(-) personal name to pay need to go to the social security bureau where the household registration, the procedures include: my ID card, recent crownless one-inch photo preparation two, premiums, application form, etc. can be. And can only apply for old age, medical insurance two.
1, pay how much is based on the local last year's social wage for calculation, and each year is not the same.
For example, if the average social wage in A is 20,000 yuan, then the amount of pension insurance is 20,000*20%=4,000 or so/year, and the medical insurance is 20,000*10%=2,000 or so/year.
2, in addition, also provides for the lowest grade and the highest grade, the lowest grade of the contribution shall not be less than 60% of the average monthly salary of social workers, the highest grade of 300% of the average monthly salary of employees. Generally, the lowest grade is the majority.
3. In addition, the minimum contribution period for pension insurance is 180 months or 15 years, and medical insurance needs to be paid for at least 25/30 years, so that when you reach retirement age, you can apply for pension benefits and medical reimbursement (as long as you renew your contributions normally, you are also allowed to do so).
(ii) or in the capacity of the unit way to pay on behalf of the purchase of social security.
Additionally, if we are talking about social security, it is best to pay through the second unit is a little better, because the unit will bear a large part of the cost for us, which in turn reduces the pressure of their own payment.
Nanning City, urban workers basic medical insurance
Chapter I General
Article 1 In order to establish a comprehensive basic medical insurance system, effectively protect the basic medical needs of the majority of workers, to safeguard the legitimate rights and interests of the majority of workers, according to the "Chinese People's **** and the State Social Insurance Law", "Provisional Regulations on the Collection and Payment of Social Insurance Premiums", "The State Council on the Establishment of the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Workers (Guo Fa [1998] No. 44) and the Notice of the Guangxi Zhuang Autonomous Region on the Implementation of Municipal Integration of Basic Medical Insurance for Urban Workers (Gui Zheng Fa [2010] No. 30) and other relevant provisions, combined with the actual situation in the city, the formulation of these measures.
The second basic medical insurance system for urban workers adhere to the "broad coverage, basic protection, multi-level, sustainable" approach; adhere to the principle of rationally determining the level of basic medical care according to the level of economic and social development; adhere to the principle of basic medical insurance for urban workers integrated fund and individual accounts; adhere to the principle of territorial management The principle that all urban employers and their employees should participate in basic medical insurance for urban workers, and that basic medical insurance premiums should be paid by both employers and employees***; the principle that the fund should be based on revenues to meet expenditures, with a balance of revenues and expenditures, and a slight surplus; and the principle of coordinating and integrating all types of medical insurance systems to ensure that they are well integrated with one another in terms of basic policies, standards, and management measures.
Article 3 Nanning City, the basic medical insurance for urban workers to implement municipal coordination. Municipal and county social insurance administrative departments are responsible for the basic medical insurance for urban workers in their administrative areas.
Chapter 2: Scope of Participation
Article 4 Within the administrative area of Nanning City, all kinds of urban enterprises and their employees, state organs and their staff, public institutions and their employees, social organizations and their full-time staff, private non-enterprise units and their employees, as well as urban individual industrial and commercial households and their employees shall participate in the basic medical insurance for urban workers.
Workers within the administrative area of Nanning City who have established labor relations with state organs, institutions and social organizations shall participate in the basic medical insurance for urban workers.
Individual entrepreneurs without employees, part-time urban workers who have not participated in the basic medical insurance for urban workers at their employers, and other urban flexibly employed persons (hereinafter collectively referred to as "flexibly employed persons") may participate in the basic medical insurance for urban workers.
Chapter 3: Registration and Payment of Contributions
Article 5 An employer shall, in accordance with the regulations, go to the social insurance agency for registration, change or cancellation of registration, and procedures for additions, deletions, and changes in social insurance in the following cases.
(1) Newly established units shall apply for social insurance registration within 30 days from the date of establishment with business license, registration certificate or unit seal.
(2) In case of changes in social insurance registration information such as name, address, legal representative or person in charge, account bank and account number of the insured unit, the unit shall apply for the change at the social insurance agency within 30 days from the date of the change with the relevant supporting documents.
