Longnan City (municipal) urban workers basic medical insurance hospitalization expense settlement management measures
Article 1 In order to further strengthen the management of medical insurance services, enhance the level of management, effective control of medical expenses, safeguard the rights and interests of the insured and medical institutions, to ensure the healthy operation of medical insurance, the fund to achieve a balance of income and expenditure, in accordance with the former Ministry of Labor and Social Security and other five ministries and commissions, "on the Issued to strengthen the urban workers basic medical insurance cost settlement management advice notice" (Ministry of Labor and Social Security issued [1999] No. 23), Longnan region, "urban workers basic medical insurance implementation rules" (Long Department Office [2002] No. 21) of the spirit of the urban workers basic medical insurance, combined with the urban workers of the city's basic medical insurance operation, the development of this approach.
The second hospitalization declaration procedures. The insured person is sick must go to the designated medical institutions. Do need to be hospitalized, by the attending physician issued a hospitalization notice, the insured patient or relatives with a unit letter of introduction and medical insurance card, to the Municipal Social Security Bureau to declare approval for hospitalization procedures. If the employer and the insured person have not paid the basic medical insurance premiums in full according to the regulations, they will not be declared for hospitalization and will not be entitled to the basic medical insurance treatment.
Article 3 Settlement of hospitalization expenses. Participating in the basic medical insurance for urban workers hospitalization costs incurred by the participants and the Social Security Bureau and the designated medical institutions to settle separately. Where the basic medical insurance policy stipulates that the individual's burden of the starting standard, the individual should be responsible for the proportion of the insured person discharged from the hospital directly with the fixed-point medical institutions to settle in cash; the remaining part of the medical costs by the Municipal Social Security Bureau in accordance with the "hierarchical quota, the total amount of control, and regular checking and settlement" approach with the fixed-point medical institutions to transfer the settlement method. The Municipal Social Security Bureau signs a service agreement with the designated medical institutions through an annual review, introduces a competitive mechanism, and carries out dynamic management.
Article IV graded fixed standard. Municipal Social Security Bureau to the designated medical institutions in the previous three years (07, 08, 09) the average cost of discharged patients as the basis, deducting the cost of basic medical insurance payments outside the scope of the reasonable determination of the settlement of the management approach to the implementation of the first year after the fixed rate standard. Subsequent years each year by the Municipal Social Security Bureau of different levels of hospitals in the previous year the average cost of hospitalized persons, after deducting the costs outside the scope of payment of basic medical insurance, approved with all levels of medical institutions per person hospitalization fee settlement quota standard.
Article 5 Settlement and Payment Scope of the Coordinated Fund.
1, all belonging to the "Longnan region urban workers basic medical insurance hospitalization disease catalog" in the disease, hospitalization can be paid by the integrated fund in accordance with the provisions.
2. The costs of medicines included in the "Gansu Provincial Urban Workers' Basic Medical Insurance Drug Catalog" and the medical costs stipulated to be paid in the "Interim Measures for the Administration of the Scope of Diagnostic and Treatment Items and Medical Service Facilities of Gansu Provincial Urban Workers' Basic Medical Insurance" can be paid by the coordinated fund.
Article 6 of the integrated fund disbursement. Municipal Finance Bureau according to the beginning of the year approved the basic medical insurance costs, monthly disbursement to the Municipal Social Security Bureau; Municipal Social Security Bureau in accordance with the settlement procedures and fixed-point medical institutions.
Article 7 of the integrated fund settlement procedures. The fixed-point medical institutions shall fill in the "Approval Form for Disbursement of Hospitalization Medical Expenses" and "Settlement Statement of Hospitalization Expenses" of the discharged persons of the previous month before the 5th day of each month, and attach the "Medical Insurance Certificate" of the hospitalized persons and the list of the hospitalization expenses, and then the Municipal Bureau of Social Security shall, after examination and approval, pay 90% of the fixed standard of the fixed amount to the fixed-point medical institutions within five working days, and the remaining 10% of the fixed amount shall be paid according to the half-yearly appraisal of the fixed-point medical institutions (the The assessment method is formulated separately). At the year-end assessment, if the actual incurred medical fees are below 90% of the flat-rate standard, the settlement will be made according to the actual incurred amount, and the fixed-point medical institution will be appropriately rewarded; if the actual incurred medical fees are within the range of 90%-110% of the flat-rate standard, the settlement will be made according to the flat-rate standard; if the actual incurred medical fees are between 110%-120% of the flat-rate standard, the social security bureau will pay 50% for the part that exceeds it; if the medical fees above 120% of the flat-rate standard are paid by the medical institution, the remaining 10% will be paid according to the half-yearly assessment (the assessment method is formulated separately). 120% or more of the medical expenses shall be borne by the medical institution.
