Contents
Chapter 1 General Principles
Chapter 2 Fund Raising
Chapter 3 Fund Utilization
Chapter 4 Supervision and Administration
Chapter 5 Legal Liability
Chapter 6 Supplementary Provisions
Chapter 1 General Principles
Article 1 In order to strengthen the supervision and management of the medical insurance fund, safeguard the safety of the fund, promote the effective use of the fund, and safeguard the legitimate rights and interests of citizens' medical insurance, these measures are formulated in accordance with the Law of the People's Republic of China on Social Insurance, Regulations on the Supervision and Management of the Use of the Medical Insurance Fund and other laws and regulations, and in the light of the actual situation of this province.
Article 2 These measures apply to the administrative region of the province's basic medical insurance (including maternity insurance) fund, medical assistance fund and other medical insurance fund, the mobilization, use and supervision and management.
Article 3 The supervision and management of the medical insurance fund is a combination of government supervision, social supervision, industry self-discipline and personal trustworthiness.
Article 4 The people's governments at or above the county level shall strengthen the leadership of the supervision and management of medical insurance funds, coordinate and solve the major problems in the supervision and management of medical insurance funds, establish and improve the supervision and management mechanism of medical insurance funds and law enforcement system, and strengthen the supervision and management of medical insurance funds and the construction of the capacity of the team to provide protection for the supervision and management of medical insurance funds.
Article 5: The administrative departments of medical insurance of the people's governments at or above the county level shall be responsible for the supervision and management of the medical insurance fund within the administrative regions.
The competent departments of health care of the people's governments at or above the county level are responsible for supervising and regulating the practice of medical institutions in accordance with the law; and the market supervision and management departments of the people's governments at or above the county level are responsible for supervising and inspecting the behavior of medical service prices.
Other relevant departments of the people's governments at or above the county level are responsible for the supervision and management of the relevant medical insurance funds within their respective areas of responsibility.
Article VI of the medical institutions, drug business units (hereinafter collectively referred to as pharmaceutical institutions) and other units shall implement the main responsibility for the use of medical insurance fund, standardize the behavior of medical services.
Pharmaceutical and health and other industry associations should develop self-regulatory conventions, promote industry self-regulation and self-restraint, and enhance the integrity of the industry.
Chapter II Fund Mobilization
Article 7 of the medical insurance fund to implement the municipal level, and gradually implement the provincial level.
Employers and employees shall, in accordance with state regulations **** the same employees' basic medical insurance premiums.
Basic medical insurance for urban and rural residents shall be a combination of individual contributions and government subsidies.
Article 8 Employees of an employing organization shall participate in basic medical insurance for employees in accordance with the law.
Individual industrial and commercial households without employees, part-time workers who have not participated in the basic medical insurance for employees at their employing units, and other flexibly employed persons may participate in the basic medical insurance for employees.
People who do not participate in the basic medical insurance for employees or who are not entitled to other medical protection in accordance with the regulations shall participate in the basic medical insurance for urban and rural residents in accordance with the law.
People who participate in the basic medical insurance for employees and the basic medical insurance for urban and rural residents are hereinafter collectively referred to as insured persons.
Article 9 Employers shall declare themselves and pay the basic medical insurance premiums in full and on time.
Medical insurance agencies shall approve the contribution base for employers and insured persons in accordance with the relevant national and provincial regulations.
Basic medical insurance premium collection agencies shall collect employees' basic medical insurance premiums in full and on time, and shall not suspend or reduce payment except for force majeure and other legal reasons.
Article 10 Employers shall not engage in the following acts when participating in the insurance premiums:
(1) failing to apply for the registration of employees' basic medical insurance, payment of the premiums, or change of procedures in accordance with the regulations;
(2) untruthfulness of financial and accounting statements, concealment or underreporting of employees' total wages or information about the insured;
(3) issuing false certificates of labor and personnel relations;
(iv) withholding or misappropriating the employees' basic medical insurance premiums paid by the insured.
Article 11 Participants shall not participate in basic medical insurance by falsifying household registration, school registration, labor-management relationship or fraudulently using other people's information.
Chapter III Use of Funds
Article 12 The use of the medical insurance fund shall be in accordance with the scope of payment stipulated by the State. The following medical expenses shall not be included in the scope of payment of the basic medical insurance fund according to law:
(1) those that should be paid from the Workers' Compensation Insurance Fund;
(2) those that should be borne by a third party;
(3) those that should be borne by the public ****health;
(4) those who seek medical treatment outside of China.