(3) In the event of separation, merger, termination, restructuring or bankruptcy of an insured entity, the entity shall, within 30 days from the date of occurrence, apply for change or cancellation of the registration procedures at the social insurance agency where it was originally registered with the relevant legal documents and approvals from the competent authorities.
(4) The insured unit shall register its employees with the social insurance administration organization for social insurance within 30 days from the date of employment.
(e) If the number of insured persons changes due to new recruitment, transfer, resignation or voluntary separation of employees, termination of the labor relationship with the unit or retirement of employees for various reasons, the insured unit shall, before the 10th day of each month, go to the social insurance agency with the relevant materials to apply for the change of the number of persons who have paid contributions for the current month.
Article 6: Flexible workers participating in the basic medical insurance for urban workers shall apply to the social insurance agency for individual registration with relevant materials in accordance with the regulations.
Article 7 The insured unit shall take the average monthly salary of the working staff of the unit in the previous year as the contribution base, and the unit and the individual shall pay the basic medical insurance premiums in accordance with the following provisions **** the same:
(1) The insured unit shall pay the basic medical insurance premiums at the rate of 8% of the average monthly salary of the working staff of the unit in the previous year.
(2) The employees pay 2% of their average monthly salary in the previous year. The basic medical insurance premiums to be paid by individual employees shall be withheld and paid on behalf of the participating organizations.
(3) If the last year's salary of an employed employee is less than 60% of the average salary of an employed employee of an urban unit of the whole region in the previous year, 60% of the average salary of an employed employee of an urban unit of the whole region in the previous year shall be counted as the contribution; if the salary of an employed employee of an urban unit of the whole region in the previous year exceeds 300% of the average salary of an employed employee of the whole region in the previous year, 300% of the average salary of an employed employee of an urban unit of the whole region in the previous year shall be counted as the contribution.
(d) the basic medical insurance for urban workers, the individual to reach the statutory retirement age, contributions to the required number of years, for the change of in-service to retirement procedures, the participating units and individuals in the month following the change will no longer pay the basic medical insurance premiums, with the unit as a whole to enjoy the unified provisions of the basic medical insurance retirement benefits.
Article 8: Flexible employees shall take 60% of the average salary of urban on-the-job workers in the region as the contribution base and pay the basic medical insurance premiums at a rate of 8% (the contribution rate shall be adjusted at the same time with the contribution rate of the insured units).
Article 9 The social insurance agency approves the amount of basic medical insurance premiums to be paid by the insured unit for the current month before the 20th day of each month and collects them in accordance with the prescribed payment method.
Article 10 The insured units shall pay the basic medical insurance premiums in full every month in the prescribed manner. If the following circumstances occur, the following provisions:
(a) the insured unit is temporarily unable to pay due to economic difficulties, shall submit a written application to the municipal (county) social insurance administrative department within the prescribed payment time, after examination and approval, may be partially or fully deferred, deferred for a period of up to 90 days. During the deferred payment period, late fees are exempted. Those who fail to pay the contributions or make up the basic medical insurance premiums in accordance with the stipulated period shall be suspended from the payment of benefits by the basic medical insurance co-ordination fund.
(2) When an employer goes bankrupt, closes down, auctions, withdraws or cancels, merges, splits up, transfers and restructures according to law, it must settle the basic medical insurance premiums payable in accordance with the current relevant provisions. The basic medical insurance premiums payable in accordance with the relevant provisions in force shall be included in the overall consideration of the cost of restructuring.
Starting from the establishment of the basic medical insurance system for employees in the integrated area, employers and employees shall participate in the basic medical insurance for employees in accordance with the regulations, and shall make up for the years they should have participated in the insurance but have not done so. For those who have retired in the integrated area according to the current policy, or those whose accumulated contributions to the basic medical insurance do not reach the minimum number of years of contributions in the integrated area (including the deemed years of contributions and the actual years of contributions) at the time of transferring from active employment to retirement, the employers shall make contributions based on 60% of the average salary of the on-service employees in the whole urban area in the previous year at the time of bankruptcy, closing down, auctioning, abolishing or canceling, merging, separation, transferring and restructuring and the proportion of contributions stipulated at the time of retroactive contributions. the contribution ratio stipulated at the time of making up for the difference in the number of years of basic medical insurance premiums, its insured retirees can enjoy the unified provisions of the basic medical insurance retirement benefits.
