Go to the social security bureau for reimbursement, take the invoice, list, ID card, hospitalization medical records, diagnostic certificates.
Tianjin basic medical insurance regulations
Chapter I General
Article 1
In order to standardize the relationship between basic medical insurance, and to safeguard the legitimate rights and interests of citizens to participate in basic medical insurance and enjoy the benefits of basic medical insurance, in accordance with the "People's Republic of China *** and the State Social Insurance Law" and the relevant provisions of the State, combined with the actual situation in the city, to formulate the present provisions.
Article 2
The basic medical insurance system adhere to the policy of broad coverage, basic protection, multi-level, sustainable, in accordance with the principle that the level of protection and the level of economic and social development, according to the financial situation, the employer and the individual affordability to determine the financing standards, the implementation of urban and rural co-ordination, city-wide co-ordination, and the gradual realization of the workers and residents of the basic medical insurance system articulated conversion.
Article 3
The employers and their employees and retirees within the administrative area of the city, as well as urban and rural residents shall participate in basic medical insurance in accordance with the provisions of this regulation. Basic medical insurance includes employees' basic medical insurance and residents' basic medical insurance. Institutions, groups, enterprises, institutions, private non-enterprise units, other organizations and individual industrial and commercial households with employees (collectively referred to as employers) and their employees and retirees shall participate in the basic medical insurance for employees. Students, children and unemployed urban and rural residents shall participate in basic medical insurance for residents. Individual industrial and commercial households without employees, part-time workers who do not participate in the basic medical insurance for employees at the employing organization, and other flexibly employed persons may choose to participate in either the basic medical insurance for employees or the basic medical insurance for residents.
Article 4
The people's governments of cities and districts and counties shall incorporate the cause of basic medical insurance into their national economic and social development plans, and give it the necessary financial support. The people's governments of the districts and counties shall organize employers and residents in their administrative areas to participate in basic medical insurance in accordance with the law.
Article 5
The municipal administrative department of human resources and social security is responsible for the administration of basic medical insurance in the city. Departments of finance, health, education, pricing, food and drug supervision, audit, civil affairs, industry and commerce, and public security are responsible for the relevant basic medical
health insurance work within their respective areas of responsibility.
Article 6
The municipal medical insurance agency is responsible for the registration of basic medical insurance, the collection of insurance premiums, the recording of individual rights and interests, and the payment of insurance benefits, and it provides guidance on the handling of medical insurance services such as fixed-point medical institutions and fixed-point pharmacies.
Article 7
The city establishes a multi-level medical insurance system, encourages the development of supplementary medical insurance, and the government supports the establishment of supplementary medical insurance by enterprises.
Article 8
The municipal human resources and social security administration department employs representatives of employers, representatives of insured persons, and relevant experts as social supervisors of medical insurance to implement social supervision of the relevant departments and personnel of medical insurance management and administration services, designated medical institutions, designated pharmacies, and physicians and pharmacists, and compliance with the basic medical insurance laws, regulations and rules by employers and insured persons. Implementation of social supervision. Any organization or individual has the right to report or complain about violations of basic medical insurance laws, rules and regulations.
Article 9
Medical insurance agencies shall regularly publicize to the community the status of participation in medical insurance, as well as the income, expenditures, balances and revenues of the medical insurance fund.
Chapter II: Raising Basic Medical Insurance Premiums
Article 10
Employing units and employees, retirees and residents shall pay basic medical insurance premiums in accordance with the prescribed standards.
Article 11
Employees shall pay monthly basic medical insurance premiums at a rate of not less than 2% of their average monthly wages for the previous year, and employers shall pay monthly basic medical insurance premiums at a rate of not less than 10% of the sum of the individual employee's contribution base. The entire amount of the basic medical insurance premiums paid by the individual employee and the portion transferred from the basic medical insurance premiums paid by the employer in accordance with the regulations shall be credited to the individual account. The principal and interest of the individual account shall be owned by the individual, and the interest on the individual account shall be calculated with reference to the bank's interest rate on demand savings deposits for the same period.
