Insurance editor to help you answer, more questions can be answered online.
Answer part of the answer, but also my interpretation of the latter policy (on the new provisions of the real-time reimbursement I did not find, but also not clear)
1. outpatient emergency a year of cumulative cost of the starting line of 2000 (Article 40 a), set your outpatient emergency spending for x, then the health insurance for your reimbursement of the money for the amount of 0.5 * (x-2000). The condition is 2000<x<42000. i.e. the cap is 42,000 dollars.
2. The "supplementary medical insurance" mentioned in the "Beijing Basic Medical Insurance Regulations" and the "supplementary medical insurance" (i.e. the one your company gives you) are not a concept at all.
The former should actually be called "large medical expenses mutual fund", is part of the medical insurance, the mutual fund is responsible for two parts of the reimbursement amount, one is the previous article 1 said that the outpatient emergency 2000 to 42000 of the part, and the second is the hospitalization expenses medical insurance reimbursement more than 178,860,000 yuan (according to). Article 32, the 2009 Beijing average wage 44,715 yuan) after the part of the money, this part of the money reimbursement of 70%, up to 100,000 yuan can give you.
The latter is commercial insurance, bought from a company like Ping An Insurance Company, to supplement the portion that is not reimbursed under the Beijing Basic Medical Insurance Regulations. That is, the x<2000 or x>42000 part. Depending on the insurance company's regulations, some commercial insurance companies also cover the part of 2000<x<42000 (because this part of the medical insurance only covers 50%) and the part of the medical insurance reimbursement that exceeds the maximum limit of 278,860,000 yuan. It still depends on the fine print of the commercial insurance your company chooses.
Overall, because the social security has a starting line, reimbursement rate, the limit of the upper limit, the limit of designated hospitals, there are some out-of-pocket drugs and treatment cost limit, there are exemption limit (such as crime, self-inflicted injuries, traffic accidents, etc.), so you need to commercial supplemental medical insurance, and the country for the enterprise on the supplemental medical insurance has preferential policies, the enterprise to the employees on the supplemental medical insurance is not a big burden.
Beijing Municipal Basic Medical Insurance Regulations
(Published by Beijing Municipal People's Government Decree No. 68 on February 20, 2001
First amended by Beijing Municipal People's Government Decree No. 141 on December 1, 2003
Second amended by Beijing Municipal People's Government Decree No. 158 on June 6, 2005)
Contents
Chapter I General Provisions
Chapter II Basic Medical Insurance Fund
Chapter III Individual Accounts for Basic Medical Insurance
Chapter IV Basic Medical Insurance Benefits
Chapter V Supplementary Medical Insurance
Chapter VI Medical Care Management
Chapter VII Organization, Management and Supervision
Chapter VIII Legal Liability
Chapter IX Supplementary Provisions
Chapter I General Provisions
Article 1 In order to ensure that employees and retirees receive basic medical treatment when they fall ill and enjoy medical insurance, these provisions are formulated in accordance with the relevant provisions of the State and in the light of the actual situation in the city.
Article 2 All employers in the cities and towns within the administrative area of the city, including enterprises, organs, institutions, social organizations, private non-enterprise units (hereinafter referred to as employers) and their employees and retirees shall be subject to the provisions of this regulation.
The specific time for employers and their employees and retirees to participate in basic medical insurance shall be prescribed by the municipal labor and social security administrative department (hereinafter referred to as the municipal labor security administrative department).
Article 3 The municipal labor security administrative department is in charge of the city's medical insurance work, organizes the implementation of the medical insurance system, and is responsible for the management, supervision and inspection of medical insurance work.
Districts and counties of labor security administrative departments are responsible for the management, supervision and inspection of medical insurance work in their administrative areas.
Cities and districts, county labor security administrative departments set up by the social insurance agency, the specific management of medical insurance work.
Article 4 of the basic medical insurance premiums for the implementation of the employer and the individual employee, *** with the payment, the principle of citywide coordination. The basic medical insurance fund to implement the principle of social integration and individual accounts. The level of basic medical insurance should be commensurate with the level of development of the city's social productivity and financial, employer and individual affordability.
Article 5 of the city in the implementation of basic medical insurance based on the establishment of a large medical expenses mutual aid system, the implementation of state civil servants medical subsidies, enterprises and institutions can establish supplementary medical insurance, employers and individuals are encouraged to participate in commercial medical insurance.
Article 6 combines the establishment of a basic medical insurance system with the active promotion of reform of the urban medical and health system, to provide relatively high-quality medical services for employees and retirees at relatively low cost, and to meet the needs of the general public for basic medical services.
Chapter II: The Basic Medical Insurance Fund
Article 7: The basic medical insurance fund shall determine expenditure on the basis of income and balance income and expenditure.