(3) If an employer fails to declare the amount of basic medical insurance premiums to be paid in accordance with the regulations, the social insurance agency may determine the contribution base at 110 percent of the contribution base of the employer for the previous year; after the employer has made up for the declaration, the social insurance agency will settle the bill in accordance with the regulations.
(d) The employer to recover the basic medical insurance premiums for the current year or previous years must hold the effective arbitration or litigation legal documents and other relevant documents to apply for the retroactive payment procedures.
Article 11: Flexible employees can choose to participate in the basic medical insurance for urban workers by paying the basic medical insurance premiums for one year or half a year. For those who choose to pay the premiums on a one-year basis, the normal payment time is from July to September every year; for those who choose to pay the premiums on a semi-annual basis, the normal payment time is from July to September every year for premiums from July to December of the current year, and from January to March every year for premiums from January to June of the current year.
Flexible employment personnel to implement the integrated fund payment waiting period, the waiting period for the first time to participate in the insurance for three months from the month of payment; not in accordance with the specified time to pay contributions, can be handled to make up for the waiting period of three months from the month of payment, waiting for the month after the expiry of the next month before enjoying the urban workers basic medical insurance integrated fund payment treatment; insured unit employees to participate in the urban workers basic medical insurance by the flexible employed staff to leave the unit. In case of interruption of basic medical insurance contributions, the renewal period shall be three months from the first month of the interruption. At the time of renewal, the basic medical insurance premiums for the interrupted period can be paid up; if they are not paid up or are not paid up within the renewal period, the waiting period for the payment of the integrated fund after the renewal will be treated as the first time of joining the insurance.
If a flexibly employed person terminates his/her basic medical insurance relationship in the year in which he/she pays the premiums, or if he/she changes his/her status to an employee of the insured organization, the remaining months of the current year's basic medical insurance premiums paid by the individual will be transferred to his/her basic medical insurance personal account.
Article 12 The basic medical insurance contribution period for urban workers includes the actual contribution period and the deemed contribution period.
Before the establishment of the basic medical insurance system for urban workers in this coordinating area, the consecutive years of service or working experience that can be calculated in accordance with the relevant policies of the State and autonomous regions during the working period in state-owned enterprises, collective enterprises at or above the county level, and institutions is regarded as the contributory years.
Article XIII of the basic medical insurance for urban workers, its employees in accordance with the provisions of the state and autonomous regions for retirement procedures or apply for basic pension insurance benefits, the cumulative contribution period of 25 years for men and 20 years for women, and in the coordinated area of the actual contribution period of five years and above, the participating units and individuals from the month following their own retirement or to enjoy the month of the basic pension, will no longer be paying the basic medical insurance premiums, the individual with the unit as a whole, and the unit will not pay the basic medical insurance premiums. Medical insurance premiums, individuals with the unit as a whole to enjoy the unified provisions of the basic medical insurance retirement benefits.
After the establishment of the basic medical insurance system for urban workers in the integrated area, the employers and employees shall participate in the insurance and make contributions in accordance with the law. The years after the establishment of the basic medical insurance system for urban workers are all the years that should be insured, and the employers and employees must make up for the years that they should have been insured but actually were not.
After the employer pays the basic urban workers' medical insurance premiums for the employees according to the law, if the employees do not reach the number of years of contributions stipulated in the preceding paragraph when they retire, they can enjoy the basic medical insurance retirement benefits after making a one-time contribution or paying the part of the basic medical insurance premiums of the insufficient years year by year by the individuals. The standard of the one-time payment of basic medical insurance premiums shall be based on the contribution ratio stipulated at the time of payment and 60% of the average salary of the urban workers on duty in the whole region in the previous year.
Article 14 Flexible employment personnel who have reached the legal retirement age or the conditions for enjoying the basic pension insurance benefits, and who have accumulated 25 years of contributions for men and 20 years for women, and who have actually paid contributions for 15 years or more in the region, shall be entitled to the basic medical insurance retirement benefits when they go through the process of retirement or enjoy the basic pension in accordance with the provisions of the State and the autonomous regions.
