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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(March 23, 2004 Suzhou municipal people's Government at the 24th Executive meeting on April 1, 2004, Suzhou municipal people's Government, the 48th released as of May 1, 2004) Chapter I General provisions article to meet the need of establishing a socialist market economic system, further perfect the reform of the basic medical insurance system for urban employees, effective protection of employees ' basic medical needs, according to the State Council decision on establishing the basic medical insurance system for urban employees and the
    Collection and payment of social insurance regulations, Jiangsu Province, Jiangsu Province medical insurance system for urban workers and the provisions of the implementation of the reform, considering the actual situation, reform of the medical insurance system, I run, these measures are formulated.
    Article reform of the medical insurance system is the main task: adapt to the Socialist market economy, according to finance, enterprises and individuals can afford, established to protect workers ' basic medical needs of social medical insurance system.
    Article is in principle on establishing the basic medical insurance system for urban employees: the level of basic medical insurance to be commensurate with the level of economic and social development town all basic medical insurance for employers and their workers to participate in and implement territorial management; basic medical insurance premiums borne by the employer and employee sides together; the basic medical insurance fund combines social pool and personal accounts.
    Labor and Social Security Bureau, Suzhou fourth (hereinafter referred to as the labor Security Department) is responsible for policy formulation, organization and implementation of medical insurance, supervision and management; social insurance fund management center, Suzhou city (hereinafter referred to as the social security centre) is responsible for the collection, use, and management of the health insurance fund.
    Fifth article medicine health sector should active active tie medical insurance system reform, synchronization advance medicine health reform, implementation non-profit sex and profit sex medical institutions of classification management, implemented hospital drug payments two article line management, advance drug and medical with supplies concentrated tender procurement work, strengthening medicine practitioners ethics education, specification medical and business behavior, do for disease Shi rule, and reasonable check, and reasonable medication, and reasonable charges, reasonable control medical costs.
    Sixth article by the financial and auditing departments and NPC deputies and CPPCC National Committee members, representatives of trade unions, social security supervision committees with representatives of insured persons, coordinated the city's social safeguards, according to law exercise supervision over social security policy, management of the Fund.
    Article seventh report violations of Medicare rules and against interests of insured persons, who, by the labor and social security departments to give certain incentives. Chapter II scope and target article eighth of urban employee basic medical insurance is a compulsory social insurance stipulated by the State.
    Coverage: all employers within the administrative area of the city, including State-owned (collective) enterprises, joint-stock companies and foreign-funded enterprises, private enterprises and other enterprises, government agencies, public institutions, private non-enterprise units, social groups, provincial units of the Department and the field missions and the Soviet Union, are in accordance with the principle of territorial management, participating in basic medical insurance.
    Nineth articles within the scope of the above employer of all employees (including those working in the employer, and paid for by all categories of personnel) and retirees, were participating in basic medical insurance (hereinafter insured person).
    Owners of individual economic organizations and their workers, the self-employed, such as flexible employment personnel should also participate in the basic medical insurance.
    Article tenth of retired cadres retired medical expenses in the urban area, Suzhou medical expenses in accordance with the relevant provisions of the interim measures for the management, implementation of integrated management by the social security centre.
    11th second Serie b disabled revolutionary soldiers in accordance with the above second grade b or above, Suzhou city disabled revolutionary provisions of the interim measures for the management of medical insurance, enjoyed basic medical insurance for urban employees care.
    12th civil servants in accordance with the relevant provisions of Suzhou urban civil servants interim measures for the Medicaid participating in basic medical insurance enjoy the civil servants on the basis of Medicaid policy.
    13th insured dependent immediate family members, college students, not covered by basic health insurance coverage, medical expenses in accordance with the former regulations, funds from channels.
    14th employee for workers ' compensation and maternity medical costs incurred from workers ' compensation and maternity insurance fund expenditures; has not been effected areas of workers ' compensation and maternity insurance, according to the original rules were the original channels.
    Chapter III health insurance medical insurance funds, including fund raising 15th section of basic medical insurance fund, supplementary medical insurance and social relief fund large medical costs. 16th basic medical insurance premiums paid by employers and employees together.
    Employing unit at 9% of the workers wages to pay basic medical insurance; employees according to 2% of my salary to pay basic medical insurance premiums from employers withhold from the wages paid by the month. 17th unity employer employee payroll contribution base as a basic medical insurance premiums.
