China's publicly-funded medical care and labor insurance medical care established in the early 1950s are collectively referred to as employees' social medical insurance. It is an important part of the national social security system and one of the important programs of social insurance.
China's medical insurance has played a positive role in safeguarding the health of workers and maintaining social stability for more than 40 years. However, with the establishment of the socialist market economy and the deepening of the reform of state-owned enterprises, it has become difficult for this system to solve the problem of basic medical protection for employees under the conditions of the market economy.
In 1988, the Chinese government began to reform the public medical care system for institutions and the labor insurance medical care system for state-owned enterprises, and in 1998, the Chinese government promulgated the Decision on the Establishment of a Basic Medical Care Insurance System for Urban Workers, beginning the establishment of a basic medical care insurance system for urban workers throughout the country.
The basic medical insurance system is based on the principle of combining social coordination and individual accounts, organically combining the two modes of social insurance and savings insurance, and realizing the organic combination of "horizontal" social ****ancial protection and "vertical" individual self-insurance. Organic combination of "horizontal" social security and "vertical" individual self-insurance, which is conducive to giving full play to both the strengths of social coordination *** relief, and the advantages of individual accounts with their incentives and constraints, which is more in line with China's national conditions and is easily accepted by the majority of workers. This medical insurance model, in line with China's national conditions, is a social medical insurance system with Chinese characteristics.
The basic medical insurance fund is, in principle, coordinated at the local and municipal levels. Basic medical insurance covers all urban employers and their employees; all enterprises, state administrative organs, public institutions and other units and their employees must fulfill their obligation to pay basic medical insurance premiums. The contribution rate for employers is about 6% of total wages, and the contribution rate for individuals is 2% of their own wages. The basic medical insurance premiums paid by an organization are partly used to establish a comprehensive fund and partly transferred to an individual account; the basic medical insurance premiums paid by an individual are credited to an individual account. The integrated fund and the individual account bear different responsibilities for the payment of medical expenses. The integrated fund is mainly used to pay for hospitalization and outpatient treatment of some chronic diseases, and the integrated fund has a starting standard and a maximum payment limit; the individual account is mainly used to pay for general outpatient expenses.
In order to ensure that insured workers enjoy basic medical services and to effectively control the excessive growth of medical costs, the Chinese Government has strengthened the management of medical services, formulating standards for basic medical insurance drug lists, diagnostic and therapeutic items, and medical service facilities, and qualifying medical institutions and pharmacies that provide basic medical insurance services, as well as allowing insured workers to make choices. In line with the reform of the basic medical insurance system, the State is simultaneously promoting reform of medical institutions and the system for the production and distribution of medicines. Through the establishment of a competitive mechanism among medical institutions and a market mechanism for the production and distribution of medicines, efforts are being made to realize the goal of "providing relatively high-quality medical services at relatively low cost".
In addition to basic medical insurance, a system of mutual assistance for large medical expenses has also been established to cover medical expenses above the maximum payment limit of the social fund. The State has established a medical subsidy system for civil servants. Enterprises that are in a position to do so may establish enterprise supplementary medical insurance for their employees. The State will also gradually set up a social medical assistance system to provide basic medical protection for the poor.
China's reform of its basic medical insurance system is advancing steadily, and the coverage of basic medical insurance is expanding. By the end of 2001, 97 percent of the country's prefectures and municipalities had initiated reforms of basic medical insurance, with some 76.29 million workers participating in basic medical insurance. In addition, publicly-funded medical care and other forms of medical insurance systems cover more than 100 million people in cities and towns, and the Chinese government is gradually incorporating these populations into the basic medical insurance system.
The Ministry of Human Resources and Social Security (MOHRSS) has learned that the "Guiding Opinions on Improving the Agreement Management of Basic Medical Insurance Designated Medical Institutions" has recently been published, explicitly requesting that all coordinated areas across the country, by the end of 2015, completely abolish the "qualification examination of basic medical insurance designated medical institutions" and the "qualification examination of basic medical insurance designated medical institutions" implemented by the social insurance administrative departments.
