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Medical insurance is different is in different areas, but the page did not vary too much, depending on the specific local regulations, which can refer to the following
Look at the (October 20, 2000 Shanghai People's Government promulgated Decree No. 92) BR/> Article 1 (Purpose and Basis)
In order to protect the basic medical needs of employees, according to the "Shanghai to implement the State Council on the establishment of a basic medical insurance system, urban workersof> the implementation of the program Chapter I," formulated. Article
(Scope of application)
This approach applies to the city within the urban area of enterprises, institutions, institutions, organizations and private non-essential social enterprises (hereinafter referred to as the employer) and their employees' medical insurance and related management activities.
The term employees, including active workers, retirees and other insurance. Article
(Management)
Shanghai Medical Insurance Bureau (hereinafter referred to as medical insurance) is the city's basic medical insurance, basic medical insurance, the city is responsible for the unified management of the administrative authority. The district and county medical insurance offices (hereinafter referred to as district and county medical insurance offices) are responsible for the administration of basic medical insurance within their jurisdiction.
City health, labor and social security, finance, audit, drug supervision, civil affairs and other departments in accordance with their respective responsibilities, collaborative work to be done, basic medical insurance management.
Responsible for the medical insurance work of the collection of the city's social insurance agency.
Shanghai Medical Insurance Service Management Center (hereinafter referred to as the medical center) is the city's medical insurance agency responsible for the settlement of medical expenses, as well as funding the management of the basic medical insurance individual account (hereinafter referred to as the individual medical account).
Chapter II Registration and Payment
Article (Registration)
Employers in accordance with the provisions of the Municipal Health Insurance Bureau, and designated the social insurance agency for the registration of the basic medical insurance; the newly established employers should be between the establishment of the basic medical insurance handle 30 days from the date of the registration procedures.
The employer terminates according to law or changes in the registration of basic medical insurance events, it must be in the relevant circumstances, cancel or change the registration of the original registration authority 30 days from the date.
Social insurance agency in the two paragraphs of this section, the procedure for the former processing should be carried out in accordance with the requirements of the audit of the Municipal Health Insurance Bureau, and according to the employer in a timely manner, change the registration of registration or deregistration notification of the municipal health insurance.
Article (calculation of the employee contribution base and contribution rate)
My average monthly salary last year in the past year in the basic salary of the active employees. Last year I was employed in the past year's average monthly salary of 300% of the city's average monthly salary of employees, the excess is not counted as the contribution base; lower than the previous year, more than one year as the contribution base of 60% of the city's average monthly salary of employees, 60% of the city's average monthly salary of employees in the service.
Individual service workers should pay the basic medical insurance premiums in accordance with the proportion of 2% of the contribution base. Retired individuals do not pay basic medical insurance premiums.
Article (used to calculate and pay the proportion of the employer's contribution base)
Employer's contribution base employee's basic salary of the unit and.
The employer shall pay the proportion of the base to contribute 10% of the basic medical insurance premiums and 2% of the local additional medical insurance based on the wages of their contribution base.
Article 7 (health insurance premium collection channel) health insurance premiums.
Article VIII (collection management)
The calculation of employer and employee contributions, the number of payment procedures, and the collection of dispute handling, in accordance with the relevant provisions of the management of the collection of social insurance premiums.
Chapter III Individual Medical Accounts, Coordinated Fund and Additional Fund
Article 9 (Basic Medical Insurance Fund)
Consisting of the Coordinated Fund and the Individual Medical Accounts Basic Medical Insurance Fund.
The employer pays the basic medical insurance, in addition to the way Article 11.2, the third paragraph is included in the individual medical account, the rest into the integrated fund.
Article 10 (establishment of individual health accounts) municipal medical centers, individual medical accounts shall be established for employees.
11 (credited to the individual medical account funds)
Payment of services to the staff are included in the basic medical insurance all of my personal health account.
The employer pays the basic medical insurance premiums, in accordance with the following percentage of active employees credited to the individual health account:
(a) 34, 0.5% of the previous year % of the age of less than according to the average wage of workers in the city;
(b) 35 to 44 years of age, according to the previous year, the average wage of workers in the city of a percent;
(c) 45 years of age retired, according to the 1.5 percent of the salary of the average urban worker in the previous year.