    Base upper limit and lower limit of the municipal labor and social security, the financial sector reported each year after the approval of the Municipal Government announced.
    Payroll calculating, according to the National Bureau of the provisions on the composition of wages and the organs and staff of the institution wage system reform in labour statistics a number of provisions of the notice of the Executive.
    18th local supplementary medical insurance management of scope and objects are all participating in the administrative area of the city basic medical insurance for urban employees employers and insured persons (not including full financial allocations and implementing unit of medical benefits for civil servants and staff). Local supplementary medical insurance fund for employer contributions, the combination of basic medical insurance fund allocation and financial subsidies.
    Where the employing unit based on the number of insured, in accordance with 1% of the basic medical insurance contribution base monthly pay social security centre at 11% draw 1% in the basic medical insurance payment rate, monthly transferred from the funds of basic medical insurance supplementary health insurance fund; municipal financial subsidy for retiree standard of 100 yuan per person per year, with revenue growth increased in the future.
    Self-employment where flexible employment, such as supplementary medical insurance by an individual in accordance with basic medical insurance 1% contribution every month in base pay.
    Local supplementary medical insurance fund earmarked special accounting.
    19th large medical cost social relief fund sources for the insured persons 5 Yuan per person per month, paid by active workers and retirees. 20th conditions the employer shall continue in accordance with the provisions of the interim measures on Enterprise complementary medical insurance in the urban area, Suzhou city, take a variety of forms to establish supplementary medical insurance.
    Supplementary health insurance in the total wages of staff and workers of 3% within the drawing, from the cost would be covered by.
    21st medical insurance fund paid channel: administrative offices and fully funded by the financial institutions included in the departmental budget, funds in local financial budget; other institutions according to the original funding channels; business expenses from the employee benefits expenses.
    22nd medical insurance funds into the financial management accounts, earmarking may not be misappropriated. Article 23rd withdrawn, mergers, acquisitions, transfer, lease, when contracting, receive, or continue to the contractor shall be liable for its employees ' medical insurance, timely payment of employees ' medical insurance premiums.
    Bankrupt enterprise shall be in accordance with the relevant provisions of the Bankruptcy Act, giving priority to pay off unpaid health insurance premiums. 24th medical insurance premium or tax authorities on a monthly basis by the social security centre collection.
    Employers and workers shall, in accordance with the provisions of the regulations on collection and payment of social insurance in Jiangsu Province, paid medical insurance premiums.
    Employers should be announced to the staff health insurance premiums paid on a regular basis, and accept supervision by the workers.
    25th individual medical insurance premium paid by, not included in the personal income tax base and value of medical insurance fund and shall be exempt from tax.
    The fourth chapter of basic medical insurance fund, 26th Division of basic medical insurance funds and personal accounts for basic medical insurance funds and personal accounts in two parts. 27th social centre for all insured persons in the establishment of basic medical insurance individual account (hereinafter referred to as personal account).
    Personal accounts coding using citizen identity number.
    28th proportion of recorded personal accounts and amounts.
    (A) the fee specified percentage of total wages for employees according to my (personal section) recorded: 45 years old according to my payment total wages of staff and workers of 3% credited; more than 45 years of age (45 years old) employee press 3.5% I pay wages credited.
    (Ii) retired personnel by age paragraph respectively determine for: 70 age following by annual 500 Yuan remember into; 70 age above (containing 70 age) by annual 550 Yuan remember into; founding Qian participate in revolution work of old workers per person annual 900 Yuan; Enterprise retired model workers of personal account in above standard based Shang separately increased, which: national lamor per person annual increased 400 Yuan, provincial lamor per person annual increased 200 Yuan. Article 29th personal accounts are mainly used for out-patient medical expenses, personal accounts can be used either in previous years can also be used for hospital medical expenses of outpatient ego part. Personal account if you have balances that year, according to provisions of interest.
    Personal account of principal and interest for the individual, and can be carried forward for use, and inherited according to law.
    30th the employer pay credited to the individual account of basic medical insurance other than the part as the basic medical insurance fund, managed by the social security centre, to coordinate the use.
    31st basic medical insurance funds for insured persons in designated medical institutions inpatient and outpatient health care costs to a particular item, should be paid as required by the social security centre part. Article 32nd outpatient diagnosis refers to a particular item by specifying the hospital, out-patient specific treatment programs of social security centers.