The "two" qualification examination of "basic medical insurance designated retail pharmacy qualification examination", synchronize and improve the agreement management of social insurance agencies and pharmaceutical institutions, improve the level of management services and the efficiency of the use of the fund.
The Opinions put forward clear requirements on how to improve the management of the agreement after the abolition of the "two" qualification examination carried out by the social security administration. All kinds of medical institutions established by law, regardless of their level, type and nature of ownership, can voluntarily apply to the social security agencies against the conditions to become a fixed point of medical insurance, social security administrative departments no longer carry out prior approval. At the same time, the agency to establish an open and transparent assessment mechanism, explore third-party evaluation and other ways to carry out the assessment, and select the quality of service, reasonable price, standardized management of the pharmaceutical institutions negotiated service agreements. Chapter III of the basic medical insurance
Article 23 of the workers shall participate in the basic medical insurance for workers, by the employer and employees in accordance with state regulations **** the same basic medical insurance premiums. Individual industrial and commercial households without employees, part-time workers who do not participate in the basic medical insurance of employees in the employing unit, and other flexible employment may participate in the basic medical insurance of employees, and individuals shall pay the basic medical insurance premiums in accordance with state regulations. Article 24 The State establishes and improves the new rural cooperative medical care system. The administration of the new rural cooperative medical care shall be regulated by the State Council. Article 25 The state establishes and perfects the basic medical insurance system for urban residents. Basic medical insurance for urban residents is a combination of individual contributions and government subsidies. The government shall subsidize the portion of individual contributions required by persons enjoying the minimum subsistence guarantee, persons with disabilities who have lost the ability to work, and elderly persons over the age of sixty and minors from low-income families. Article 26 The treatment standards for basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with national regulations. Article 27 individuals participating in the basic medical insurance for employees, reaching the legal retirement age when the accumulated contributions to reach the national regulations for a number of years, after retirement, no longer pay the basic medical insurance premiums, in accordance with the provisions of the state to enjoy the basic medical insurance benefits; has not reached the national regulations for a number of years, you can contribute to the national regulations for a number of years. Article 28 in line with the basic medical insurance drug list, diagnostic and treatment items, medical service facilities standards, as well as emergency and rescue medical expenses, in accordance with state regulations from the basic medical insurance fund. Article 29 The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons. Article 30 The following medical expenses are not included in the scope of payment of the basic medical insurance fund: (a) they should be paid from the workers' compensation insurance fund; (b) they should be borne by a third party; (c) they should be borne by the public ****health; and (d) they should be paid when seeking medical treatment outside the country. If the medical expenses should be borne by a third person in accordance with the law, and the third person does not pay or 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 costs from the third party after making the payment in advance. Article 31 The social insurance administration organization may, according to the needs of management services, sign service agreements with medical institutions and drug business units to regulate the behavior of medical services. Medical institutions shall provide reasonable and necessary medical services to insured persons. Article 32 If an individual is employed across the integrated region, his basic medical insurance relationship shall be transferred with him, and the years of contribution shall be cumulative. (a) Individual account establishment
The social medical insurance agency establishes a basic medical insurance individual account for each insured person, with the person's identity card number as the lifelong medical insurance number. The funds in the individual account of the basic medical insurance for employees are owned by the individual, and are directed to be used for medical consumption, with no compensation for overspending, and the balance rolled over, and no cash may be withdrawn. When an employee dies, the individual account is canceled and the balance is inherited in accordance with the regulations.