Medical expenses shall be borne by a third person in accordance with the law, and if the third person fails to pay or if the third person cannot be identified, the basic medical insurance fund shall pay in advance. The basic medical insurance fund shall have the right to recover the expenses from the third party after paying them first.
Article 13 The individual account of employees' basic medical insurance can be used, in accordance with the state regulations, to pay for the individually borne medical expenses incurred by the insured person himself, his spouse, his parents and his children when they seek medical treatment at the designated medical institutions, the individually borne expenses incurred by them when they buy drugs, medical equipment and medical consumables at the designated retail pharmacies, and the individual contributions made by them when their spouses, parents and children participate in the basic medical insurance for urban and rural residents, etc. The basic medical insurance fund has the right to make the first payment. The individual contributions of the spouse, parents and children to the basic medical insurance for urban and rural residents.
Article 14: The people's governments at or above the county level shall, in accordance with the relevant requirements of the State, strengthen the construction of the medical insurance management system, provide standardized and normative medical insurance management services, and achieve full coverage of the province, city, county, township (street) and village (community).
Article 15 of the medical insurance administrative departments to promote medical insurance services into the government service center for business, the establishment of a unified medical insurance service hotline, through the "Wan matter through the Office" and other platforms to realize the medical insurance services for online processing of service matters.
Article XVI of the medical insurance agency shall establish collective bargaining and consultation mechanism with the designated medical institutions, in accordance with the principle of equality and voluntariness, consensus, and eligible designated medical institutions to sign a service agreement. Medical insurance agencies shall, within 15 days after the signing of the agreement to the same level of medical insurance administrative department for the record.
Internet hospitals that meet the conditions set by the state can rely on their entity's medical institutions to apply for the signing of supplementary service agreements.
The medical insurance agency shall announce to the public the name and address of the designated medical institution that has signed the service agreement through the government website, governmental new media, and the notice board in the office hall.
Article 17 The medical insurance agency shall settle and disburse the medical insurance fund in a timely manner in accordance with the service agreement.
Article 18 The fixed-point medical institutions shall establish an internal management system for the use of medical insurance fund, by a specialized agency or personnel responsible for the use of medical insurance fund management, equipped with networking equipment real-time uploading of medical insurance-related information, the establishment of a sound system of management and assessment and evaluation of the relevant medical insurance.
Article 19 of the fixed-point medical institutions and their staff shall implement the real name of the medical and pharmaceutical management regulations, verification of medical insurance vouchers, in accordance with diagnostic and treatment specifications to provide reasonable and necessary medical services, to the insured person to truthfully issue bills and related information, shall not have the following acts:
(a) decomposition of hospitalization, hospitalization;
(b) violation of (ii) over-diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescribing, and repeated prescribing;
(iii) double charging, over-standard charging, and decomposition of project charging;
(iv) collusion of medicines, medical consumables, diagnostic and treatment items, and services;
(v) inducing or assisting others to seek medical treatment and purchase medicines under false pretenses or under false names.
The designated medical institutions shall ensure that the expenses paid by the medical insurance fund are in accordance with the stipulated scope of payment; in addition to emergency treatment, rescue and other special circumstances, the provision of medical services outside the scope of payment by the medical insurance fund shall be agreed by the insured person, or his close relatives or guardians.
Article 20 The insured person shall hold his medical insurance voucher for medical treatment and purchase of medicines, and take the initiative to present it for inspection. Participants have the right to request the designated medical institutions to truthfully produce the cost documents and related information.
Participants should keep their medical insurance vouchers in a safe place to prevent others from using them under false pretenses. If for special reasons it is necessary to entrust another person to purchase medicines on their behalf, they should provide proof of the identity of the entrusted person and the trustee.
Participants shall enjoy medical insurance benefits in accordance with the regulations and shall not be entitled to duplicate benefits.
Participants have the right to request the medical insurance organization to provide medical insurance consulting services and to make suggestions for improvement in the use of the medical insurance fund.
Article 21 Participants shall not take advantage of their entitlement to medical insurance benefits to resell medicines, accept the return of cash or in-kind goods or obtain other illegal benefits.
Designated medical institutions shall not facilitate participants to take advantage of their enjoyment of medical insurance benefits to resell medicines, accept the return of cash or in-kind goods, or obtain other illegal benefits.
Article 22: Medical insurance agencies, designated medical institutions and other units and their staff, as well as insured persons and other persons, shall not fraudulently obtain medical insurance funds by forging, altering, concealing, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information, and other relevant information, or by fictionalizing medical service items.
