The social medical insurance mentioned in these Measures includes employee medical insurance, basic medical insurance for residents and serious illness insurance for urban and rural residents. Article 3 Social medical insurance shall adhere to the principles of full coverage, basic coverage, multi-level and sustainability, and establish and improve a multi-level social medical insurance system based on basic medical insurance, combining supplementary medical insurance with serious illness insurance for urban and rural residents, and ensuring a level that is compatible with the level of economic and social development. Article 4 The municipal, city (county) and district people's governments shall incorporate social medical insurance into the national economic and social development plan, raise funds for social medical insurance through multiple channels, establish an overall monitoring system for medical expenses, clarify the control objectives of medical expenses, control unreasonable expenditures of medical expenses, and improve the medical security level of the insured. Article 5 The municipal social insurance administrative department shall be responsible for the management of social medical insurance within the administrative area of this Municipality.
City (county), the district people's government to determine the social medical insurance management department is responsible for the area of social insurance management.
City, city (county) social medical insurance agencies are responsible for the management of specific affairs of social medical insurance in the overall planning area.
Health, finance, public security, food and drug supervision, price and other departments shall, in accordance with their respective responsibilities, do a good job in the management of social medical insurance. Article 6 The people's government in the overall planning area shall set up a social insurance supervision committee composed of representatives of employers, insured persons, trade union representatives and experts to supervise the management and policy implementation of social medical insurance. Chapter II Medical Insurance for Employees Article 7 Medical insurance for employees includes basic medical insurance for employees and supplementary medical insurance for employees. Article 8 Employers and their employees shall participate in medical insurance for employees according to law and pay medical insurance premiums in accordance with state regulations.
Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees of the employing unit and other flexible employees (hereinafter referred to as flexible employees) can participate in the medical insurance for employees according to law, and individuals pay medical insurance premiums in accordance with state regulations. Article 9 The employing unit shall pay medical insurance premiums according to the total wages of employees in the last month, and employees shall pay medical insurance premiums according to their wage income. The upper and lower limits of the employee medical insurance premium payment base are proposed by the municipal social insurance administrative department in conjunction with the municipal finance department and determined after being approved by the Municipal People's government.
The medical insurance payment base of flexible employees is determined by the municipal social insurance administrative department.
The adjustment of medical insurance premium rate for employees shall be proposed by the municipal social insurance administrative department jointly with the municipal finance department, and shall be submitted to the provincial people's government for determination or filing with the consent of the Municipal People's government. Article 10 If an employee retires at the specified age and enjoys the basic old-age insurance benefits on a monthly basis, he/she can enjoy the medical insurance benefits for retirees only after the accumulated payment period of medical insurance for employees (including deemed payment period) is 25 years for male employees, 20 years for female employees and 10 years for actual payment period.
If the accumulated payment period or the actual payment period is insufficient, after paying the average social wage of the previous year and the employer's current medical insurance premium rate announced by the municipal social insurance administrative department, they will enjoy the medical insurance benefits for retirees. Eleventh employees who participate in medical insurance will enjoy medical insurance benefits from the next month when they pay medical insurance premiums.
Flexible employees to participate in medical insurance, the implementation of treatment waiting period system; You can use personal account funds during the waiting period, and you can enjoy medical insurance-related benefits after the waiting period expires. Article 12 The basic medical insurance fund for employees consists of overall funds, individual accounts and risk adjustment funds. Thirteenth basic medical insurance premiums for employees, after deducting the funds included in individual accounts, shall be included in the overall fund to pay the following expenses:
(1) The hospitalization expenses are above Qifubiaozhun and below the maximum payment limit;
(2) Outpatient treatment expenses for special diseases above Qifubiaozhun and below the maximum payment limit;
(three) outpatient co-ordination costs;
(four) other expenses that should be paid by the overall fund.
The scope of special diseases shall be determined and published by the municipal social insurance administrative department jointly with relevant departments. Article 14 Individual accounts shall be transferred by social insurance agencies in accordance with regulations, pre-recorded at the beginning of the year, liquidated at the end of the year and bearing interest, and the balance may be carried forward and inherited.
Personal accounts are used to pay medical expenses incurred in designated medical institutions, as well as medical expenses incurred in the treatment of critical illness in non-designated medical institutions; Those who meet the prescribed conditions can also be used to pay for health-related insurance and other expenses. Article 15 The risk adjustment fund shall be drawn from the overall fund to be used for the medical expenses required by the overall fund if it fails to meet the expenses or the insured has a major emergency.
The extraction ratio and use method of risk adjustment fund are proposed by the municipal social insurance administrative department, audited by the municipal finance department, and implemented after being approved by the Municipal People's government.