Article 8 The basic medical insurance fund consists of the following:
(1) the basic medical insurance premiums paid by employers;
(2) the basic medical insurance premiums paid by individual employees;
(3) the interest on the basic medical insurance premiums;
(4) late payment of the basic medical insurance premiums;
(5) (vi) Other funds included in the basic medical insurance fund in accordance with the law.
Article 9: Basic medical insurance premiums shall be paid by employers and individual employees*** together. Employers and employees shall pay the basic medical insurance premiums in full and on time. If they do not pay in full and on time, the individual account shall not be counted, and the basic medical insurance fund shall not pay their medical expenses.
Article 10 of the workers pay 2% of their average monthly wages in the previous year to the basic medical insurance premiums.
The employee's average monthly salary for the previous year is less than 60% of the average monthly salary of the employees in the city in the previous year, 60% of the average monthly salary of the employees in the city in the previous year as the basis for the payment of wages, pay the basic medical insurance premiums.
The part of the employee's average monthly salary in the previous year which is higher than 300% of the average monthly salary of the employees in the city in the previous year shall not be regarded as the base of the contribution salary, and shall not pay the basic medical insurance premiums.
If it is not possible to determine the average monthly salary of the employee in the previous year, the average monthly salary of the employees in the city in the previous year shall be the basis for the payment of basic medical insurance premiums.
Article 11: Persons who have retired before the implementation of the provisions of the basic medical insurance premiums are not paid.
After the implementation of these provisions to participate in the work, the cumulative total of 25 years of basic medical insurance premiums for men, women 20 years, in accordance with the provisions of the State for retirement procedures, receive a monthly basic pension or retirement benefits, enjoy the basic medical insurance for retirees, no longer pay the basic medical insurance premiums.
Participation in the work before the implementation of the provisions of the implementation of the retirement, the payment of basic medical insurance premiums less than the number of years specified in the preceding paragraph, by the person shall be a one-time full employer and the individual basic medical insurance premiums paid by the basic medical insurance, enjoy the basic medical insurance treatment of retirees, no longer pay the basic medical insurance premiums. If the labor security administrative department determines that the employee's consecutive years of service or years of work are in line with the national regulations, it shall be regarded as the number of years of contribution to basic medical insurance.
Article 12: The employer shall pay the basic medical insurance premiums at the rate of 9% of the sum of all the employees' contributory wages.
Article 13 of the basic medical insurance premium contribution ratio needs to be adjusted by the municipal labor security administrative department, in conjunction with the municipal finance department, for approval by the municipal people's government.
Article XIV of the employer should be on time to the social insurance agency truthfully declare the average monthly salary of employees in the previous year, the social insurance agency in accordance with the provisions of the approved basic medical insurance contribution wage base.
Article 15 of the basic medical insurance premiums payable by the employer, the social insurance agency entrusted the employer's depository bank to "entrusted bank collection (no payment period)" settlement method of monthly withholding.
The basic medical insurance premiums to be paid by individual employees shall be withheld and paid by the employing organization from their own wages on a monthly basis.
Article 16 of the basic medical insurance fund to implement the city's co-ordination, hierarchical management, all included in the social security fund financial account, the implementation of the two-line management of income and expenditure.
Basic medical insurance fund should be earmarked, shall not be squeezed or misappropriated, and shall not be used to balance financial income and expenditure.
Article XVII of the basic medical insurance fund raised in the current year, the part of the bank demand deposit interest rate; the previous year's carry-over of the fund principal and interest, according to the three-month deposit rate of the bank; deposited in the social security fund of the financial account of the sinking fund, compared with the three-year zero deposit savings deposit rate of interest, and not less than the level of the interest rate of the grade.
Article 18 of the basic medical insurance fund to implement a unified social insurance budgeting system, financial accounting system and internal audit system.
Chapter III Basic Medical Insurance Individual Accounts
Article 19 The social insurance agency shall establish basic medical insurance individual accounts (hereinafter referred to as individual accounts) for employees and retirees.
Article 20 of the individual account consists of the following items:
(a) the basic medical insurance premiums paid by individual employees;
(b) the basic medical insurance premiums paid by the employer in accordance with the provisions of the individual account;
(c) the interest on the amount of money stored in the individual account;
(d) other funds included in the individual account in accordance with the law.
Article 21: A portion of the basic medical insurance premiums paid by the employer shall be transferred to the individual account in accordance with the following standards:
(1) 0.8% of the monthly wage base of the employee less than 35 years of age shall be transferred to the individual account;
(2) 1% of the monthly wage base of the employee more than 35 and less than 45 years of age;
(3) 1% of the monthly wage base of the employee more than 35 and less than 45 years of age shall be transferred to the individual account;
(4) other funds to be included in the individual account in accordance with the law.
