Article 2: the city's basic medical insurance for urban residents to implement municipal coordination, local management and hierarchical management. Provincial (city, district) labor and social security bureau is responsible for supervision, management and implementation.
Article 3: All counties (cities and districts) are responsible for the basic medical insurance agency for urban residents, the main duties are:
(1) responsible for the basic medical insurance fund for urban residents, management and payment;
(2) preparation of the basic medical insurance fund for urban residents of the final budget, report the basic medical insurance for urban residents of the city
all kinds of financial and statistical statements. Medical insurance various types of financial and statistical reports;
(3) is responsible for the initial examination of the application and relevant supporting materials with the urban residents of the basic medical insurance designated medical institutions, reported to the municipal labor security department for approval and confirmation, and announced to the community.
Article 4: the counties (cities, districts) financial departments in accordance with the number of participants approved by the medical insurance agency, according to the appropriate standards for the community and other agencies to allocate the agency fee, the agency fee is included in the financial budget at the same level.
Article 5: The municipal medical insurance agency shall withdraw 3% of the basic medical fund for urban residents to establish a transfer fund year by year, but the total amount shall not be withdrawn after the accumulated total reaches 15% of the current year's income of the integrated fund, which shall be used specifically for the purpose of preventing the major risks arising from the operation of the basic medical insurance for urban residents.
Article 6: the implementation of the rules adapted for not belonging to the basic medical insurance system for urban workers, coverage of primary and secondary school students (including vocational high schools, junior colleges, technical schools students), children and teenagers (hereinafter referred to as the children of the residents); 60 years of age or older elderly residents; other non-employed urban residents: not included in the new rural cooperative medical system of the municipal district of the rural residents.
The determination of the age of majority for each category is based on January 1 of each year.
Article 7: Urban residents, on a household basis, with valid documents such as the Household Register and Resident Identity Card, and non-local students, on a school basis, shall register for insurance at the labor security work agency of the street (township) where their household registration is located.
Article 8: The basic medical insurance for urban residents starts from October 1, 2007 to March 31, 2008 in Hecheng District and from January 1 to June 30, 2008 in other counties (cities and districts). The basic medical insurance premiums are paid on a regular basis, from October 1 to December 30 of each year by natural year.
The basic medical insurance for urban residents started the year in the prescribed period of enrollment, from the payment of fees from the next month to enjoy the basic medical insurance for urban residents. Those who are subject to urban medical insurance but have not enrolled within the prescribed period will be enrolled in the future and will be entitled to urban residents' basic medical insurance benefits from 90 days after the payment of the fees (except for newborn children and those who have newly moved into the household registration).
People whose household registration has been moved in after the launching period shall enroll in the insurance in the year following the year of household registration moving in, and those who are required to enroll in the insurance in the same year shall pay all the premiums of the current year, and shall not be entitled to the medical treatments prior to the enrollment and payment of the premiums.
Infants born after the start-up period, after 30 days of birth, have gone through the household registration procedures, and both parents are enrolled in social health insurance, can be enrolled in that year. When enrolling, they shall pay all the premiums for the current year and shall not be entitled to the medical treatment before enrolling and paying the premiums.
If the insured person fails to pay the basic medical insurance premiums in full and on time, he/she will stop enjoying the urban residents' basic medical insurance treatment from the next month, and if he/she requests to be insured again, he/she will be able to enjoy the treatment only after he/she pays all the unpaid fees of the previous years for 90 days, and his/her consecutive years of participation in the insurance premiums will be recalculated again.
No refund or transfer of health insurance premiums will be made in the event that a resident moves out of the city or dies during the period of entitlement.
Article 9: the basic medical insurance for urban residents consists of individual contributions and government subsidies in two parts, the financing standard per person per year: 80 yuan for children of residents, other urban residents 200 yuan.
The government subsidizes according to the following standards:
(1) Anyone who participates in the basic medical insurance for urban residents shall be subsidized 40 yuan per person per year.
(ii) Children of residents who are low-income recipients or who have disabilities of the second degree or above are given an additional subsidy of 10 yuan per person per year, while other low-income recipients, persons with disabilities of the second degree or above who have lost the ability to work, and elderly persons aged 60 or above from low-income families who are in need of assistance are given an additional subsidy of 60 yuan per person per year.
(3) The "three have-nots" who are unable to work, have no source of livelihood, and have no legal dependents or supporters shall be fully subsidized by the government at the same level.
Article 10: The insured person, with the original and copy of the Household Register and Resident's Identity Card, and the non-local students, with the school as the unit, will go to the agency in the place of household registration to register for the insurance, and fill in the Registration Form of Personal Information of Huaihua City Urban Residents' Basic Medical Insurance, and the agency will paste the copy of the relevant information on the back of the Registration Form for review.
Participation in the scope of low-income objects, "three have-nots", another must provide the civil affairs department issued by the urban residents of the minimum subsistence guarantee amount of evidence; low-income families 60 years of age (including 60 years old) or older, another low-income certificate issued by the civil affairs department; the second level of disability, another must provide the civil affairs department issued low-income certificate. Low-income certificate issued by the civil affairs department; persons with disabilities above the second level must also provide the People's Republic of China **** and the State Disabled Person's Certificate issued by the Disabled Persons' Federation (all of the above information is provided in the original and photocopies).