Flexible employees who do not meet the requirements of the preceding paragraph at the time of retirement can enjoy the basic medical insurance retirement benefits after making a one-time contribution or paying the medical insurance premiums for the part of the insufficient years year by year. The standard of the one-time payment of medical insurance premiums shall be based on the contribution ratio stipulated at the time of payment and 60% of the average salary of urban on-the-job workers in the whole region in the previous year as the contribution base. For the state-owned enterprises closed, bankruptcy, restructuring of self-employed personnel to enjoy the basic medical insurance retirement benefits of the contribution requirements, otherwise provided by the provisions of its own.
Article 15 The basic medical insurance premiums paid by the retirees as a lump sum or on a yearly basis in accordance with the provisions of Articles 13 and 14 of the present Regulations shall be included in the unified management of the basic medical insurance co-ordination fund. The lump-sum basic medical insurance premiums shall be transferred to the individual account at a lump sum of 23.33%.
Article 16 The adjustment of the basic medical insurance contribution ratio for urban workers shall be made by the municipal social insurance administrative department in accordance with the level of economic development and the income and expenditure of the fund, together with the municipal finance department, and then submitted to the municipal people's government for approval.
Chapter IV Individual Accounts and Coordinated Funds
Article 17 The individual accounts of basic medical insurance for urban workers (hereinafter referred to as "individual accounts") are mainly used to pay for the expenses incurred by designated medical institutions in conformity with the Nanning City Basic Medical Insurance Drug List, Diagnostic and Therapeutic Items, and the Scope and Payment Standards for Medical Services and Facilities (hereinafter referred to as "the three basic medical insurance standards"). (hereinafter referred to as "the three basic catalogs"), outpatient medical expenses, hospitalization costs of individuals in accordance with the prescribed proportion of out-of-pocket expenses, as well as the purchase of drugs at designated retail pharmacies.
The specific percentage of individual account shall be as follows:
(1) All the individual contributions of the insured employees shall be transferred to their individual accounts, and the basic medical insurance premiums paid by the unit shall be transferred to the individual accounts by 1% of the individual contribution base of the insured employees for those who are below the age of 45 years old (inclusive of the number), and 1.5% of the individual contribution base of the insured employees for those who are above the age of 46 years old (inclusive of the number) and until their retirement, and 1.1% of the individual contribution base of the insured employees. The working employees who are above 46 years old (including this number) to the time of retirement shall be allocated to the individual account at 1.4% of the individual contribution base of the insured employees.
(2) Flexibly employed persons shall be assigned to their individual accounts according to the contribution base of the basic medical insurance premiums paid by themselves, and according to different age groups, in the following proportions: 1% for those under 45 years of age (inclusive), and 1.4% for those above 46 years of age (inclusive) until they reach the age of applying for the basic old-age pension.
(3) Retirees who are entitled to basic medical insurance retirement benefits according to the regulations will have 3.8% of their average retirement fee or average pension for the previous year allocated to their individual accounts.
Individual accounts accrue interest in accordance with the regulations, and the principal and interest are owned by the insured individual and can be carried forward. Upon the death of a participant, the balance of his individual account is paid in a lump sum to his designated beneficiary or legal heir.
Article 18 The basic medical insurance fund for urban workers is mainly used to pay for the medical expenses of hospitalization, outpatient specific items, special examinations and special treatments that are in line with the "three basic catalogs".
Article 19: The basic medical insurance card is the voucher for the use of the individual account and the integrated fund by the insured, who shall apply for the basic medical insurance card according to the regulations when applying for the registration of the insured, and shall take the initiative to present the basic medical insurance card and make the settlement in a timely manner when consulting the doctor or purchasing medicines. If the basic medical insurance card of the insured person is lost or damaged, he should go to the designated place to apply for the procedure of losing or replacing the card in a timely manner.
The State and the Autonomous Region have new regulations on the issuance and use of basic medical insurance cards.
Article 20 The insured shall go through the procedures of transferring their medical insurance relationship in accordance with the regulations in the following cases:
(1) If an employee of an insured organization is employed across the integrated region for various reasons, the insured organization shall go to the social insurance agency to go through the procedures of transferring the basic medical insurance relationship for the employee. The insured person who is employed flexibly shall apply for the transfer of basic medical insurance relationship to the social insurance agency by himself. The balance of the individual account of the basic medical insurance will be transferred with the insured person.