    Out specific projects include: critically ill with uremic dialysis, outpatient treatment of cancer chemotherapy and radiotherapy, organ transplant anti-rejection drugs, mental illness schizophrenia, severe depression, accompanied by psychotic symptoms of mania, bipolar disorder (hereinafter referred to as severe mental illness), as well as home care. The fifth chapter of medical insurance benefits

    Article 33rd when insured persons are sick, the employee's medical insurance card issued by the social security centre, the employees ' medical insurance in medical records and the social insurance card (IC card) to the designated medical institutions or appointed retail drugstores (hereinafter referred to as fixed-point units) doctor dispensing, enjoy basic medical insurance treatment provided. Article 34th insured persons in outpatient medical expenses a targeted, paid out of the personal account; personal account after use and outpatient patients by basic medical insurance for a specific project in accordance with the regulations of the Fund be supplemented.
    Other outpatient medical expenses of basic medical insurance ranges from local supplementary medical insurance fund or to establish supplementary medical insurance for certain benefits. 35th article parameter insurance personnel in Sentinel medical institutions occurred of hospital medical costs, implemented determine up pay standard, and over up pay standard part segment paid and basic medical costs capped approach: (a) parameter insurance personnel first hospital of up pay standard by different grade Hospital respectively determine for, city level and the city level above hospital: on-the-job workers 1000 Yuan, retired personnel 800 Yuan; district (County) level hospital: on-the-job workers 750 Yuan, retired personnel 600 Yuan And township grass-roots hospitals: employees and retirees are the 400 Yuan. Standard of pay and other specialized hospitals of traditional Chinese medicine. When hospitalized for the second time standards for the first time to pay the standard 50% when more than a third in hospital up to the same standard of 200 Yuan. Worker hospitalized more than 180 consecutive days every 180 days to make a settlement in hospital, part of the more than 180 days according to the readmission. Local referral the insured due to the illness of personnel needs, calculated according to the higher standard of paying hospitals.
    Payment of medical expenses incurred by the insured individual ego, personal account balance funds available the previous year also be offset. (Ii) each hospital over up pay standard, and in 40,000 Yuan within of meet medical insurance knot pay provides of hospital costs, and manpower Fund and personal implemented segment by proportion paid approach, personal segment burden proportion for: 10,000 yuan following (containing 10,000 yuan) of part, on-the-job workers conceit 20%, retired personnel conceit 15%; 10,000 yuan to 20,000 yuan (containing 20,000 yuan) of part, on-the-job workers conceit 15%, retired personnel conceit 10%; 20,000 yuan to 40,000 yuan (containing 40,000 yuan) of part, on-the-job workers conceit 10%,
    Retirees ego 5%.
    36th article outpatient specific project of medical with in personal account with finished Hou, by Social Security Center by following approach knot pay: (a) heavy syndrome uremia dialysis (including using restructuring people red blood cells generated pigment) costs, and organ transplant Hou anti-row different drug treatment, and malignant tumors chemotherapy radiotherapy of drug and the treatment costs in 40,000 Yuan within of part, by basic medical insurance and manpower Fund knot pay 90%, personal since pay 10%. (B) severe mental patients on an outpatient basis using prescribed psychiatric drugs, cost per year access to basic medical health care insurance quota of 2000.
    Within this limit, funds according to 60% workers, 70% paid proportion of retirees.
    (C) severe uremia after dialysis, organ transplant anti-rejection drug therapy, chemotherapy and radiotherapy of malignant tumors as well as severe mental illness, calculated according to annual health care out-patient paid to a particular item, in outpatient specific pay period paid project cost according to the above standards.
    (D) home care medical clearing every 180 days, each time the payment standard is 500 Yuan, can enter the basic medical insurance the cost limit for 3000 Yuan (without paying), within this limit, the basic medical insurance fund paid 80%.
    37th based on the principle of guaranteeing the basic medical workers one year cumulative inpatient and outpatient medical costs 40,000 yuan for a specific project top line, more than 40,000 yuan above the CAP cost, basic medical insurance funds are no longer paid.
    38th annual total inpatient and outpatient health care costs to a particular item lines for five more than 40,000 yuan to 200,000 yuan, in line with the scope of medical insurance paid, social relief funds paid by a large medical costs 95%, personal ego 5%.