(2) Issuance of Individual Account Cards
Employers shall apply for individual medical account cards for their employees at the same time as they participate in basic medical insurance. Within 30 days from the date of enrollment, the employer shall submit an application and provide relevant information to the social medical insurance agency for newly enrolled employees. Upon receipt of the employer's application to establish an account for the employee, the social medical insurance agency shall carefully examine the relevant information, establish an individual account for the employee within 15 days, and issue an individual account settlement card. Funds shall be injected into the employee's individual medical account in a timely manner, and interest shall be accrued in accordance with the relevant regulations. Retirees who are resettled in other places may not be issued cards for the time being.
Participants can use their individual medical account cards to purchase medicines at any designated medical institutions and designated pharmacies in the region. In case of insufficient funds in the individual medical account, cash payment will be made.
(3) Transfer and Inheritance of Individual Account
If a participant is transferred out of the local area, the funds in the individual medical account will be transferred together with him/her; if it is not possible to transfer the funds, the balance of the individual account will be returned to him/her, and at the same time, his/her individual account will be canceled.
If a participant dies, the balance of the individual account can be inherited by his legal heirs.
(4) Loss and reissuance of individual account card
Participants should keep the individual account card properly, and if it is damaged and needs to be replaced with a new one, the cost shall be borne by the individual. If the individual account card is lost, it should be lost in time with relevant documents to the medical insurance agency or designated unit, the medical insurance agency should immediately block the account. 30 days can not be found, the new card should be handled at their own expense. For medical expenses incurred during the period of loss, the individual account portion shall be paid in cash by the individual employee. If the individual account card is used fraudulently before the registration of the loss, the loss will be borne by the insured person.
When the insured person purchases medicine and settles the medical expenses with the card, the service personnel of the designated medical institutions and pharmacies shall carefully verify the card, and shall immediately detain the card if it is found to be forged or fraudulently used, and notify the social medical insurance administration organization. The designated medical institutions and pharmacies shall not refuse to accept the card funds, and shall not exchange cash for the cardholder.
In January 2010, the Ministry of Human Resources and Social Security announced the Interim Measures for the Transfer and Continuation of Basic Medical Insurance Relationships for Mobile Employed Persons, which stipulates that, starting from July 1, 2010, mobile workers who are employed in other provinces can transfer their medical insurance relationships, and their personal accounts will also be transferred with the transfer. In addition to the transfer of health insurance relationships across provinces, three different types of health insurance relationships, namely employee health insurance, resident health insurance and new rural cooperative medical care, can also be transferred to each other as the status of the insured changes. Migrant workers who go to the cities can participate in the local Employee Basic Medical Insurance at their place of employment, and when they return to the countryside, they can bring it back and transfer it to the new type of Rural Cooperative Medical Insurance without any interruption. (A) declaration acceptance of the health insurance agency collection department accepts the participating units to fill out the "health insurance contribution base change declaration form", and requires the following information:
1. salary payment details;
2. "the increase or decrease in the number of people enrolled in the health insurance details"
3. other information specified by the health insurance agency.
(2) Approval of contributions
1. The collection department of the health insurance organization examines the approved form of contribution declaration and related information filled in by the insured unit. After passing the audit, the procedures for approval or increase or decrease in the number of insured persons.
2. The collection department of the health insurance organization records the time of enrollment and the current payroll for the new enrollees in a timely manner according to the declaration and approval of the contributions. The collection department of the health insurance organization approves the current contribution base according to the declaration of the participating units.
3. The collection department of the health insurance organization calculates the amount to be paid according to the approved contribution base and contribution rate of the insured unit for the current period, and prints out the Notice of Medical Insurance Contribution to give back to the declaring unit, and collects on this basis.
(3) Collection of Fees
1. The health insurance organization charges fees through the "income account deposit" account bank, and can also take checks, cash, wire transfers, cashier's checks and other means of charging, and issue a special receipt. The financial management department of the health insurance organization reconciles with the bank every month and gives feedback to the collection department on the arrival of the account.
