its employees and pay the employee's medical insurance expenses in a timely manner. Insolvency enterprises should prioritize the contributory health insurance payments, in accordance with the relevant provisions of the Insolvency Law.
Article 24 Medical insurance payments are paid by the Social Insurance Centre or by the tax administration. The user units and their employees shall pay their health insurance payments in full and on time, in accordance with the provisions of the Southern Susang Province Social Insurance Regulations.
The user unit shall be subject to the supervision of the worker by making the payment of the health insurance payments regularly available to the employee.
Article 25 Health insurance payments paid by individuals are not included in the base for the payment of personal incomes, and the Medical Insurance Fund and its value added portion are exempted from taxation.
Chapter IV
Article 26 The Basic Health Insurance Fund is divided into two parts of the Integrated Fund and Personal Account.
Article 27 establishes a basic health insurance personal account for all insured persons (hereinafter referred to as a personal account). The number of citizenship is used in personal accounts codes.
Article 28
(i) In-service workers are recorded by a proportion of the total salary paid by themselves (with the individual paying part) at 3 per cent of the total salary paid by the employee under 45 years of age (45 years) and at 3.5 per cent of the total salary paid by themselves.
(ii) Retirements are defined by age as follows: under the age of 70 years is recorded at $500 per year; over 70 years of age (70 years of age) are recorded at 550 per year; the number of older workers who participated in the revolution prior to the establishment of the State is $900 per year; and the personal accounts of the enterprise retired labour model have increased on the basis of the above criteria: 400 per person at the national level and 200 dollars per year in provincial modelling.
Article 29 of the personal accounts are mainly used for medical treatment, and the personal accounts of the previous year can be used both for referral or for the self-sufficiency portion of the medical expenses. The individual accounts may be counted on the basis of the required balances for the year. The personal accounts and interest are owned by the worker and can be transferred and inherited by law.
Article 33 Basic health insurance payments paid by a person's unit are recorded as part of the personal accounts as an integrated fund for basic health insurance, managed by the Centre for Social Insurance and integrated use.
The Integrated Fund for Basic Health Insurance is used to attend the insured person in the hospitalization of the targeted medical institutions and in the medical costs of a particular project, which should be paid by the Centre in accordance with the provisions.
Article 32 refers to the specific treatment projects identified by the Centre for Social Insurance, which are diagnosed by designated hospitals. Specific projects for diagnosis include: urus of acute urx diseases for treatment of treatment, sterilization of maloxinology, organ transplanatory drug treatment, mental seconomies in mental illness, depression, sychiarrhoea with psychiatric symptoms, bisexual disorders (hereinafter referred to as severe illnesses) and family beds.
Chapter V Medical insurance treatment
In the event of illness by the insured person, the Employer Health Insurance Certificate, the Employees' Health Insurance and the Social Insurance Card (ICC) were granted by the Career Insurance Centre to the targeted medical institution or the pharmacies (hereinafter referred to as a identifiable unit) to receive the basic medical treatment required.
Article 344 Medical expenses incurred by the insured person in the targeted unit are paid from the personal accounts; after the completion of the personal accounts, the illnesses of specific projects are provided by the Integrated Fund for Basic Health Insurance. Other medical fees that are in line with the basic health insurance are paid, and supplementary health insurance funds established by local supplemental health insurance funds or units.
Article XV provides for inpatient medical expenses incurred by the insured person in the targeted medical institution, with the application of the criteria for payment, the payment of more than the payment of the standard part of the payment and the basic medical cost-free-charge approach:
(i) The first-ever hospitalization rate of the insured person is determined by different levels of hospitals, and at the municipal and municipal levels: In-service staff amounting to 1000, retirees; district (areas) hospitals: 750 active workers, 600 retirees; grass-roots hospitals, such as townships: 400 for active workers and retirees. The criteria for medical treatment and the entry of its specialist hospitals are also determined. When the second inpatient rate was 50 per cent of the first payment standard, the rate of payment for more than three years was harmonized with $20 million. Employers have been hospitalized for more than 180 days per 180 days, with more than 180 days being treated again. In the case of illness, the insured person is required to carry out an internal referral facility, which is based on the payment criteria for the high-ranking hospital. Medical costs within the pay line are borne by the individual insured person and can be offset by the previous Personal Account balances Fund.
(ii) Inpatient costs for each inpatient in excess of the payment standard, in accordance with the medical insurance payment requirements in the amount of US$ 40,000, the proportion of the individual subparagraphs is paid:
The amount of €10,000 (with €10,000) is 20 per cent for active workers and 15 per cent for retirees;
Between 1 million yen and 20,000 dollars (with a $2 million), 15 per cent of active workers and 10 per cent of retirees themselves;
Between 20,000 and 40,000 dollars (40,000 dollars) were covered by 10 per cent for active workers and 5 per cent for retirees.