    39th for low-income and disadvantaged families, workers, due to excessive medical expenses and affect the lives of working families, by appropriate subsidies from the welfare of workers, or through employees help each other on mutual assistance activities. 40th after employers and workers pay health insurance premiums for the month, from next month on health insurance benefits; not required to pay Social Security Center from the month following the suspension of the treatment of insured persons covered by health insurance.
    Medical costs incurred during the suspension, borne by the employers and trade unions, health insurance fund shall not be paid.
    41st employer and their employees participate from the months of basic medical insurance, should be continuous uninterrupted payment of health insurance premiums to the national statutory retirement age. 42nd when employees retire, pay health insurance costs the minimum age, must reach men for 30 years and women under 25 years.
    According to last year's average of less than age and Medicare payment rate that year, once paid in full until after the above payment years of health insurance before they can enjoy medical insurance benefits for retired workers.
    Full implementation of the basic medical insurance for urban area of Suzhou time (July 1, 2002) to insured persons, the basic old-age insurance payment period and the actual payment period, considered to be the basic medical insurance payment years.
    Article 43rd insured mobility, death or termination of an employment contract, the employer upon proof to the social security centre on health insurance changes or termination procedures. The sixth chapter designated medical institutions and the management of appointed retail drugstores 44th basic medical healthcare institutions and appointed retail pharmacy management system.
    Designated medical institutions, qualifications of appointed retail drugstores and managed approach, developed separately by the labor and social security authorities and the relevant sectors.
    45th Security Center with designated medical institutions, appointed retail drugstores medical insurance services agreement, specifying the responsibilities, rights and obligations.
    Article 46th insured persons in the designated medical institutions dispensing or Medicare private prescription directly to the designated retail pharmacy to buy drugs.
    Drug list for basic medical insurance for non-prescription drugs, insured persons may in medical records, medical insurance card and social security card swipe the card directly to the designated retail pharmacies to buy.
    47th designated medical institutions and appointed retail drugstores in the medical treatment of insured prescription, check the certificate of medical insurance for workers, and on the employees ' medical insurance medical doctor dispensing detail records.
    48th designated medical institutions and appointed retail drugstores should strictly implement the basic medical insurance drug list and the list of basic medical insurance diagnosis and treatment facilities and services and the management measures of Suzhou city basic medical insurance drug list and other relevant provisions, outside the medical expenses, medical insurance is not paid.
    49th medical institutions and appointed retail drugstores should be staffed with full-time management staff, a sound internal management system, actively cooperate with the social security centre for improving medical insurance management, reasonably control the growth of medical costs.
    50th Labor Protection Department, in conjunction with health, drug, prices, and other relevant departments to strengthen the designated medical institutions and appointed retail pharmacy services and management of the supervision and inspection on a regular basis. Seventh chapter medical costs of management and settlement 51st article parameter insurance personnel sick in this city Sentinel medical institutions visits Shi, meet provides of outpatient costs can directly from personal account (IC card) in the paid, personal account insufficient paid Shi by workers personal cash paid; over place added medical insurance and Manpower Management provides of conceit amount Hou, by place added medical insurance and manpower Fund by provides of amount and proportion be grants; hospital costs except should by parameter insurance personnel personal bear of costs outside, The remaining costs are covered by the social security centre with designated medical institutions for settlement.
    Specific measures for the settlement separately. 52nd clinic paid a particular item: critically ill with uremic dialysis, cancer chemotherapy and radiotherapy, severe mental patients under outpatient fees directly to a particular item with the IC card in the designated medical institutions or appointed retail drugstores after dispensing card settlement.
    After an organ transplant anti-rejection medications, home health-care costs, advances made from the insured individual, then with a valid medical insurance bills, expense list, medical records, social insurance card to the Social Security Center paid as required.
    53rd designated medical institutions and social security centres and the individual settlement of medical charges, and shall at the same time to provide pay-related examination, treatment and medication list. 54th fixed-point units and social security centres monthly.
    Social Security Centre for undelivered orders should be submitted by the designated medical institutions for approval, to meet the medical expenses paid under 90% and 10%-end assessment examination, according to the assessment to be allocated accordingly.
    55th approved permanent residence social security officers of the insurance Center field and the diagnosis and treatment of medical expenses incurred in the field, by the social security centre, Suzhou city, according to the basic medical insurance for urban employees go outside and people outside the medical interim measures for the administration of the relevant provisions of the settlement.