2. The collection department of the health insurance organization issues a "Notice of Reminder of Social Insurance Premiums" to the insured units that have not paid the full amount of health insurance premiums or have not paid health insurance premiums in time after the declaration, based on the payment of health insurance premiums fed back by the financial management department. If the notice is not complied with after the deadline, the relevant circumstances and information will be provided to the labor security administrative department, and the labor security administrative department will make corrections within a time limit.
3. Before the 25th of each month, the insured units delayed payment, from the date of arrears in payment of 2 per cent late fee per day. May be a one-time payment of a month, a quarter, half a year or a year. If the contribution is made on a quarterly or annual basis, it shall be paid from the beginning of the quarter or the beginning of the year. If you are temporarily unable to pay, apply for a deferral, the deferral period shall not exceed 2 months.
(4) Repayment of arrears
1. The collection department of the health insurance organization establishes data information on arrears based on the situation of arrears in medical insurance, fills in the Notice of Repayment of Social Insurance Premiums, and notifies the insured units to make up for the arrears.
2. The collection department of the health insurance organization signs an agreement on the payment of social insurance premiums with the insured units that are unable to pay the outstanding premiums in full at one time due to financing difficulties. In case of merger, separation, bankruptcy, etc. of a unit in arrears of contributions, a supplementary contribution agreement shall be signed in the following manner.
(1) If the unit in arrears of contributions is merged, signing a supplementary contribution agreement with the merging party.
(2) If the delinquent unit is separated, a retroactive payment agreement shall be signed with each of the separating parties.
(3) If the delinquent unit enters into bankruptcy proceedings, a liquidation agreement is signed with the liquidation group.
(4) If the unit is sold or leased by auction, signing a retroactive payment agreement with the competent authority.
3. The insured unit handles the retroactive payment according to the Notice of Social Insurance Premium Replacement or the agreement on retroactive payment, and the collection department of the health insurance organization accepts it and notifies the financial management department of the health insurance organization to collect the money.
4. If the insolvent unit is unable to settle the outstanding contributions, the collection department of the health insurance organization accepts the application made by the insolvent liquidation group of the unit and sends it to the audit and supervision department for processing after examination.
5. The collection department of the health insurance organization adjusts the information about the arrears of fees of the insured units based on the information about the arrival of the arrears of fees to be repaid transmitted by the financial management department and the information about the write-off transmitted by the auditing and supervision department. Settlement Procedures for Hospitalization and Outpatient Treatment of Special Diseases The designated medical institutions will submit the statement of expenses of patients discharged from hospitals in the previous month, the statement of hospitalization and relevant information to the medical insurance agency before the 10th day of each month, which will review and approve them as the basis for the monthly preallocation and year-end final accounts. The medical insurance agency makes monthly advance payments of the previous month's coordinated fees for hospitalization and outpatient treatment of special diseases.
Participants who are recognized as suffering from special diseases should go to one of the designated medical institutions designated by the Labor and Social Security Department for medical treatment and purchase of medicines, and medical expenses incurred will be recorded directly and settled instantly.
(2) Emergency Settlement Procedures
Participants who are hospitalized in non-designated medical institutions in the city or in other medical institutions due to emergency medical treatment shall first pay the medical expenses incurred by themselves or their units in advance, and then, after the emergency medical treatment is over, they shall apply for reimbursement with the hospital's emergency medical records, examination and laboratory report forms, invoices, and detailed lists of medical fees and charges, etc., in accordance with the provisions of the medical insurance agency.
(3) Settlement Procedures for Relocated Staff
1. Relocated staff will be assigned 1-2 fixed-point medical institutions in their place of residence by their respective units, and will report to the medical insurance agency for record.
2. The medical expenses incurred by a staff member resettled in a foreign country who falls ill and attends a designated medical institution in his place of residence shall be advanced by the staff member himself or by his employer, and after the completion of the treatment, the employer shall settle the bill with the medical card of the insured person and his medical records, valid expense bills, duplicate prescriptions, and a list of hospitalization expenses, etc., at a specified date with a social medical insurance agency.