Article 12
If the average monthly salary of an employee in the previous year is higher than 300% of the average monthly salary of an employee in the city in the previous year, 300% of the average monthly salary of an employee in the city in the previous year shall be used as the base for payment of basic medical insurance premiums. If the average monthly salary of the employee in the previous year is lower than 60% of the average monthly salary of the employees in the city in the previous year, 60% of the average monthly salary of the employees in the city in the previous year shall be the basis for the payment of basic medical insurance premiums. If the employee's average monthly salary for the previous year cannot be determined, the average monthly salary of the employees in the city for the previous year shall be the basis for the payment of basic medical insurance premiums.
Article 13
If an employer has difficulties in making contributions in accordance with the provisions of Article 11 of these Regulations, the employer may, upon the approval of the employees' representative assembly or the employees' general meeting, reduce the contribution ratio in accordance with the relevant regulations and not establish an individual account. Individual industrial and commercial households without employees, part-time workers who are not insured by their employers, and other flexibly employed persons may pay the basic medical insurance premiums in accordance with the relevant provisions, without establishing individual accounts.
Article 14
Residents participating in basic medical insurance are subject to a differential contribution system. Students, children and adult residents pay basic medical insurance premiums in accordance with the prescribed standards. Adult residents pay contributions at different levels, which they choose to pay voluntarily. The Government provides appropriate subsidies for individual contributions in accordance with the prescribed standards. Persons with severe disabilities, low-income insurance and those from families with special difficulties are enrolled in the insurance program according to the prescribed levels
Personal contributions are not required and are fully subsidized by the government. Residents should pay their basic medical insurance premiums for the following year in a lump sum between September and the end of December each year.
Article 15
Subsidized funds for residents' participation in basic medical insurance shall be borne by the municipal and county people's governments*** together.
Article 16
The Municipal People's Government shall, in accordance with the level of economic and social development, make corresponding adjustments to the standards of contributions and government subsidies for basic medical insurance. Municipal human resources and social security administrative department in conjunction with the municipal finance and other relevant departments to formulate the adjustment program, reported to the municipal people's government for approval and implementation.
Chapter III basic medical insurance treatment
Article 17
Employees enjoy basic medical insurance treatment from the month of payment. If an employee reaches the legal retirement age and has paid basic medical insurance premiums for a total of 25 years for men and 20 years for women, and has actually paid premiums for 5 years, he or she shall not pay basic medical insurance premiums after retirement and shall continue to enjoy the basic medical insurance benefits; if he or she has not paid the premiums for the above number of years, he or she shall enjoy the basic medical insurance benefits after he or she has paid the basic medical insurance premiums payable by his or her employer and individual in a single lump sum according to the payment standard of the current year at the time of his or her retirement. Medical insurance treatment. Individual industrial and commercial households without employees, part-time workers who are not insured by their employers, and other flexibly employed persons are entitled to basic medical insurance benefits from the time they have paid contributions for six months. Students and children who are enrolled in schools and nurseries are entitled to basic medical insurance from September of the year of payment to August of the following year, while other residents are entitled to basic medical insurance from January to December of the year following the year of payment.
Article 18
The medical expenses incurred by insured persons for hospitalization, outpatient (emergency) consultation, etc., which are in line with the scope of the national and municipal catalogs of medicines, diagnostic and therapeutic items, and the catalogs of medical services (collectively referred to as reimbursement scope) of the basic medical insurance shall be paid out of the basic medical insurance fund in accordance with the regulations.
Article 19
The starting standard for reimbursement of medical expenses incurred by insured persons for hospitalization is determined according to the level of the hospital and the number of hospitalizations. If a participant is hospitalized for more than two times within one year, the starting standard shall be 30% from the second hospitalization for employees and retirees, and no more starting standard for residents.
Article 20
The hospitalization reimbursement rate of the basic medical insurance for employees shall be appropriately taken care of for retirees and other groups, and the hospitalization reimbursement rate of the basic medical insurance for residents shall be set according to the rank of the hospitals and the level of contributions.