(2) the coordinated area outside the transfer to the city to participate in the insurance by the receiving unit in accordance with the provisions of the social insurance agency for its health insurance procedures; no receiving unit of individuals, should be suspended within three months after the basic medical insurance relationship to the social insurance agency for registration procedures, in accordance with the provisions of the basic medical insurance to participate in the urban workers.
Chapter V Settlement of Medical Insurance Benefits
Article 21 The basic medical insurance benefits for urban workers include general outpatient services, hospitalization, outpatient specific items, special examinations, special treatments and other benefits.
Article 22 The basic medical insurance consultation and referral for urban workers shall be handled in accordance with the following procedures:
(1) Medical expenses incurred by insured persons at designated medical institutions and expenses for purchasing medicines at designated retail pharmacies shall be settled by the basic medical insurance fund only if the basic medical insurance card is in possession of the basic medical insurance card.
(2) Specific outpatient programs, special examinations and special treatments must be reported to the municipal and county social insurance agencies for approval in accordance with the regulations.
(3) In case of transferring to a hospital for consultation outside the co-ordinated area, the relevant referral procedures should be carried out in accordance with the procedures at the designated designated medical institutions, social insurance administrative organizations and social insurance administrative departments.
(4) If the insured person resides or works outside the co-ordination area for more than three months (including three months), he/she should first go to the social insurance administrative organization in the co-ordination area to apply for the procedure of reporting his/her residence in a different place.
(e) If the insured person visits his relatives, goes on a business trip, or studies outside the integrated area within three months due to a sudden and acute illness, and needs to seek medical treatment at a local designated medical institution, he shall report to the social insurance agency in the integrated area for the record.
Article 23 The outpatient medical expenses incurred by the insured in the designated medical institutions and the cost of medicines purchased by the designated retail pharmacies shall be paid by the insured individuals in accordance with the policy, and those who can use their individual accounts to settle the bill shall settle the bill by holding the basic medical insurance card or by paying the bill in cash; and the portion of the bill that should be paid by the integrated fund shall be paid in the first instance by the designated medical institutions and the designated retail pharmacies. The social insurance agency and the designated medical institutions and designated retail pharmacies to settle directly on a monthly basis.
Article 24 The hospitalization expenses of urban workers' basic medical insurance shall be settled as follows:
(1) Calculation of the number of hospitalization times
The number of hospitalization times shall be calculated as 1 for each hospitalization treatment for which the insured person has gone through the procedures of hospitalization and discharge at the designated medical institutions. Among them:
1. If a participant is hospitalized directly after treatment in the emergency observation room, his/her one hospitalization is calculated from the date of admission to the observation room;
2. If a participant is hospitalized continuously for a long period of time according to his/her medical condition, the number of hospitalizations is calculated once in every three months, and if it is less than three months, it is calculated according to the number of one hospitalization.
3. If the current hospitalization crosses the medical insurance year, the year of calculation of the individual out-of-pocket ratio shall be treated as the hospitalization expenses incurred in the year of discharge.
(2) The starting standard for hospitalization is set up, and the starting standard and the following expenses are paid by individuals. During the medical insurance year, each time a participant is hospitalized, the individual pays the starting standard of the integrated fund according to the level of the medical institution. The specific standards are as follows:
For the first hospitalization during the year, the starting standard of the coordinated fund for the hospitalization of the third-level, second-level and first-level medical institutions is 700 yuan, 600 yuan and 300 yuan respectively;
For the second or more hospitalizations, the starting standard of the coordinated fund for the hospitalization of the third-level, second-level and first-level medical institutions is 400 yuan, 200 yuan and 100 yuan respectively.
If a participant is hospitalized several times during the year, and the medical expenses for the first hospitalization are lower than the prescribed starting standard for the first hospitalization, the difference will be carried forward to the next hospitalization and settled cumulatively with the prescribed starting standard for the second hospitalization.