(4) Referral and transfer settlement
1. If the insured person is referred to other medical institutions for diagnosis and treatment due to the limitations of the designated medical institutions or due to specialized diseases, he/she has to fill in the approval form for referral and transfer. By the attending physician to put forward the reasons for referral and transfer, the department head to put forward the referral and transfer opinions, the medical insurance office of the medical institution, signed by the director in charge, reported to the Municipal Medical Insurance Center for approval before the transfer of hospitals.
2. The principle of referral and transfer of hospitals in the city and then outside the city, the province and then outside the province. Intra-city referrals and transfers are to be made between designated medical institutions. Out-of-town referrals and transfers must be made by the designated medical institutions above the third level in the city.
3. The medical expenses incurred by a participant after being referred to a hospital shall be paid in cash by the individual or the unit, and after the end of medical treatment, the participant or his/her agent shall reimburse the hospitalization expenses that are covered by the integrated fund to the medical insurance agency with the referral and transfer approval form, medical record certificate, prescriptions and valid documents. The reimbursement process for all participants is as follows:
(1) For outpatient treatment at a designated institution by a participating farmer with a New Farmers' Cooperative Card, the designated medical institution will directly reduce or waive the medical fees according to the amount available in the family outpatient account clinic account of the New Farmers' Cooperative Card, and the participant will be required to pay for anything beyond that amount out of his own pocket. The fixed-point medical institutions should settle the bill with the Farmers' Medical Institute in a timely manner.
(2) participating farmers in the city, county, township designated medical institutions hospitalization, by the designated medical institutions for direct subsidies. The fixed-point medical institutions will audit the medical expenses incurred by them and advance the amount of subsidy payable according to the standards stipulated in the implementation measures.
Participating farmers hospitalized in provincial fixed-point medical institutions and non-fixed-point medical institutions are compensated by the township agricultural medical institutions. Their hospitalization medical expenses for a lump sum of less than 2,000 yuan (including 2,000 yuan) will be reviewed and reimbursed by the township (township) Agricultural Medical Office, while those above 2,000 yuan or those who have doubts about the hospitalization information will be reviewed by the township (township) Agricultural Medical Office and then submitted to the county Agricultural Medical Bureau for review and approval before reimbursement is made.
(1) When applying for reimbursement, you need to bring your ID card, hukou book, New Farmers' Cooperative Card (the original of these three certificates will be photocopied and stored in the bottom after the audit), valid hospitalization invoices of the medical institutions, hospital discharge summaries (or medical records), cost lists and referral certificates.
(2) Participating farmers suffering from outpatient major diseases (chronic diseases) at the prescribed time (generally in July and December each year), need to bring their ID cards, household registration, "New Farmers' Cooperative License", outpatient invoices and lists, outpatient medical records, inspection reports, outpatient major diseases (chronic diseases) of hospitals of second class or above, or specialized hospitals to the township (township) Farmers' Medical Office to apply for the certificate.
(3) For farmers who have participated in commercial insurance and school students who have participated in student medical insurance, when they need both commercial insurance and NNH compensation after discharge from the hospital, the farmers should submit the original hospitalization invoice and a copy of the invoice to the Farmers' Medical Office or the county-level designated medical institutions for checking and reimbursement, and then submit the original hospitalization invoice to the commercial insurer for reimbursement. The copy of the invoice will be kept by the Farmers' Medical Institute or the county-level designated medical institution, but only the original can be reimbursed for trauma patients (except for students).
(4) Hospitalization expenses are subject to a time-limit settlement system. Reimbursement and settlement procedures can be carried out at any time within three months after discharge from the hospital, and those exceeding three months are regarded as forfeiting their own reimbursement (those who are out of the country for work can be delayed until the end of the year). The amount to be compensated by the Agricultural Medical Institute in accordance with the standards stipulated in the implementation measures will be paid to the participating farmers within 10 working days.
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