Article 8: The Coordinated Fund establishes a starting standard and a maximum payment limit for the payment of hospitalization expenses. Medical expenses below the starting standard shall be paid by the insured person.
(a) the urban workers basic medical insurance fund starting standard, the first hospital 400 yuan, second hospitals 500 yuan, third hospitals 600 yuan; employee medical insurance annual maximum payment limit of 40,000 yuan;
(b) beyond the maximum payment limit of the cost of medical insurance subsidies by the large medical insurance.
Article IX above the starting standard and below the maximum payment limit part of the medical expenses, mainly by the integrated fund, but individuals also have to bear a certain percentage (see the following table). Indeed, due to the needs of the condition, where the use of the "three catalog" outside of the therapeutic items and medication, the medical institutions must seek the views of the patient or family members, signed consent to be used. Individuals are responsible for 15% of the cost of Class B drugs, 20% of the cost of special examinations and treatments, and the rest is included in the total medical fee.
Steps of hospitalization medical expenses
Employees' personal responsibility
Proportion (%)
Retirees' responsibility
Proportion (%)
Starting line - within 20000 yuan
15
13
20001 -within 40,000 yuan
13
11
40,000 yuan or more
10
8
Article 10: Methods of reviewing hospitalization expenses. The designated medical institutions shall set up corresponding working organizations according to their work needs, and equip specialized personnel who are familiar with the basic medical insurance policies to be responsible for accounting for the hospitalization expenses incurred by the insured patients, and filling out various forms carefully and accurately as required. Medical institutions should be equipped with microcomputers to account for medical expenses (the software is developed by the Municipal Social Security Bureau). The Municipal Social Security Bureau shall periodically or irregularly spot-check the cost audit of medical institutions, and the designated medical institutions shall actively cooperate when checking the relevant medical record information and questioning the insured patients. If any problem is found, it will be penalized according to the relevant provisions of the service agreement.
Article 11 in accordance with the relevant provisions of the basic medical insurance and the service agreement to determine the transfer ratio, it is necessary to transfer to the field hospitalization of insured persons, as well as in accordance with the provisions of the field business trip and family leave during the period of hospitalization due to an acute medical condition, the first by the person in advance, after the completion of the treatment, with the hospitalization expense statement and the relevant medical records to the Bureau of Social Security to handle the reimbursement procedures. All the hospitalization medical expenses of the retirees who are resettled in other places as confirmed by the Municipal Social Security Bureau shall be reimbursed according to the above method.
Article XII of the designated medical institutions shall adhere to the principle of "treatment of disease, reasonable examination, reasonable medication, reasonable fees", and further standardize the medical service behavior of medical personnel. The development of relevant supporting systems, clear responsibilities of the leaders in charge, to determine the full-time staff, strengthen internal management, to eliminate the occurrence of irregularities. The fees and charges of the designated medical institutions shall be subject to the supervision and inspection of the municipal price department. If any irregularities occur in the fixed-point medical institutions, once verified, the Municipal Social Security Bureau will deduct the corresponding irregular fees.
Article XIII of the natural disasters, sudden illnesses, epidemics and other sudden factors caused by a wide range of critical, emergency and serious patients' medical expenses, the municipal government to comprehensively coordinate the solution.
Article XIV of the county (district) with reference to this approach to develop the county (district) implementation rules.
Article XV of these measures shall be implemented from the date of publication, valid for five years.
Longnan city (city) urban workers basic medical insurance individual account management measures
Article 1 in order to strengthen the city's basic medical insurance individual account standardized management, with reference to the "Longnan region urban workers basic medical insurance implementation rules" (Longzhi Office of the [2002] No. 21) of the provisions of the formulation of this approach.
The second municipal urban workers' basic medical insurance participants personal account card management. IC card by the Municipal Bureau of Social Security issued by the unified IC card production. IC card production costs borne by the individual participants.
Article 3: The IC card is used to record the basic situation of the insured and the income and expenditure of the individual account funds.
Article 4: Composition of Individual Account Funds:
(1) All basic medical insurance premiums (2%) paid by the insured person are transferred to the individual account.
(2) The basic medical insurance premiums paid by the organization shall be transferred to the account at 1.6% of the paid wages of the active employees; and 3.8% of the paid wages of the retirees.
(iii) Interest income from the above two parts.
Article 5 Entry of Funds in Individual Accounts:
(1) The Municipal Social Security Bureau establishes an individual contribution ledger and an individual account fund transfer record ledger for the insured.
(2) The Municipal Social Security Bureau shall validate the record of transferring the personal account of the insured person on a monthly basis and transfer the personal account on time and in full.
(3) The personal accounts shall be periodically reconciled by the employer and the Municipal Social Security Bureau.