Article 21
The maximum payment standard for basic medical insurance hospitalization shall be implemented in accordance with national regulations. Employees and retirees are subject to the same maximum payment standard for hospitalization at all levels of hospitals, while the maximum payment standard for residents' hospitalization is set in accordance with the level of hospitals and the level of contributions.
Article 22
The reimbursement rate for outpatient (emergency) medical expenses for common diseases within the scope of reimbursement incurred by employees and retirees shall be set in accordance with the level of hospitals. The reimbursement rate for residents' outpatient (emergency) medical treatment in first-class hospitals (including community health centers) shall be determined in accordance with the level of contributions.
Article 23
Participants suffering from diseases within the scope of the regulations may apply for treatment in home hospital beds due to their advanced age and mobility, and the medical expenses incurred shall be subject to the policy of reimbursement of inpatient medical expenses. The standard of basic medical insurance treatment for insured persons suffering from outpatient specific diseases within the prescribed scope is determined in accordance with a higher standard than that for outpatient (emergency) general diseases.
Article 24
The medical expenses of insured persons suffering from Class A infectious diseases shall be fully paid by the basic medical insurance fund. Appropriate care shall be given to patients suffering from other infectious diseases.
Article 25
The Municipal People's Government shall, according to the level of economic and social development and the ability of the basic medical insurance fund to pay, make corresponding adjustments to the level of basic medical insurance benefits. The municipal human resources and social security administrative department, in conjunction with the municipal finance and other relevant departments, shall formulate an adjustment program and submit it to the municipal people's government for approval and implementation.
Chapter IV: Collection and Settlement of Basic Medical Insurance Premiums
Article 26
Basic medical insurance premiums are collected by the city as a whole. The medical insurance organization is responsible for the specific work of collecting basic medical insurance premiums.
Article 27
Registration of residents for basic medical insurance is carried out on a categorized basis, and residents shall register with the medical insurance agencies in accordance with the following provisions:
(1) Students and children in schools and childcare institutions at all levels and in all types of schools and childcare institutions shall be responsible for registering for medical insurance with the medical insurance agencies;
(2) Persons enjoying the benefits of the low income insurance, persons from families with special difficulties, and persons in favor of the welfare of the people (c) Persons with severe disabilities are identified by the Disabled Persons' Federation and the details of the persons are forwarded to the medical insurance agency for registration;
(iii) Persons with severe disabilities are identified by the Disabled Persons' Federation and the details of the persons are forwarded to the medical insurance agency for registration;
(iv) Spouses and widows of retired cadres shall have their identities confirmed by the management of the old cadres and their details forwarded to the medical insurance agency, which shall then register them for coverage;
(e) rural residents shall register for coverage at the township and street labor security service agencies respectively, on a village-by-village basis, and other residents on a family-by-family basis.
Article 28
Students and children enrolled in school and nursery schools shall have their basic medical insurance premiums collected and paid on their behalf by the schools and nursery institutions. Rural residents shall be collected and paid on their behalf by the village committees.
Article 29
Medical insurance agencies pay medical expenses in full and on time to designated medical institutions, designated pharmacies or insured persons in accordance with the provisions of basic medical insurance in accordance with the methods of total pre-payment, payment by type of disease, payment by item, payment by head, or negotiated payment.
Article 30
Participants who seek medical treatment and purchase medicines through the medical insurance information-based payment system for immediate settlement of medical expenses shall pay only the portion of the medical expenses borne by individuals to the designated medical institutions or designated pharmacies, and the other expenses shall be settled on a monthly basis by the medical insurance administrative organization and the designated medical institutions and designated pharmacies. Where the State and the City have special provisions on advance payment, they shall apply.
Chapter V: Management of Basic Medical Insurance Services
Article 31
Medical insurance agencies shall establish and improve operational, financial, security and risk management systems. Medical insurance agencies collect and summarize relevant data through business operations and statistical surveys, and relevant units and individuals shall provide timely and truthful information. Streets, townships, labor security service agencies and their community and village labor security work agencies are responsible for organizing residents to participate in the survey of resources, participation in the registration of approved and advance medical fee collection.