    56th insurance staff on during the emergency, in local town (Street) over diagnosis and treatment in medical institutions, unit certificates, medical records, expense list, and settlement documents to the Social Security Center paid as required.
    Apart from the emergency and first-aid, and insured personnel expenses in non-designated medical institutions for treatment, medical insurance is not paid. Eighth chapter penalty is 57th article Sentinel medical institutions and Sentinel retail pharmacy occurred following behavior of, except buckle back violations costs outside, by labor guarantees sector be warning, and can sentenced 10,000 yuan above 30,000 yuan following of fine; constitute crime of, law held criminal: (a) not identification medical insurance medical voucher, occurred fake medical, and dispensing, caused medical insurance fund loss of; (ii) to Medicare drug for at their own expense drug, and health products, and life supplies, to drug easy drug, and to drug easy real of behavior, Loss of health insurance fund (iii) decomposition of prescription or dispensing health care Fund in excess waste; (iv) the illegal acquisition and use of Medicare private prescription, obtaining medical insurance fund (v) sale of counterfeit, fake, expired, expired medicines, against health insurance personnel, obtaining medical insurance funds;

    (Six) repeat charges, and decomposition charges, and independence charges project, more received more remember medical costs, increased medical insurance fund or parameter insurance personnel burden of; (seven) will non-medical insurance fund knot pay range of medical with included medical insurance fund knot pay of; (eight) any extended parameter insurance personnel hospital time, and decomposition hospital, to medical still damage parameter insurance personnel interests, increased medical insurance fund paid of; (nine) forged outpatient or hospital records, will outpatient patients titular hospital, behavior cheat medical insurance fund knot pay of;
    (J) the malicious attacks health care network, network or data damage caused and (11) other serious violations of the relevant provisions of the health insurance, loss of health insurance fund. 58th article employing units has following behavior one of of, labor guarantees sector except recovered should received of medical insurance fund or not reasonable costs outside, depending on plot weight, give informed criticism, and can sentenced 10000 Yuan following fine: (a) will not belongs to workers medical insurance of personnel included medical insurance range of; (ii) less reported workers payroll and less paid medical premium of; (three) false, and heavy reported medical costs of; (four) will not meet health conditions of personnel temporary recruitment to units work,
    Arrangements for its employees ' medical insurance (v) did not change in time insurance medical insurance medical insurance benefits for affected workers and (vi) other acts that violate the provisions of the health insurance. 59th an employer is not required to pay and withholding payment of health insurance premiums, paid by the labor and social security departments ordered; still fails to pay the overdue, outside except to pay unpaid principal and interest, from the date of default of payment, subject to 2 per thousand from day to late fees. Late into the health insurance fund.
    Concealed, omitted base responsibility, in accordance with the relevant provisions of the interim regulations on the collection and payment of social insurance will be punished. 60th article parameter insurance personnel occurred following behavior of, except buckle back violations costs outside, by labor guarantees sector be warning, and can sentenced 1000 Yuan following fine; constitute crime of, law held criminal: (a) take with others IC card medical dispensing, cheat medical insurance fund of; (ii) using Medicare policy, large dispensing, changed hands reselling, illegal profit of; (three) and Sentinel medical institutions or pharmacy personnel collusion, to drug easy drug, to drug easy real of; (four) short-term within large repeat dispensing, and
    Health insurance fund will result in waste; (v) IC cards will I lend it to others.
    61st article Social Security Center and subordinates handling institutions staff occurred following behavior of, by labor guarantees sector be administrative sanctions, deadline rectification; constitute crime of, law held criminal: (a) work dereliction of or violation financial discipline caused medical insurance fund loss of; (ii) and parameter insurance personnel or Sentinel units collusion, will not should by medical insurance fund knot pay of costs included Fund knot pay of; (three) levy paid medical premium and the audit medical available engages in, misappropriating public funds should be of;
    (D) the use of bribes, on the mandate and work of personal gain and (v) other serious violations of Medicare rules and against the interests of the insured person.
    Nineth chapter supplementary articles article 62nd all county-level cities under this approach, combined with the actual, specific measures for its implementation.
    63rd city in accordance with economic and social development and changes in the levels of medical expenses, the employer and the individual payment standards and treatment adjusted accordingly. 64th these measures shall come into force on May 1, 2004.
                            After April 1, 2004, prior to the implementation of the present measures employees ' medical insurance management in accordance with the measures implemented.