(c) 2% of the monthly contributory wage base for employees over 45 years of age;
(d) 4.3% of the average monthly wage of municipal employees of the previous year for retirees less than 70 years of age;
(e) 4.8% of the average monthly wage of municipal employees of the previous year for retirees over 70 years of age.
When the standards listed in the preceding paragraph need to be adjusted according to the social and economic development and the income and expenditure of the fund, the municipal administrative department of labor security, in conjunction with the municipal finance department to put forward an adjustment plan for the approval of the municipal people's government after the announcement of the implementation of the municipal people's government.
Article 22 of the personal account storage amount each year with reference to the bank during the same period of the residents of the demand deposit interest rate.
Article 23 of the individual account principal and interest for personal ownership, can only be used for basic medical insurance, but can be carried forward and inheritance.
When employees and retirees die, the amount stored in their individual accounts shall be transferred to the individual accounts of their heirs; if the heirs do not participate in basic medical insurance, the amount stored in the individual accounts may be paid to the heirs in a lump sum; if there are no heirs, the amount stored in the individual accounts shall be included in the basic medical insurance fund.
Article 24 If an unemployed person does not pay the basic medical insurance premiums, the individual account stops being credited, and the balance can continue to be used. Unemployed persons during the period of receiving unemployment insurance benefits, in accordance with the provisions of unemployment insurance to enjoy medical benefits.
Article 25: When a person participating in basic medical insurance moves within the district or county in which he is insured, only the basic medical insurance relationship is transferred, not the amount stored in the individual account; when he moves across districts, counties or co-ordinated areas, the basic medical insurance relationship is transferred, and at the same time, the amount stored in the individual account is transferred.
Chapter IV: Basic Medical Insurance Treatment
Article 26: The basic medical insurance fund and the individual account shall have their own scope of payment, and shall be accounted for separately, and shall not be crowded out by each other. Medical expenses that meet the scope of payment of the basic medical insurance fund shall be paid by the basic medical insurance fund and the individual account respectively.
Article 27 of the basic medical insurance fund to pay for the medical expenses of employees and retirees shall be in accordance with the basic medical insurance drug catalog, diagnosis and treatment items catalog, as well as the scope of services and facilities and payment standards stipulated by the city.
The specific measures for the basic medical insurance drug list, diagnostic and therapeutic item list, as well as the scope of medical service facilities and payment standards shall be formulated separately by the municipal labor security administrative department in conjunction with the relevant departments.
Article 28: Individual accounts shall cover the following medical expenses:
(1) outpatient and emergency medical expenses;
(2) expenses for purchasing medicines at designated retail pharmacies;
(3) medical expenses below the starting standard of the basic medical insurance fund;
(4) medical expenses exceeding the starting standard of the basic medical insurance fund, which shall be borne by individuals in accordance with the proportion of the expenses. proportion, should be borne by the individual medical expenses.
The part of medical expenses not covered by the individual account shall be paid by the individual himself/herself.
Article 29: The basic medical insurance fund shall pay for the following medical expenses:
(1) medical expenses for hospitalization;
(2) medical expenses within 7 days of hospitalization for those who are hospitalized after emergency rescue and hospitalization;
(3) outpatient medical expenses for radiation therapy and chemotherapy for malignant tumors, renal dialysis, and anti-rejection medication for those who take anti-rejection medication after renal transplantation. Outpatient medical expenses.
Article 30: The basic medical insurance fund shall not pay for the following medical expenses:
(1) medical treatment at a medical institution other than one's own designated medical institution, except for emergencies;
(2) medicines purchased at a retail pharmacy other than one's designated pharmacy;
(3) injuries caused by traffic accidents, medical accidents, or other liable accidents;
(4) injuries caused by one's own (d) Injuries caused by drug abuse, fighting and assault or other illegal acts;
(e) Treatment for suicide, self-inflicted injuries, alcoholism and other reasons;
(f) Treatment in foreign countries or in Hong Kong or Macao Special Administrative Regions as well as Taiwan;
(g) In accordance with the provisions of the state and the city should be paid by the individual.
Article 31: The medical expenses of an enterprise employee who is injured at work or suffers from an occupational disease shall be carried out in accordance with the relevant provisions of the work injury insurance. The medical expenses for childbirth of female workers shall be implemented in accordance with the relevant provisions of the State and the city.
Article 32: The starting standard for payment by the Basic Medical Insurance Coordination Fund shall be set at about 10% of the average wage of the workers in the city in the preceding year. Individuals hospitalized for the second time in a year and beyond, the basic medical insurance coordinating fund to pay the starting standard of about 5% of the average wage of employees in the city in the previous year.
Article 33 of the basic medical insurance co-ordination fund in a year to pay for the medical expenses of employees and retirees of the cumulative maximum payment limit in the previous year the average wage of the city's employees to determine about four times.