Article 32
Medical insurance agencies may, in accordance with the needs of management services, sign service agreements with designated medical institutions and designated pharmacies to regulate the behavior of medical services.
Article 33
Specified medical institutions and designated pharmacies shall specify the medical insurance work organization, determine the basic medical insurance full-time (part-time) staff, and be responsible for the basic medical insurance management and service work of the organization.
Article 34
Specified medical institutions shall give priority to providing medical services to insured persons within the scope of the prescribed basic medical insurance drug catalog, diagnostic and therapeutic item catalog, and medical service facility catalog. When providing insured patients with drugs, medical consumables, and diagnostic and therapeutic items at their own expense, they shall obtain the consent of the insured patients in advance, and at the same time shall provide a breakdown of the medical expenses.
Article 35
Designated pharmacies shall establish a management system compatible with the basic medical insurance; ensure the quality and variety of medicines used for the basic medical insurance, and provide reasonable medication counseling services for the insured.
Article 36
The municipal administrative department of human resources and social security, in conjunction with the municipal health, food and drug supervision and other departments, shall establish and improve the management system of the basic medical insurance directory of physicians and pharmacists, and supervise and inspect the implementation of the basic medical insurance policies by the physicians and pharmacists.
Basic medical insurance service physician, pharmacist directory specific management by the municipal human resources and social security administrative departments in conjunction with the municipal health, food and drug supervision and other departments to formulate.
Article 37
In case of disputes between the medical insurance agency and the designated medical institution or designated pharmacy over the fulfillment or change of the service agreement, they may apply for mediation to the mediation agency for medical insurance settlement disputes, or file a lawsuit with the People's Court.
Article 38
The municipal administrative department of human resources and social security establishes and improves the basic medical insurance information system, and realizes the functions of enrollment in the network for registration and payment of premiums, payment of benefits through the network, and real-time monitoring of the network. The medical insurance agency uses the basic medical insurance information system to pay insurance benefits, and shall ensure that all-weather and no-holiday network settlement is realized with the designated medical institutions and designated pharmacies. The designated medical institutions shall establish and improve their own information management systems, and realize network settlement and real-time information ****sharing between outpatient (emergency) clinics, hospitalization and medical insurance agencies. The designated pharmacy shall establish and improve the unit information management system to realize and medical insurance agencies network settlement and real-time information **** enjoy.
Article 39
Participants shall hold their own social security cards to purchase medicines. If a participant is unable to go to a designated medical institution or a designated pharmacy to purchase medicines due to special circumstances, he or she may entrust another person to purchase medicines on his or her behalf with the participant's social security card, and the person entrusted to purchase medicines shall show his or her identity proof.
Article 40
Participants may choose to seek medical treatment and purchase medicines at the designated medical institutions within the prescribed scope, or they may purchase medicines at the designated pharmacies with prescriptions. The medical institutions shall provide outbound prescriptions for the insured persons who choose to purchase medicines at designated pharmacies.
Article 41
The municipal administrative department of human resources and social security, in conjunction with the relevant administrative departments, shall establish an integrity system for basic medical insurance.
Chapter VI Basic Medical Insurance Fund
Article 42
The basic medical insurance fund consists of the following funds:
(1) basic medical insurance premiums paid by employers and insured persons;
(2) government subsidy funds;
(3) social contribution funds;
(4) late payment fees ;
(v) interest;
(vi) other funds.
Article 43
The portion of the basic medical insurance fund raised in the current year shall bear interest at the interest rate of bank demand deposits; the principal and interest of the fund carried over from the previous year shall bear interest at the interest rate of three-month lump-sum bank deposits; and the deposited funds deposited in the social security financial account shall bear interest at the interest rate of three-year lump-sum savings deposits.
Article 44
Basic medical insurance shall be city-wide, and the basic medical insurance fund shall be managed in a special financial account and deposited in the bank which undertakes the business of medical insurance. The basic medical insurance fund includes the employees' basic medical insurance fund and the residents' basic medical insurance fund, which are separately accounted for and accounted for in separate accounts, implementing the unified accounting system of the State.