Article 23 promotes the integrated development of medical insurance in the Yangtze River Delta, implements a unified basic medical insurance policy, and gradually realizes the unification of the catalog of medicines, diagnostic and therapeutic items, and the catalog of medical service facilities.
Chapter IV Supervision and Management
Article 24 The medical insurance administrative department shall strengthen the budgetary management of the medical insurance fund, improve the safety prevention and control mechanism of the medical insurance fund, and ensure the safe, efficient and reasonable use of the medical insurance fund.
Article 25 The administrative department of medical insurance shall strengthen the exchange of information and *** enjoyment with the relevant departments, innovate supervision and management methods, promote the use of information technology, relying on the national unified medical insurance information system, the implementation of real-time dynamic and intelligent monitoring of big data, and to strengthen the management of the whole process of *** enjoyment of the use of the data, to ensure *** enjoyment of the security of the data.
Article 26 The administrative department of medical insurance shall establish and improve the system of daily inspections, special inspections, cross-checks and thorough investigations to realize the whole process and all-round supervision of the medical insurance fund.
Article 27 The administrative department of medical insurance may carry out joint inspections with the departments of health, traditional Chinese medicine, market supervision and management, human resources and social security, finance and public security.
Article 28 The administrative department of medical insurance may introduce third-party forces such as information technology service organizations, accounting firms, and commercial insurance organizations to participate in the supervision and management of the medical insurance fund through the purchase of services by the government.
Article 29 The administrative department of medical insurance implements the national credit management system, incorporates the results of daily supervision and inspection and the results of administrative penalties into the national credit information ****sharing platform and other relevant information disclosure systems, and implements disciplinary measures in accordance with the relevant provisions of the state.
Article 30 The administrative department of medical insurance shall establish an information disclosure system, regularly publicize the results of supervision and inspection of the medical insurance fund to the society through the official website, WeChat public number or the news media, expose the cases of illegal use of the medical insurance fund according to law, and accept the supervision of the society.
Article 31 The administrative department of medical insurance shall regularly carry out law enforcement capacity training for administrative law enforcement personnel.
Medical security agencies shall do a good job of publicizing and training the medical insurance policies, management systems, payment policies, and operational procedures of designated medical institutions, and provide medical insurance consulting and inquiry services.
Article 32 of the fixed-point medical institutions should be organized to carry out medical insurance fund related systems, policies, learning and training, regular inspection of the use of medical insurance fund, and timely correction of irregularities in the use of medical insurance fund.
Article 33 of the medical insurance and other administrative departments, medical insurance agencies, accounting firms and other institutions and their staff shall not obtain in the course of their work, know the data of the subject of the investigation or related information for purposes other than the supervision and management of the medical insurance fund, and shall not disclose, tamper with, destroy, or unlawfully provide others with the subject's personal information and commercial secrets.
Chapter V Legal Liability
Article 34 If an employer violates the provisions of the third and fourth subparagraphs of Article 10 of these Measures, it shall be ordered by the administrative department of medical insurance to make corrections; if it fraudulently obtains medical insurance benefits, it shall be ordered by the administrative department of medical insurance to return the basic medical insurance fund that it has fraudulently obtained and shall be subject to a fine of not less than two times and not more than five times the fraudulently obtained amount.
Article 35 If a participant violates the provisions of Article 11 of these Measures, the administrative department of medical insurance shall order him to make corrections; if he cheats on his medical insurance treatment, the administrative department of medical insurance shall order the return of the basic medical insurance fund that he cheated on and impose a fine of not less than two times and not more than five times the amount of the cheating.
Article 36 Any staff member of the administrative department of medical insurance or other administrative departments who abuses his power, neglects his duties, or engages in favoritism or malpractice in the supervision and management of the medical insurance fund shall be dealt with in accordance with the law.
Article 37 Violation of the provisions of these Measures, the relevant units or individuals causing losses, shall bear the responsibility for compensation.
Article 38 Violation of the provisions of these measures, the Chinese People's **** and the State Social Insurance Law "Regulations on the Supervision and Management of the Use of the Medical Insurance Fund" and other relevant laws and regulations have been punished, shall be subject to its provisions.
Chapter VI Supplementary Provisions
Article 39 These Measures shall come into force on May 1, 2022, and the "Interim Measures for Supervision and Administration of Basic Medical Insurance in Anhui Province" shall be repealed simultaneously.