(3) The part above the starting standard shall be paid by the Basic Medical Insurance Coordination Fund and the individual in proportion to the following standards:
The proportion of out-of-pocket payment by the individual shall be increased by 5 percentage points, and the proportion of payment by the Coordination Fund shall be reduced by 5 percentage points, if the participant's hospitalization costs are transferred to a non-designated medical institution within the coordinated area due to an acute or critical illness, or are transferred to a hospital outside the coordinated area for hospitalization and treatment, and if the participant's hospitalization costs in a different location are in line with the regulations. The proportion of payment by the integrated fund will be reduced by 5 percentage points accordingly.
(4) The maximum standard for the urban workers' basic medical insurance co-ordination fund to pay for ordinary beds is 25 yuan per bed per day; the maximum standard for the intensive care ward beds is 30 yuan per bed per day. If the actual amount of bed charges is lower than the above standard, the actual settlement shall be made.
Article 25 Settlement of Outpatient Specific Items and Medical Expenses of Urban Employees' Basic Medical Insurance.
(1) The types and scope of specific outpatient items
1. Outpatient emergency detention: mainly including acute severe trauma, traumatic brain injury, bone fracture, dislocation, laceration, burns, acute abdominal pain, sudden high fever, acute hemorrhage, vomiting of blood, signs of internal hemorrhage, diarrhea, severe dehydration, shock, convulsions or unconsciousness, the ear, nose and throat, pharyngeal, intraocular, trachea, bronchus and esophagus with foreign bodies, eye, eye, eye, eye and throat. esophagus, acute pain, redness and swelling of the eyes or sudden visual impairment, respiratory distress, sudden onset, severe symptoms, rapid deterioration after the onset of the onset of poisoning, drowning, electrocution, acute urinary incontinence, acute allergic diseases, virulent infectious diseases suspected of, as well as other diseases, by the attending physician or above, that is considered a life-threatening emergency should be emergency resuscitation.
2. Family beds: the scope of treatment mainly includes patients with mobility problems such as sequelae of cerebrovascular accidents, advanced malignant tumors, chronic obstructive pulmonary disease, senile cerebral atrophy, bone fracture recovery, cardiac insufficiency due to chronic cardiovascular diseases, urinary retention due to various reasons requiring indwelling catheters, chronic failure, chronic uremia and so on.
3. The scope of outpatient major diseases:
(1) a variety of malignant tumors: ① non-radiotherapy, chemotherapy, ② radiotherapy, chemotherapy; (2) anti-rejection treatment after organ transplantation; (3) chronic renal insufficiency: ① non-dialysis treatment, ② dialysis treatment; (4) chronic obstructive pulmonary disease; (5) chronic congestive heart failure; (6) chronic active hepatitis consolidation; (7) cirrhosis; (8) diabetes mellitus; (9) coronary heart disease; (10) Psychosis (limited to schizophrenia and paranoid mental disorder); (11) active tuberculosis; (12) hemophilia; (13) psoriasis; (14) hypertension (high-risk group); (15) hyperthyroidism; (16) sequelae of cerebrovascular disease; (17) Parkinson's syndrome; (18) systemic lupus erythematosus; (19) aplastic anemia; (20) thalassemia of severe and intermediate type; and (21) rheumatoid arthritis.
(2) Outpatient Specific Items Payment Ratio
After approval, outpatient specific items are paid by the integrated fund and the insured individuals in proportion to the standard as follows:
1. Outpatient Emergency Observation: The payment of medical expenses incurred by the insured persons each time they are hospitalized in the emergency observation room of a designated medical institution is the same as that of inpatient hospitalization medical expenses.
2. Home hospital beds: for active employees, within two months, the individual pays 20% and the integrated fund pays 80%; from the third month onwards, the individual pays 30% and the integrated fund pays 70%. For retirees, within 2 months, the individual pays 10%, and the comprehensive fund pays 90%; from the 3rd month onwards, the individual pays 15%, and the comprehensive fund pays 85%.
3. Outpatient major diseases: the insured persons shall submit applications for outpatient major diseases according to the regulations, and after evaluation and recognition, they shall enjoy the outpatient major disease medical treatment from the date of application by the designated medical institutions (second level and above):
(1) chemotherapy and radiotherapy for various malignant tumors, anti-rejection treatment after approved organ transplantation, and dialysis for severe uremia: the individuals of the active employees shall pay 15%, and the individuals of the retired shall pay 8%, and the co-ordinated fund shall pay 85%. pay 8%, and 85% and 92% are paid by the integrated fund respectively.