The employer pays the basic medical insurance premiums, in accordance with the proportion of retirees included in the individual medical account is as follows:
(a) Retirement to the age of 74 years, according to the previous year, the average annual salary of workers in the city 4%; 4.5%
(b) More than 75 years, according to the previous year, the annual salary of workers in the city's average salary of workers.
12 (Individual health account funds stop counting)
Employees should be uninterrupted payment of contributions to the basic health insurance or enjoy the basic pension insurance benefits to stop this practice Article XI of both models are included in the funds or the third paragraph.
Article XIII (use of individual health accounts and interest-bearing funds)
Individual health account funds owned by the individual can be used for many years to carry over and inheritance of the law.
Funds in individual health accounts and funds are included in the calendar year divided into surplus funds.
Individual health account funds, in accordance with the relevant provisions of the interest accrued and credited to the individual health account.
Article 14 (access to personal health account funds)
Staff can inquire and expenditures are calculated within the Municipal Health Insurance Bureau, county, city health insurance I have a personal health insurance center in the capital account should be easy for staff to inquire.
15 (additional funds)
If the employer pays for additional health insurance, are included in the local additional health insurance fund (hereinafter referred to as additional funds).
16 (Definition of designated medical institutions and designated retail pharmacies)
The term designated medical institutions, and refers to the administrative department of health allowed to practice and review by the municipal health insurance, after the medical institutions are allowed to establish a settlement relationship with the basic medical insurance.
The term fixed-point retail pharmacy, is approved by the drug supervision and management department of the business of the qualifications and after the municipal health insurance review and settlement is allowed to set up the relationship between the basic medical insurance drug retail enterprises.
Article 17 (designated medical institutions, designated retail pharmacies and service requirements)
Designated designated retail pharmacies shall provide services to workers in medical institutions and in accordance with the basic medical insurance, medical services and drug standards applied to the scope of treatment programs and payment of medical expenses settlement.
18 (diagnosis and treatment programs, medical service facilities, medication and payment standards range)
City diagnosis and treatment programs of basic medical insurance, medical services and drugs in accordance with the scope and payment standards of the municipal health insurance with the relevant departments *** with in accordance with national regulations.
Article 19 (workers' medical and pharmaceutical)
Workers can go to designated medical institutions within the city.
Workers dispensing medical institutions, but also in accordance with the provisions of the fixed-point retail pharmacy dispensing.
Living or working in other provinces, as well as first responders outside the city, you can go to local medical institutions.
Article 20 (Health Insurance Certificate)
Employee designated medical institutions in the city, when the designated retail pharmacy to dispense medicines, must show proof of health insurance.
Designated medical institutions, designated retail pharmacies or health insurance certificate for workers should be verified.
No individual may fraudulently use, forge, alter, or lend medical insurance certificates. Chapter
Payment of medical expenses Article 21 (Conditions for workers to enjoy basic medical insurance)
Employers and employees pay the medical insurance premiums in accordance with the provisions of the basic medical insurance benefits for workers; do not pay the medical insurance premiums, the workers can not enjoy the basic medical insurance benefits.
Employer's health insurance application for deferral in accordance with the relevant provisions of the approved deferral period, the employee does not stop enjoying basic health insurance benefits.
Payment of health insurance premiums are not paid by the employer and the employee, and the worker can continue to enjoy basic health insurance benefits after full payment of health insurance.
Employer and employee payment of health insurance premiums (including the period of deemed contributions) accumulated more than 15 years, the staff can enjoy the basic medical insurance benefits after retirement. The deemed contribution period is calculated separately by the municipal government medical insurance. Enjoy the basic medical insurance treatment in accordance with the relevant provisions of the retiree, there is no restriction on this part.
Article 22 (emergency medical services staff outpatient costs)
Outpatient emergency medical services workers, or to a designated retail pharmacy dispensing occurs, in addition to Article 24, charges Article 25, the provisions of its individual medical account funds. According to the following provisions (excluding the designated retail pharmacy dispensing costs incurred) the shortfall is paid:
(a) born on December 31, 1955, 31 December 2000 to participate in the work of the first 10% paid by the individual first one year of the average wage of the workers in the city, a portion of the medical expenses exceeded by 70% of the additional funds for the remaining portion of the active workers out of their own pocket to pay.