Article 11: the inclusion of financial subsidies to the object of enjoying the minimum subsistence allowance, persons with disabilities above the second level, the "three have-nots", low-income families aged 60 years (including 60) or older, by the domicile of the local street labor security station once a year for a period of seven working days, after the public announcement of the relevant functional departments for review and confirmation. After the report to the relevant functional departments for examination and confirmation.
Article 12: The agency checks all kinds of information and enters the basic information of the insured person into the computer information system; it prints out the payment slip for the insured person, and the insured person goes to the designated bank with the payment slip to go through the procedure of payment; the agency issues the Receipt for Social Insurance Fund with the receipt of the payment, and at the same time determines the time of enrollment by the time of payment to make the payment registration in the computer information system; the agency regularly prepares the "Wyoming City Urban and Rural Insurance Fund", which is the most important document in the city. The agency regularly prepares the "Summary Table of Huaihua City Urban Residents' Basic Medical Insurance Participation and Individual Maintenance Fees", summarizes the payment documents, and submits them to the medical insurance agency for review and accounting; after the review by the medical insurance agency, it issues the "Huaihua City Urban Residents' Basic Medical Insurance Handbook" and IC card.
Article 13: At the end of the contribution period, the medical insurance agency prepares a table of residents' participation in the current year and reports it to the Bureau of Labor and Social Security for approval and the Bureau of Finance for examination and approval, and the financial subsidies shall be subsidized in place by the end of September each year.
Article 14: The medical insurance agencies shall uniformly issue the "Basic Medical Insurance Handbook for Urban Residents of Huaihua City" and the IC card for recording personal identity to the insured. The Handbook of Basic Medical Insurance for Urban Residents of Huaihua City and the IC card shall be kept in a safe place and shall not be lent or altered. If they are lost, they should go to the medical insurance agency in time to apply for loss and reissuance procedures.
Article 15: If a participant is transferred from the basic medical insurance for residents to the basic medical care for employees, he shall make up the difference in the amount of scrapping based on the average social wage of the employees in this coordinated area of the previous year at the time of transferring in.
Article 16: Hospitalization expenses incurred by insured persons who are hospitalized due to illness shall be reimbursed by the Urban Residents' Basic Medical Insurance Fund in accordance with the prescribed standards.
Article 17: The fund shall set the starting standard and the maximum payment limit for hospitalization. The starting standard for hospitalization in a settlement year shall be 600 yuan for a tertiary hospital, 300 yuan for a secondary hospital, and 100 yuan for a primary hospital, and the maximum payment limit in a settlement year shall be 50,000 yuan for children of residents, and 25,000 yuan for non-working residents.
Article 18: The hospitalization expenses of the insured persons shall be borne by the fund and the insured persons in the following proportions (including the hospitalization medical expenses for accidental injuries of the non-responsible party):
(1) The part of the hospitalization expenses below the starting standard shall be borne by the individuals;
(2) The part of the hospitalization expenses above the starting standard and below the maximum payment limit shall be borne by the fund and the individuals ****together:
The fund of first-class hospitals (including community health service organizations) pays 65%, and the individual is responsible for 35%;
The fund of second-class hospitals pays 55%, and the individual is responsible for 45%;
The fund of third-class hospitals pays 40%, and the individual is responsible for 60%.
Participants who have been continuously insured and paid contributions to the fund, the proportion of hospitalization expenses paid by the fund will be increased by 2% per year from the second year onwards, and the maximum increase will not be more than 10%.
(3) The portion above the maximum payment limit shall be entirely borne by individuals and families.
Article 19: For outpatient medical expenses incurred by insured persons for malignant tumors, aplastic anemia, schizophrenia, total paralysis of cerebral diseases, renal failure, organ transplantation, and other six diseases in accordance with the regulations, there is a fund that pays 60% of the expenses up to 2,000 yuan in a year, and the part exceeding that amount is to be paid by the individuals themselves.
Article 20: The fund shall pay 50% of the prescribed outpatient medical expenses incurred by the resident's children due to accidental injuries with no other party responsible.
Article 21: Medical expenses incurred by insured persons for medical treatment in the following cases shall not be included in the scope of payment by the fund:
(1) Suicide, self-inflicted injuries, brawls, alcoholism and drug addiction;
(2) Traffic and medical accidents;
(3) Work-related injuries, occupational diseases of the medical treatment and rehabilitation and the remaining insurance payment coverage;
(4) Plastic surgery, plastic surgery;
(v) medical treatment abroad or in Hong Kong, Macao or Taiwan;
(vi) unauthorized medical treatment in non-urban residents' basic medical insurance designated medical institutions;
(vii) exceeding the urban residents' medical insurance drug catalog, diagnostic and therapeutic item catalog, scope of medical services and facilities and the standard of payment;
(viii) other unlawful acts leading to illnesses , injury or disability.