(2) Except for chemotherapy and radiotherapy for malignant tumors, anti-rejection treatment after organ transplantation and dialysis for severe uremia, for the part of the cumulative cost of limited medicines exceeding RMB 300 Yuan/month within one month, the individual serving employee pays 20%, and the coordinated fund pays 80%; and the individual retired person pays 10%, and the coordinated fund pays 90%.
(3) The validity period of the outpatient treatment for major illnesses is one year, and the outpatient treatment card for major illnesses is subject to a one-year review system.
Article 26 The scope of special examination and special treatment items of urban workers' basic medical insurance.
(a) special examination mainly includes: the application of χ-ray computed tomography device [CT], stereotactic radiography device [γ-knife, χ-knife], cardiac and angiography χ-line machine [including digital subtraction equipment], nuclear magnetic *** vibration imaging device [MRI], Single Photon Emission Computer Scanning Device [SPECT], medical linear gas pedal and other large-scale medical equipment for medical examinations and single cost of more than 200 yuan / times of medical examinations.
(2) special treatment mainly includes:
1. extracorporeal vibration wave lithotripsy treatment, hyperbaric oxygen therapy, medical linear gas pedal treatment, intensive care and rescue CCU, ICU ward treatment;
2. kidney transplantation, heart valve transplantation, cornea transplantation, skin transplantation, vascular transplantation, bone transplantation, bone marrow transplantation, pancreatic islet transplantation;
3. heart pacemaker, heart valve transplantation, bone marrow transplantation, pancreatic islet transplantation. 3. Replacement and installation of artificial organs in the body such as pacemaker, artificial joint, artificial crystal, artificial larynx, artificial hip joint, etc., cardiac bypass surgery, cardiac catheterization and balloon dilatation;
4. Hemodialysis, peritoneal dialysis;
5. Cardiac laser perforation, anti-tumor cellular immunotherapy, interventional therapy, and fast neutron therapy projects;
6. Treatment projects whose single cost exceeds 200 yuan / times of the treatment program.
Article 27 The costs of special examination and special treatment for outpatient or hospitalization of the insured shall be paid directly by the individual and the integrated fund within the maximum payment limit of the integrated fund***, with the following standards: 30% out-of-pocket payment by the individual in the workplace, and 70% from the integrated fund; 15% out-of-pocket payment by the individual in the workplace, and 85% from the integrated fund for the retired. For special examinations and special treatments that are approved to be transferred outside the integrated area, the proportion of payment from the integrated fund will be reduced by 5%.
Due to the needs of the condition, the use of artificial organs in special treatment, the costs incurred in the body of the material, approved by the social insurance agency, in the integrated fund within the maximum payment limit directly from the individual due to the needs of the condition, the cost of a single more than 200 yuan of medical materials (excluding the body of the material), approved by the municipal social insurance agency, the integrated fund with reference to the provisions of the special inspection and special treatment Payment ratio settlement.
The approved diagnostic and therapeutic items with a single cost of 5,000 yuan or more shall be paid by the basic medical insurance co-ordination fund at a rate of 50%.
Article 28 The specific management methods for outpatient specific items, special examinations and special treatments shall be separately formulated by the municipal social insurance administration organization.
Article 29 The medical blood used by insured persons in the following circumstances can be included in the scope of the overall fund to pay part of the expenses:
(1) acute hemorrhage (including intraoperative hemorrhage), hemorrhagic shock and other acute and critical conditions of blood rescue;
(2) large burns must be blood treatment;
(3) hemophilia and other platelet dysfunction (4)Blood treatment for hemorrhage caused by thrombocytopenia and granulocytopenia due to bone marrow suppression or failure caused by disease, chemotherapy, radiotherapy, or severe infections;
(5)Blood treatment for hemorrhage caused by defects of other blood components (congenital or acquired FⅡ, FⅤ, FⅦ, FⅩ, FⅪ, and FⅧ deficiency);
(6)Blood treatment for massive burns;
(7) Hemophilia and other platelet function disorders /p>
(6) Blood transfusion treatment necessitated by bone marrow hematopoietic dysfunction or severe anemia due to disease or other reasons.