Article 45
The draft budget and final account of the income and expenditure of the basic medical insurance fund shall be compiled by the municipal medical insurance agency, reviewed by the municipal administrative department of human resources and social security, examined by the municipal financial department, and reported to the municipal people's government for approval before implementation.
Article 46
The people's governments of the districts and counties and the competent units of the designated medical institutions and designated pharmacies shall strengthen the management and supervision of the medical expenses of the designated medical institutions and designated pharmacies, to ensure the legitimate medical needs and to maintain the safety of the operation of the basic medical insurance fund. The designated medical institutions and designated pharmacies shall strengthen the education and management of their physicians, pharmacists and staff, standardize the diagnosis and treatment behavior, and provide reasonably necessary medical services for the insured patients.
Article 47
The administrative departments of human resources and social security shall strengthen the supervision of the medical insurance agencies and the income and expenditure of the basic medical insurance fund, and establish and improve the basic medical insurance fund's budgetary system, financial accounting system and internal audit system; the financial departments are responsible for the management of the basic medical insurance fund's special account; and the auditing departments carry out audit supervision of the basic medical insurance fund according to law. The auditing departments are responsible for the management of the special account of the basic medical insurance fund.
Chapter VII Legal Liability
Article 48
The administrative departments of human resources and social security shall strengthen the supervision of compliance with basic medical insurance laws, regulations and rules. The municipal administrative department of human resources and social security may entrust medical insurance supervision and inspection organizations with the specific implementation of basic medical insurance supervision and inspection and other administrative law enforcement work. Human resources and social security, health, food and drug supervision and other administrative departments shall establish basic medical insurance violations found, investigated, identified communication and coordination and information *** enjoyment mechanism.
Article 49
If a designated medical institution engages in any of the following acts to defraud the basic medical insurance fund of its expenditures, it shall be ordered by the administrative department of human resources and social security to return the defrauded medical insurance premiums, and shall be subject to a fine of not less than two and not more than five times the amount of the defrauded premiums; it shall terminate the service agreement with the medical insurance administration agency; and if the person directly responsible for the competent personnel and other directly responsible personnel have a practicing qualification The health and food and drug regulatory authorities shall revoke their practicing qualifications in accordance with the law:
(1) forging or falsifying the records of medical consultations of insured persons;
(2) admitting insured persons who do not meet the conditions for hospitalization to hospitalization treatment or intentionally prolonging the period of hospitalization, or handling false hospitalization and hospitalization in false names;
(3) admitting insured persons who do not meet the conditions for registration of outpatient specific diseases by forging or falsifying the conditions for registration of outpatient specific diseases; and (C) the participants who do not meet the conditions for registration of outpatient specific diseases, registered as outpatient specific diseases by means of forging or altering relevant certificates and given treatment;
(D) forging, altering, falsely opening, buying, selling, transferring, or failing to keep the special bills for basic medical insurance in accordance with the stipulated time limit;
(E) transferring the basic medical insurance expense card machine, renting out the diagnostic and therapeutic departments to carry out diagnostic and therapeutic activities or applying the record of the physician's name, the name of pharmacist Reporting of medical expenses;
(vi) fraudulent use, convergence of other people's social security card fraudulent basic medical insurance fund;
(vii) duplication of charges, decomposition of charges. The administrative department of human resources and social security shall inform the administrative department of health at the same level if it imposes the penalties stipulated in the preceding paragraph
on a designated medical institution. Medical insurance agency to terminate the service agreement with the designated medical institutions, shall inform the same level of health administration department, and the termination of the service agreement of the designated medical institutions promptly announced to the community.