(ii) January 1, 1956 to December 31, 1965 was born before December 31, 2000 to participate in the work of the last year paid by the individual workers in the city 10% of the average wage, the medical expenses of the part of the fund in excess of the additional 60% to pay part of the medical expenses, and the rest by the assumption of the active workers.
(3) born after January 1, 1966, December 31, 2000 to participate in the work of the first year by the individual paid 10% of the average salary of the employee in the city, the rest of the additional excess medical expenses from the Fund to pay 50%, borne by the active employees.
(4) January 1, 2001, after the work of the new trainees, by the active employees at their own personal expense.
Article 23 (emergency outpatient retiree medical expenses)
Retiree medical clinic or emergency room, in addition to Article 24, dispensing at a designated retail pharmacy in addition to the costs incurred in Article 26, the provisions of its personal medical account funds. According to the following provisions (excluding the costs incurred in the designated retail pharmacy dispensing) the shortfall is paid:
(a) December 31, 2000 has been retired from the procedure, the first person to pay the worker's first year of the city's average salary level of 2% of the emergency outpatient medical institutions, from the additional funds to pay 90% of the excess medical costs; outpatient emergency care at a secondary medical institution, the medical costs of over additional funds to cover 85% of the portion; in a tertiary emergency outpatient medical facility and health care costs exceeded by some additional funds to cover 80%; the rest is borne by the retiree.
(ii) born on December 31, 1955, worked on December 31, 2000 and retired after January 1, 2001 procedures, the first person to contribute 5% of the city's average salary of the previous year's employees in the emergency outpatient medical institutions, from the excess of additional funds to pay 85% of the health care costs; emergency clinics in the secondary health care institutions, from the more funds to pay 80% of the additional medical costs; emergency clinics in tertiary care outpatient medical facilities, paying 75 percent of medical costs from additional excess funds; and the rest is borne by the retiree.
(3) born from January 1, 1956 to December 31, 1965, December 31, 2000, January 1, 2001 and after the work of the retirement procedures, the first person to pay 5% of the average annual salary of the workers in the city, in the level of emergency outpatient medical institutions, from the additional funds to pay 70% of the additional medical costs; in the level of secondary health care institutions outpatient emergency Paid by the fund 65% of the additional excess medical costs; in tertiary medical institutions, from more funds to pay 60% of the additional medical costs of outpatient emergency outpatient retiree's rest at their own expense.
(4) born after January 1, 1966, participated in the work December 31, 2000 and January 1, 2001 and after the retirement procedures, the first person to pay the previous year's average salary of the city's employees in the city 5% in the emergency outpatient health care institutions, from the additional funds to pay 55% of the excess medical costs; emergency clinics in secondary health care institutions, from the more funds to pay 50% of the additional medical costs of the additional medical costs; emergency clinics in tertiary care outpatient clinics, paying 45 percent of the excess medical costs from the additional funds; the rest is borne by the retiree.
(5) after January 1, 2001 work and processing procedures, the first person to pay the first year of workers in the city average wage of 10% of the level of emergency outpatient medical institutions, more than part of the post-retirement under the fund of the additional 55% of the payment of medical expenses; outpatient emergency at the second level of health care institutions, from the additional funds to cover 50% of the excess medical expenses; at the third level of health care institutions In tertiary medical institutions, 45% of the outpatient emergency by additional funds to pay the additional medical expenses remaining to be borne by the retiree.
Article 24 (Outpatient Diseases and Home Bed Medical Expenses)
Severe uremic workers in outpatient dialysis, medical expenses for cancer chemotherapy and radiation therapy (hereinafter collectively referred to as outpatient medical diseases) incurred by the service personnel through the centralized funds to pay 85%; retirees to pay 92% of the integrated fund. Calendar year by the lack of work in the part of the funds paid by the individual medical account balance, the rest of the self-funded.
Home bed medical expenses incurred by the workers pay 80% of the centralized fund, as well as the lack of workers, over the years by the y funded portion of the balance of the individual medical account to pay the rest of the burden.