Article 22: If an insured person's condition meets the indications for hospitalization, he or she shall go to a designated medical institution for urban residents' basic medical insurance to apply for hospitalization and pay a full deposit by presenting his or her Urban Residents' Basic Medical Insurance Handbook, IC card, and resident's identity card (or household register for children of residents who are under 18 years of age).
When discharged from the hospital, the insured person or his relatives will sign the list of hospitalization expenses and settle the medical expenses borne by the individual before going through the discharge procedures.
Medical insurance agencies strictly review and identify the hospitalization notification and hospitalization expense list of the insured person in accordance with the relevant regulations, and settle the bill with the designated medical institutions on a regular basis.
Article 23: The criteria for hospitalization and discharge of insured persons shall be implemented in accordance with the relevant state regulations. If a participant should be discharged from the hospital according to his condition and is notified by the hospital and refuses to be discharged without justifiable reasons, he shall pay all the expenses from the day following the day he is notified by the hospital to be discharged; if he should be discharged from the hospital but the hospital fails to notify him of his discharge, the expenses shall be borne by the hospital.
Article 24: If the insured person is discharged from the hospital and special circumstances require consolidation of treatment, the standard amount of medicines taken with him shall not exceed five days, and the varieties of medicines shall not exceed four.
Article 25: The scope of payment and non-reimbursable items of urban residents' basic medical insurance, the scope of drug catalog, diagnostic and therapeutic items, the scope of medical service facilities and payment standards are implemented in accordance with the relevant regulations formulated by the higher authorities.
Article 26: If a participant needs to be transferred to another hospital for treatment after being hospitalized, the designated medical institution shall issue a referral form and report it to the basic medical insurance agency for examination and approval before transferring the participant to another hospital for treatment. Without the approval of the transfer of medical expenses shall be borne by the individual.
Emergency and rescue of critically ill patients can go directly to the nearest medical institution for hospitalization, but the family members should go to the medical insurance agency within three working days with the certificate of emergency hospitalization and related information to complete the referral registration formalities.
Article 27: Medical expenses incurred by approved relocated personnel shall be settled in a lump sum by December each year at the medical insurance agency with the hospitalization invoice, cost list, disease diagnosis and hospitalization medical records.
Article 28: The basic medical insurance for urban residents implements a system of hospitalization in designated medical institutions. Medical institutions that have obtained the qualification of designated medical institutions for urban residents' basic medical insurance can be designated medical institutions for urban residents' basic medical insurance, as determined by the medical insurance agency.
Specified medical institutions are determined on a yearly basis, and if there is a need for change, the change will be handled at the beginning of the next billing year.
Article 29: The medical insurance agency shall sign an agreement with the designated medical institution on the medical service personnel, scope of service, service content, service quality, settlement of medical fees, medical fee payment standards, and the audit and control of medical fees, etc., to clarify the responsibilities, rights and benefits of both parties.
Annual assessment and validation of the designated medical institutions can be renewed medical services agreement, unqualified will be canceled urban residents of basic medical insurance designated.
The fixed-point medical institutions will be announced to the public once a year.
Article 30: the fixed-point medical institutions of high, new, pointed examination program to implement the annual assessment system, the assessment criteria developed by the Hunan Provincial Department of Health, "Hunan Province, the second and third level of hospitals assessment standards implementation rules (for trial implementation)" as the basis for the annual examination of the positive rate of the program is lower than the prescribed standard, the fixed-point medical institutions should bear the cost of the negative part of the fee of 60%.
Article 31: When an insured person seeks medical treatment, the relevant personnel of the designated medical institution must carefully examine the case, and shall not provide him with medical services if his identity card does not match.
Article 32: The designated medical institutions shall abide by medical ethics, provide treatment according to the illness, conduct reasonable examinations and use medicines reasonably. In the event that medication, examination or treatment is administered in violation of basic medical regulations, the costs shall be borne by the medical institution itself and shall not be paid by the medical insurance fund.
The price of medical treatment and medicines for residents' basic medical insurance shall be in accordance with the relevant state regulations on pricing, and any violation of the regulations shall be borne by the designated medical treatment and pharmacies, and shall not be paid by the residents' medical insurance fund.
Article 33: The designated medical institutions shall provide basic medical services to the insured persons, and must use unified special diagnostic and treatment prescriptions, special diagnostic and treatment item approval forms, referral and transfer approval forms, hospitalization expense settlement forms, lists of hospitalization expenses, and lists of out-of-pocket expenses of the insured persons, as well as other medical vouchers.
Article 34: Medical expenses caused by medical malpractice shall be borne by the medical institution and the person directly responsible, and shall not be paid by the basic medical insurance fund for urban residents.
Article 35: the medical insurance agency to establish a group general letters and visits system, set up and publicize the complaint telephone and report box.
Article 36: These rules shall be implemented from the date of publication.
Article 37: The implementation of the rules by the Huaihua Municipal Bureau of Labor and Social Security is responsible for the interpretation.