Article 36 Medical costs for specific projects are paid by the Centre after the completion of the individual accounts:
(i) Synthetics (including the use of reconfiguration cell generators) costs, organ transplanted anti-malarial drug treatment, healing medicines and treatment costs for malicious ethroids, in part within 40,000 yen, with 90 per cent disbursed by the basic health insurance integrated fund and 10 per cent paid by individuals.
(ii) The cost limit for access to basic health insurance in each health insurance year is US$ 2000. Within this limit, the Integrated Fund is paid by 60 per cent of active workers and 70 per cent of retirees.
(iii) Influenza, post-planted antiretroviral treatment, therapy for malicious stereotypes and psychiatrics, the cost of a specific sychiatric project in the period of medical insurance, to be paid at the above standard.
(iv) The medical costs of the family beds are settled every 180 days, with a payment standard of $500 per month, which can enter the basic health insurance cost limit of $3000 (excluding payment criteria), and 80 per cent of the basic health insurance integrated fund within this limit.
In accordance with the principle of safeguarding basic medical care, the cost of medical care for a staff member for a year-long inpatient and patient-specific project is €40,000 per year and exceeds the cost of a 40,000 yen line and the Integrated Fund for Basic Health Insurance is no longer paid.
Article 33 Eighteen-yearly accumulated inpatient and patient medical costs of a particular project amounted to more than 40,000 yen to 200,000 dollars, in line with the coverage of the health insurance, 95% of the GF and 5 per cent for individuals.
Article 39 affects the basic life of the worker's family as a result of excessive medical expenses, which may be facilitated by the employee's unit from the welfare fee or through mutual assistance activities.
Article 40. After payment of the medical insurance expenses by the user unit and the employee in the month of the month, the medical insurance treatment was received from the previous month, without the payment of the required payment, and the CPS suspended the medical insurance treatment of the insured person from the second month. The medical costs incurred during the suspension were not covered by the Health Insurance Fund, which was borne by the user unit and the employee.
Article 40 states that the user's unit and its employees shall be exempted from paying the medical insurance fees to the national legal retirement age for the month of their participation in the basic health insurance.
Article 42, when the employee is in the process of retirement, the minimum age for the payment of health insurance expenses must be 30 years for males and 25 years for women. Inadequate-year-olds are subject to the average annual social pay and the annual health insurance rate, a one-time contribution to the medical insurance fees set for the above-mentioned years, and the pensioner's health insurance benefits are available.
The full implementation time frame for the basic health insurance in the Sus State (1 July 2002) is granted to the insured person whose basic old-age insurance is subject to the age of the same pay and the actual pay period, which may be considered as the payment of the basic health insurance.
Article 4313 When the insured person mobilizes, causes or terminates the labour contract with the unit, the person's unit is required to prove to be responsible for changes in or termination of the health insurance relationship at the Centre.
Chapter VI
Article 44 of the Basic Health Insurance introduces a targeted medical institution and a customized retail pharmacies management system. The prequalification and management approach of the targeted medical institutions, the fixed-point retail pharmacies are developed separately from the labour security sector.
Article 42 establishes health insurance services agreements with targeted medical institutions, targeted retail pharmacies to clarify the responsibilities, rights and obligations of both parties.
Article 46 provides for the purchase of medicines by the pharmacies or health-care providers directly to the pharmacies.
For non-conventional medicines in the basic health insurance medicine directory, the insured person can be bought by the medical insurance, the medical insurance certificate and the social insurance card directly to the targeted retail pharmacies.
Article 47 quantified medical institutions and targeted retail pharmacies should check the Employer Health Insurance Certificate when they are involved in the medical distribution of medical treatment by the insured person and be kept in detail on the medical distribution in the Employer Health Insurance Station.
Article 48 quantified medical institutions and customized retail pharmacies should strictly implement the relevant provisions of the Basic Medical Insurance Acquisitions, the directory of basic health insurance treatment and services facilities, the directory of basic health insurance medicines in the State of Sus State, and the Medical Insurance Fund is not paid.
Article 49 customised medical institutions and customized retail pharmacies should be equipped with dedicated management, sound internal management systems, active collaboration with the Centre for the management of health insurance and reasonable control of the growth of medical costs.
Article 50 requires the labour security sector to strengthen regular monitoring inspections with the relevant sectors such as health, pharmacies, prices of goods and services and management of targeted medical institutions.
Management and settlement of medical costs
In the case of a medical institution in the city, the medical care for the insured person may be paid directly from the personal accounts (ICC) and the personal accounts are not paid at the time of the payment of the individual's cash; after the amount of self-sufficiency provided for in the integrated management of the health insurance at the local level, the local Supplementary Health Insurance Fund is provided with the amount and proportion of the required; the remaining cost of inpatient hospitalization is payable by the Centre and the medical facility. A specific settlement approach was developed separately.
Article 52 addresses specific projects: a retroviral urology, therapeutic therapy, a severe psychiatry, and a specific project costs incurred by a IC card may be charged directly against the IC card after the distribution of pharmacies in targeted medical institutions or at-point retail stores. The medical costs of organ transplanatory drug treatment, family beds are paid by a person of the insured person before being paid by an effective vote, a schedule of expenses, medical insurance coverage, social insurance card to the Social Insurance Centre.