Article 25 (hospitalization, emergency medical expenses for in-service workers)
Service personnel in the emergency department of the hospital or inpatient observation of the medical expenses incurred by the coordinated fund to pay for the medical expenses, so that the starting standard. Starting standard for the same period last year 10% of the average wage of workers in this city.
1 year of hospitalization or emergency observation of hospitalized medical expenses incurred by the hospitalization of the part of the accumulated over the starting standard, to be within 85% of the coordinated fund of the active workers.
The starting standard of medical expenses incurred by active employees below, the balance of the individual medical account exceeded by the pooled funds, the remaining part of the difference borne by the active employees, after the payment of medical expenses funded by the annual payment.
By (hospitalization, retiree emergency medical expenses)
Retiree hospitalization or emergency observation occurs after the starting standard coordinated fund is located in the medical expenses paid Article 26. December 31, 2000 retirement starting standard last year's workers in the city average wage of 5%; participate in the December 31, 2000, 2001 work, has retired January After January 1, 2001, the starting payment standard for workers in the city of the first 8% of the annual average wage; after January 1, 2001 to continue to work and after retirement, the starting payment standard for the same period of the previous year 10% of the average wage in the city. A year of hospitalization or emergency observation of inpatient medical expenses incurred cumulatively more than 92% by the integrated fund to pay the starting standard part of the
Retirees. Starting standard below
Retiree health care costs and the rest of the integrated fund, the balance of the individual medical account by the fund over the years to pay for the medical expenses incurred after the shortfall borne by the number of retirees.
Article 27 (Coordinated Fund and exceed the maximum payment costs)
The maximum payment limit, the Coordinated Fund, last year's four times the average wage of workers in the city. 1 year hospitalization within the employee, in the observation of emergency inpatient hospitalization starting payment standard observation of what will happen to the medical expenses, as well as serious illnesses or outpatient medical expenses of the family beds in less than the maximum payment limit is paid by in accordance with the measures of Article 24. Article 24 coordinated fund Article 25 to pay Article 26.
The integrated fund above the maximum payment limit by an additional 80% of the fund to pay the medical expenses, the rest by the employee's own responsibility.
Article 28 (medical expenses paid for special illnesses part) workers, family planning surgery and its sequelae occurring in the basic medical insurance, hospital outpatient emergency, first aid provisions occurring in the hospital to receive observation of the department's medical expenses, paid in full by the Coordinated Fund.
Workers due to work-related injuries, occupational diseases, hospitalization or emergency medical expenses incurred in the hospital for observation above the starting standard of the Coordinated Fund, the cost of more than part of the entire fund to pay 50% of the rest of the medical emergency and related to outpatient expenses in accordance with the relevant provisions of the state and the city, borne by the employer.
Article 29 (non-payment of circumstances)
In one of the following cases, the centralized fund, more funds, rather than individual medical account funds to pay:
(1) in the staff of non-designated medical institutions, medicines and non-designated retail pharmacy dispensing of medicines incurred medical expenses;
(2) or the distribution of the treatment does not comply with the basic medical insurance, medical services and facilities, and other circumstances (4). Services and facilities, other circumstances (4) the state and the city regulations incurred by medical workers; payment standards for medical expenses; medical expenses
(c) workers due to suicide, self-inflicted injuries, fights and assaults, drug abuse, such as medical disputes or accidents. Medical expenses Chapter VI
Settlement of Article 30 (billed medical expenses and account debit)
When medical expenses incurred in accordance with the provisions of the basic health insurance medical or pharmaceutical workers, workers in accordance with the following provisions of the health insurance certificate:
(i) is to pool funds to pay additional funds by the designated health care institutions should be truthfully accounted for;
(ii) Payment or designated designated retail pharmacy should be deducted from the individual medical account workers health care organization individual medical account funds, the lack of funds to pay the individual medical account should be credited to the employee.
Designated retail pharmacies or medical workers dispensing designated medical institutions incurring medical expenses that do not comply with the provisions of the basic health insurance shall be credited to employees.
Article 31 (declaration and settlement of medical expenses)
Specified medical institutions, designated retail pharmacies simply deduct the medical expenses of the individual medical account from the employees, and monthly to the designated district, county medical insurance office settlement.
Specified medical institutions, accounting for the fund belongs to the co-ordination of additional funds to pay the monthly medical expenses to the designated district, county medical insurance office settlement.