Article 50
If a designated pharmacy engages in any of the following acts to defraud the basic medical insurance fund of its expenditures, it shall be ordered by the administrative department of human resources and social security to return the fraudulently obtained medical insurance premiums, and shall be subject to a fine of not less than two times and not more than five times the amount of the fraudulently obtained premiums; it shall be terminated from its service agreement by the medical insurance administration agency; and the directly responsible supervisory personnel and other directly responsible personnel who have a license to practice shall be suspended from their licenses by the Food and Drug Administration shall revoke their practicing qualifications according to law:
(1) selling medicines not in accordance with the varieties, specifications, dosage forms, and dosages specified in the outgoing prescriptions, or fabricating or altering the outgoing prescriptions;
(2) substituting non-basic medical insurance medicines or other items for basic medical insurance medicines for sale or forging or altering the medical insurance-related materials such as the bills and the details of the medicines' expenses
(c) fraudulent use or convergence of other people's social security cards to defraud the basic medical insurance fund;
(d) forging, altering, falsely opening, buying, selling, transferring, or failing to keep the special bills for the basic medical insurance in accordance with the prescribed time limit;
(e) the actual amount of the medicines does not correspond to the amount of the bills or the amount of the declarations;
(f) fraudulently using the name of the recorded pharmacist to (f) Declaring medicine expenses, or renting or contracting the designated pharmacy to a non-designated pharmacy.
Article 51
If a licensed physician or pharmacist of a designated medical institution or designated pharmacy commits any of the following acts, the municipal administrative department of human resources and social security shall give a warning and order correction; if the circumstances are serious, the municipal administrative department of human resources and social security, in conjunction with the municipal department of health and food and drug supervision and other departments, shall remove him or her from the directory of physicians and pharmacists of the basic medical insurance service. The physicians, pharmacists and supervisors directly responsible for violating the provisions of this article shall be notified and criticized:
(1) forging or falsifying medical documents or medical certificates, or issuing false prescriptions and falsely declaring the materials related to basic medical insurance;
(2) tampering with non-basic medical insurance medicines or other items as basic medical insurance medicines or tampering with non-basic medical insurance diagnostic and therapeutic items and (c) Issuing prescriptions or vouchers for medicines in the name of treatment for the insured, and colluding with the insured to exchange cash or securities for medicines instead of taking them;
(d) using expensive medicines and large-scale examinations and other diagnostic and therapeutic measures not in accordance with the needs of the condition;
(e) intentionally breaking down prescriptions, prescribing an excessive amount of medicines, and repeatedly prescribing medicines. prescribing, repeat prescribing.
Article 52
If an insured person commits any of the following acts and fraudulently obtains expenditure from the basic medical insurance fund, the administrative department of human resources and social security shall order the return of the fraudulently obtained medical insurance premiums, and impose a fine of not less than two times and not more than five times the amount fraudulently obtained:
(1) using another person's social security card to see a doctor and purchase medicines, or handing over his or her own social security card for another person's
(ii) giving one's social security card to a designated medical institution or designated pharmacy for use;
(iii) forging or altering reimbursement bills, prescriptions, etc.
(iv) reselling basic medical insurance medicines.
Article 53
If a participant commits any of the behaviors stipulated in Article 52 of these Regulations, he/she may have his/her medical expense settlement method adjusted by the municipal human resources and social security administrative department for a period of not less than one month and not more than one year. During the period of adjusting the settlement of medical expenses, the participant shall continue to enjoy the basic medical insurance benefits and the medical expenses incurred shall be reimbursed in accordance with the full advance payment method.
Article 54
If the administrative departments of human resources and social security, medical insurance agencies and their staff members abuse their powers, neglect their duties, or engage in malpractice for personal gain, the directly responsible supervisory personnel and other directly responsible personnel shall be given sanctions in accordance with the law; and if any loss is caused to the employing unit or the individual, the employing unit or the individual shall be held liable to pay compensation.
Chapter VIII Supplementary Provisions
Article 55
The city takes measures to realize the transfer and continuity of the basic medical insurance relationship of the insured across regions.
Article 56
The city establishes a system to provide assistance to employees for large medical expenses. Employees and retirees shall pay the assistance fees in accordance with the prescribed standards and enjoy the corresponding treatment.
Article 57
Establishment of the Basic Medical Insurance Accidental Injury Supplementary Insurance System; in the event of medical treatment, disability and death of insured persons due to accidental injury, the Basic Medical Insurance Accidental Injury Supplementary Insurance funds shall pay for the corresponding treatments in accordance with the prescribed standards.
Article 58
These provisions shall come into force as of March 5, 2012.
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