Article 6 The scope of use of the individual accounts of insured persons:
(1) Medical expenses for outpatient treatment at designated medical institutions;
(2) Expenses for purchasing medicines at designated retail pharmacies;
(3) Other medical expenses that should be borne by individuals.
Article 7: If employers and insured persons fail to pay the full amount of basic medical insurance premiums in accordance with the regulations, the transfer of individual accounts shall be suspended, and the transfer shall be made after the payment of the fees in the year.
Article VIII of the Municipal Social Security Bureau for the participants to set up personal accounts, the issuance of IC cards, and the establishment of personal accounts microcomputer management system. Employers are responsible for the collection and issuance of IC cards for their own insured persons. The designated medical institutions and designated retail pharmacies are equipped with card-swiping machines and are responsible for the settlement and recording of individual accounts.
Article 9: The insured persons who go to the designated medical institutions and the designated retail pharmacies to purchase medicines shall settle their accounts with their IC cards.
Article 10 of the Municipal Social Security Bureau of the unified management of individual accounts, and regularly or irregularly check the relevant situation of individual accounts. Employers, insured persons, designated medical institutions and designated retail pharmacies shall cooperate.
Article 11 The funds in the individual accounts of the insured persons shall bear interest at the deposit rate for urban and rural residents for the same period of time, and shall be transferred to the individual accounts after approval. The principal and interest of the personal account are owned by the individual, and the savings can be carried forward for use, and no cash can be withdrawn or overdrawn.
Article 12 of the Wudu city outside the insured personnel and relocation of retirees are not issued IC cards, the funds in their individual accounts are issued quarterly or annually to the insured units, which will forward them to themselves.
Article 13: If a participant is transferred within the city, if the transferring unit is insured, the relevant procedures will be carried out and the IC card and personal account will continue to be used; if the transferring unit is not insured, the personal account will be utilized until there is no balance, and the IC card will stop being used and will be kept by the participant for his own safekeeping, and then be re-instated for continued use. If the insured person is transferred outside the city, the balance of his personal account will be released to him in one lump sum and the IC card will be taken back by the Municipal Social Security Bureau.
Article 14 of the insured and the insured unit due to the dissolution or termination of labor relations and other reasons, temporary interruption of the payment of basic medical insurance premiums, its personal account until no balance, the IC card to suspend the use of the IC card, and by the person in custody, to be re-enrolled in the continued use of the IC card.
Article 15 After the death of an insured person, the balance of the individual account funds shall be inherited by the beneficiary or legal heir designated by the person before his death in accordance with the provisions of the Inheritance Law of the People's Republic of China. If the designated beneficiary or legal heir has participated in basic medical insurance, the fund balance of the individual account shall be transferred to the individual account of the designated beneficiary or legal heir and the IC card of the deceased shall be recovered by the Municipal Social Security Bureau; if the designated beneficiary or legal heir has not participated in basic medical insurance, the fund balance of the individual account shall be issued to the designated beneficiary or legal heir in a lump sum and the IC card of the deceased shall be recovered by the Municipal Social Security Bureau. The Municipal Social Security Bureau will take back the IC card of the deceased person.
Article 16 The IC card of the insured person should be kept in a safe place, and if it is lost, it should be reported to the employer in time, and the employer should apply to the Municipal Social Security Bureau for the loss of the IC card and go through the procedure of reissuing the card. The loss of personal account funds during the period of loss shall be the responsibility of the insured person himself.
Article 17 of the participants have the right to inquire about the funds in their individual accounts, and to supervise the collection, use and management of funds in their individual accounts. Municipal social security bureau and the employer of the participant's personal account balance of funds once a year to check, and the employer to the participants announced.
Article 18 of the IC card record right belongs to the Municipal Social Security Bureau. If the employer or the insured person alters, forges or steals the IC card, it shall be confiscated immediately upon discovery. Those who cause serious losses to the basic medical insurance fund as a result shall be transferred to the judicial organs for handling.
Article 19 of the individual accounts of the insured, the beginning of the year for a one-time approval. Within the year, the proportion of their personal accounts transferred to no change in the next year when the approval of a unified adjustment.
Article 20 of the designated medical institutions and designated retail pharmacies based on the IC card of the insured as a voucher for medical treatment and purchase of medicines, and thus the settlement of expenses, the reduction of personal account funds, in the quarter before the 5th quarterly medical expenses, the purchase of medicines vouchers, to the Municipal Bureau of Social Security audit for disbursement procedures.
Article 21 of the designated medical institutions and designated retail pharmacies should be provided annually to the employer and the Municipal Social Security Bureau of the use of individual account funds summary table, as well as the usual grasp of the individual account funds.
Article 22 counties (districts) with reference to these measures to develop their own county (district) implementation rules.
Article 23 of these measures shall be implemented from the date of publication, valid for five years.
Extended reading: insurance how to buy, which is good, hand to teach you to avoid these insurance "pit"