Article 53 provides a clear list of inspection, treatment and pharmaceuticals to the paying party when the targeted medical institutions are operating medical costs with the social insurance centre and the individual.
Article 54 was settled by a monthly basis with the Centre. The WCPU's statement of settlement submitted by the targeted medical institution should be reviewed and 90 per cent of the required medical costs were paid, and the remaining 10 per cent were to be paid accordingly on the basis of the evaluation.
Article 55
Article 56 of the Convention on the Protection of All Persons from Enforced Disappearances allows for medical treatment in the town of the local commune (the street) to be paid by the Centre as required.
In addition to emergency and first aid, the Medical Insurance Fund does not pay for medical expenses incurred by the non-scheduled medical institutions.
Chapter VIII Corporal punishment
Article 57 acts committed by customised medical institutions and customized retail pharmacies, which, in addition to deductions for violations, are warned by the labour security sector and may be fined by more than 3,000 dollars; and criminal liability by law:
(i) The absence of a medical certificate of medical examination, the occurrence of a healing, pharmacies, resulting in the loss of the health insurance fund;
(ii) In exchange of medical care for opioid, health care, living supplies, and drug-friendly behaviour resulting in the loss of the health insurance fund;
(iii) Disadvantaged health insurance funds by distributors or ultra-materials;
(iv) The illegal acquisition and use of specialized medical care providers to deceive the health insurance fund;
(v) The sale of false, false, expired and ineffective medicines that endanger the health of insured persons and deceive the health insurance fund;
(vi) Receiving multiple medical costs, such as repayments, distributing fees, self-payment projects, and increasing the burden on health insurance funds or insured persons;
(vii) Include medical expenses incurred by the non-health insurance fund in the payment of the health insurance fund;
(viii) The arbitrary extension of the hospitalization of the insured person and the inpatient interests of the insured person, such as the de-patient hospitalization, and the increased payment of the health insurance fund;
(ix) Servicing or inpatient diseases, and deducting patients from the Medical Insurance Fund for such acts as hospitalization;
(x) A malicious attack on the health-care network, resulting in a paralysis of the network or damage to data;
(xi) Other serious violations of the relevant provisions of the health insurance system, resulting in the loss of the health insurance fund.
Article 58 consists of one of the following acts, and the labour security sector, in addition to the recovery of the health insurance fund receivable or the unreasonable cost, is criticized in the light of the circumstances, and may be fined by €100,000:
(i) The inclusion of persons not covered by the health insurance;
(ii) Lower-paid medical insurance payments for gross salary payments for workers;
(iii) Restatement, restatement of medical costs;
(iv) Temporary recruitment of persons not in accordance with the health conditions to work in units and for their medical insurance;
(v) Failure to process changes in the health insurance relationship of the insured person in a timely manner affect the treatment of the health insurance of the employee;
(vi) Other violations of health insurance provisions.
Article 599 does not pay and deduct the payment of medical insurance expenses in full and shall be paid by the labour security sector for a period of time, which remains unpaid after the date of payment, plus 2 per 1,000 wards from the date of payment. The lag is integrated into the Integrated Health Insurance Fund. Persons responsible for concealing reports, leakage payments base are punished in accordance with the relevant provisions of the provisional Social Insurance Scheme.
In addition to deductions for violations, the labour security sector is warned and liable to a fine of up to 1,000 dollars; and a crime is criminalized by law:
(i) The use of IC cards for medical treatment and the use of health insurance funds;
(ii) The use of health insurance policies, the distribution of medicines, the sale of hand and the illicit profit;
(iii) Compilation with targeted medical institutions or pharmacies in order to be resistant to medicines;
(iv) In the short term, a large number of duplicative pharmacies and the waste of the health insurance fund;
(v) The use of IC cards by themselves to others.
Article 63/EWS and its affiliates have committed the following acts, which are administratively disposed of by the labour security sector, with a period of time relapse; constitute an offence and hold criminal responsibility under the law:
(i) Lossss of the health insurance fund caused by negligence or violation of the property;
(ii) A collusion with an insured person or a customized unit would not be included in the fund's payments;
(iii) Investing in medical insurance payments and in the clearance of medical expenses, in favour of private fraud, which undermines private fertility;
(iv) To use its mandate and work to bribe and profit from private benefits;
(v) Other grave breaches of the health insurance provisions and violations of the interests of insured persons.
Chapter IX
Article 62 may establish specific means of implementation, in line with this approach, in the light of the practice of municipalities.
Article 63 allows the municipal government to adapt to the standards of personal contributions and related treatment of the user unit and the employee, based on changes in the level of economic and social development and medical costs.
Article 64 of this approach is implemented effective 1 May 2004. After 1 April 2004, the pre-implementation health insurance management of the employee could be implemented in the light of this approach.