The employee's coordinated fund may have been in accordance with the provisions of Article 19 (3), medical expenses accounted for additional funds or personal funds used to pay for health care, by virtue of their health insurance vouchers to the designated area, the county medical insurance office settlement occurs.
Article 32 (Approval and financing of medical expenses)
Or the district or county office to apply for medical insurance settlement of medical expenses, shall be received within 10 working days of the settlement date of the application for a preliminary review, and the preliminary opinion submitted to the city health insurance.
The municipal health insurance bureau should be accepted by the district, county health insurance does not accept the preliminary opinion on June 10 within 10 working days to make the decision to grant payment or not review the suspension of payment. Municipal Health Insurance Bureau decides to defer payment to make the decision to grant shall be made within 90 days after the salary or non-payment, and inform the relevant units.
Approved by the municipal health insurance medical expenses, the municipal medical center shall be approved within seven working days from the date of the health insurance fund expenditure account for disbursement; not by the designated medical institutions, designated retail pharmacies or the employee's own burden of payment of the municipal health insurance medical expenses.
Article 33 (Settlement of medical expenses)
The municipal health insurance can take the total prepaid billing, settlement service, settlement service unit, etc., and the designated medical institutions to settle medical expenses.
Article 34 (Prohibited Actions for Settlement of Application Fees)
The designated medical institutions or individual designated retail pharmacies are prohibited from settling medical fees by improper means such as forging or falsifying accounts, information, outpatient and emergency prescriptions, and medical fee documents.
Article 35 (Supervision)
The Municipal Health Insurance Bureau, districts and counties shall supervise and inspect the settlement of medical expenses related to medical insurance designated medical institutions, designated retail pharmacies, and the unit being inspected shall truthfully provide the records, prescriptions, and medical history, as well as information related to the settlement of such information.
Chapter VII Legal Liability Article 36 (designated medical institutions, designated retail pharmacy responsibility for violations)
Designated designated medical institutions in violation of Article 17, Article 30 or Article 34, the retail pharmacy municipal health insurance bureau shall order rectification of the recovery of the medical costs have been paid, and may be sentenced to a warning, more than 3,000 yuan of 30,000 yuan of the following fine; in serious cases may be suspended from the basic medical insurance settlement relationship. In serious cases may suspend the basic medical insurance settlement relationship.
Article 37 (Offenses of individual legal responsibility)
Violation of 20 individuals (3), Article 34, the municipal health insurance shall be ordered to correct and recover the medical expenses have been paid, and may be subject to a warning, a fine of more than $ 100 to $ 1,000.
Article 38 (liability insurance administrative violations)
Medical insurance management and municipal health center staff abuse of power, dereliction of duty, resulting in the loss of medical insurance fund, the municipal health insurance bureau to recover the loss of medical insurance fund; constitutes a crime, be held criminally liable according to law; does not constitute a crime, be given administrative sanctions according to law.
Chapter VIII Bylaws Article 39 (medical insurance fund management and supervision)
Funds and additional funds, integrated management and supervision activities, in accordance with the state and the city to implement the relevant provisions of the social insurance fund.
Funds and additional funds, the integrated annual budget and final accounts, the City Health Insurance Bureau and the City Department of Finance in accordance with the requirements of the preparation of a combination of the municipal people's government signed and approved.
Article 40 (basic medical insurance for other people)
The owners of famous cities and towns and individual economic organizations and their employees, basic medical insurance for freelancers of specific measures respectively.
Receiving unemployment insurance benefits, in accordance with the relevant provisions of the state basic medical insurance payment period and the urban unemployed.
Article 41 (special provisions to extend the working life of employees)
In accordance with the procedures prescribed by the state, to reach the statutory retirement age retirement temporarily extends the working life of employees, the basic medical insurance for active employees in accordance with the provisions of the implementation; after the retirement procedures, in accordance with the provisions of the basic medical insurance for retirees of the same age.
Article 42 (socialized management of the transition period)
One year of the transition period from the date of implementation of this specific operational approach to the implementation of the transition period of basic medical insurance socialized management of the city to deal with separately.
Article 43 (effective date)
This method from December 1, 2000, the municipal people's government previously issued this practice is inconsistent with the relevant provisions, in this way prevail.