The cost of medical blood used within the scope of the regulations (excluding the reimbursable cost of non-reimbursable blood donation) shall be paid directly by the individual within the maximum payment limit of the integrated fund by 30% out-of-pocket payment, and the integrated fund shall pay 70% of the cost.
Article 30 The medical expenses incurred by insured persons in other places in conformity with the regulations shall be advanced by the individuals first, and after the treatment is over, they shall go to the social insurance agency for reimbursement with the relevant materials.
Article 31 If the insured person incurs medical expenses and cannot settle them with the medical insurance card at the designated medical institution for special reasons, he shall go to the municipal social insurance agency for reimbursement with the relevant materials within six months from the date of discharge from the hospital (outpatient settlement), and the reimbursement will not be accepted after that time.
Article 32 The maximum payment limit of the urban workers' basic medical insurance co-ordination fund shall be six times the average salary of urban workers on duty in the whole region in the previous year. After making contributions, the participants shall enjoy the maximum payment limit of the urban workers' basic medical insurance co-ordination in accordance with the following provisions:
(1) After the employees of the participating units have made contributions, their treatment within the maximum payment limit of the basic medical insurance co-ordination fund shall be calculated on an annual basis.
(2) After the flexible employment personnel have made contributions, their maximum payment limit in the integrated fund is calculated on an annual cumulative basis, and is settled on the basis of the number of months of contributions at the end of the medical treatment, and on the basis of the actual settlement at the end of the year. Each person who has contributed for 12 consecutive months in a year can enjoy the full amount of the maximum payment limit according to the payment regulations; for those who have contributed for less than 6 months, they can enjoy the payment limit at 30%; and for those who have contributed for more than 6 months but less than 12 months, they can enjoy the payment limit at 70%.
Article 33 The urban workers' basic medical insurance co-ordination fund shall not pay for medical expenses incurred within the following scope:
(1) those incurred in non-designated medical institutions (except for emergency hospitalization in non-designated medical institutions due to acute and critical illnesses);
(2) injuries caused by traffic accidents, medical malpractice, or other liable accidents;
(3) injuries caused by drug addiction, fighting, and assault; and (3) Injuries caused by one's own drug abuse, fighting and brawling, violation of laws and regulations, etc.
(4) Treatment for suicide, self-inflicted injuries, alcoholism, drug addiction, etc.
(5) Unapproved medical treatment outside the co-ordinated area;
(6) Medical treatment outside the country (including Hong Kong, Macao and Taiwan);
(7) Payment should be made out of the Workmen's Compensation Insurance Fund;
(8) Payment should be made out of the Workmen's Compensation Insurance Fund;
(9) The insurance company should pay for the injury in the event of a traffic accident or other responsible accident. /p>
(viii) those that should be borne by public **** health;
(ix) other items and expenses that are not payable under the relevant documents of the State and the Autonomous Region.
Chapter VI Medical Insurance Service Management
Article 34 The designated medical institutions and designated retail pharmacies of urban workers' basic medical insurance shall implement designated qualification management. The municipal social insurance administrative department is responsible for the qualification assessment and management of medical institutions and retail pharmacies, and publishes the list of designated medical institutions and retail pharmacies to the public in accordance with the regulations, and accepts social supervision.
Article 35 The social insurance administration agencies sign service agreements with the designated service providers according to the needs of management services, clearly define the responsibilities, rights and obligations of both parties, and conscientiously fulfill the agreements, and those who violate the provisions of the agreements shall bear the responsibility for breach of contract in accordance with the law.
Article 36 The municipal social insurance administrative department shall, according to the principle of the basic medical insurance fund for urban workers "to determine expenditure on the basis of income and balance of payments", standardize the settlement relationship between the social insurance agency and the fixed-point service agency, and formulate the cost settlement methods and standards, the settlement scope and procedures, the audit method and the management measures and other contents. The fee settlement methods.
Article 37 The fixed-point service organizations and individuals who have made outstanding contributions in the work of basic medical insurance for urban employees shall be commended and rewarded in an appropriate manner.