Article 34 of the basic medical insurance co-ordination fund to pay the starting standard and the maximum payment limit needs to be adjusted, by the municipal labor security administrative department in conjunction with the municipal finance department to put forward, reported to the Municipal People's Government for approval, issued by the municipal labor security administrative department.
Article 35 sets a settlement period for the payment of medical expenses by the basic medical insurance co-ordination fund.
The settlement period is set according to the time of inpatient treatment for employees and retirees, and the time of outpatient treatment for malignant tumor radiation therapy and chemotherapy, renal dialysis, and outpatient treatment for taking anti-rejection drugs after renal transplantation.
Article 36: Medical expenses incurred by employees and retirees during a settlement period shall be calculated and paid in segments according to the level of the hospital and the amount of the expenses, and shall be shared by the basic medical insurance co-ordination fund and the individuals according to the following proportions:
(1) Medical expenses incurred at a tertiary-level hospital:
1. For the portion of the starting standard up to 30,000 yuan, the co-ordination fund pays 85% and the employee pays 15%;
2. For the portion exceeding 30,000 yuan to 40,000 yuan, the integrated fund pays 90% and the employee pays 10%;
3. For the portion exceeding 40,000 yuan, the integrated fund pays 95% and the employee pays 5%.
(2) Medical expenses incurred in secondary hospitals:
1. For the portion of the starting standard up to 30,000 yuan, the coordinated fund pays 87%, and the employee pays 13%;
2. For the portion of the amount exceeding 30,000 yuan up to 40,000 yuan, the coordinated fund pays 92%, and the employee pays 8%;
3. For the portion of the amount exceeding 40,000 yuan, the coordinated fund pays 97%, and the The employee pays 3%.
(3) Medical expenses incurred in first-class hospitals as well as home beds:
1. For the portion of the starting payment standard up to 30,000 yuan, the coordinated fund pays 90% and the employee pays 10%;
2. For the portion of the payment standard exceeding 30,000 yuan up to 40,000 yuan, the coordinated fund pays 95% and the employee pays 5%;
3. For the portion of the payment standard exceeding 40,000 yuan, the coordinated fund pays 97% and the employee pays 3%. pays 97% and the employee pays 3%.
(4) The individual payment ratio for retirees is 60% of the employee's payment ratio.
But the maximum amount to be paid by the Basic Medical Insurance Coordination Fund according to the proportion shall not exceed the maximum payment limit stipulated in Article 33 of these Regulations.
When the payment ratio of the basic medical insurance fund listed in the first paragraph of this Article needs to be adjusted, the municipal labor security administrative department in conjunction with the municipal finance department shall put forward a plan for adjustment, and report it to the municipal people's government for approval before promulgation and implementation.
Chapter V Supplementary Medical Insurance
Article 37 establishes a system of mutual aid for large medical expenses. Mutual funds for large medical expenses shall be used to pay, on a pro rata basis, for outpatient and emergency medical expenses incurred by employees and retirees in excess of a certain amount in a single year, and for medical expenses incurred in excess of the maximum limit of payment by the basic medical insurance fund (excluding those below the starting standard and those borne by the individual). Employers and their employees and retirees participating in the basic medical insurance shall participate in the mutual assistance for large medical expenses, except for those employers and their employees and retirees who are subject to the medical subsidy scheme for state civil servants.
Methods for mutual assistance in large medical expenses shall be formulated by the municipal labor security administrative department in conjunction with the municipal finance department.
Article 38: Mutual aid funds for large medical expenses shall be paid by both the employer and the individual ****. The employer shall pay 1% of the sum of all employees' contributory salary base, and the employees and retirees shall pay 3 yuan per month. The mutual funds for large medical expenses are paid together with the monthly basic medical insurance premiums.
When the mutual aid fund for large medical expenses is insufficient to cover the payment, the finance will give appropriate subsidies.
When the proportion and amount of contributions to the large medical expenses mutual funds need to be adjusted, the municipal labor security administrative department in conjunction with the municipal finance department shall make a proposal and submit it to the municipal people's government for approval.
Article 39: Mutual Funds for Large Medical Expenses shall be integrated throughout the city, separately accounted for, and included in the financial account of the social security fund, and interest shall be accrued in accordance with the method of accruing interest on the basic medical insurance fund.
Mutual funds for large medical expenses shall be centrally raised, managed and utilized by the social insurance agency.
Article 40 Mutual Funds for Large Medical Expenses shall pay for large medical expenses in accordance with the provisions of the basic medical insurance fund in the following ways:
(1) For the part of the outpatient and emergency medical expenses of the employees exceeding RMB 2,000 in total within a year, the mutual funds for large medical expenses shall pay 50%, and the individuals shall pay 50%.
(2) For retirees whose outpatient and emergency medical expenses exceed 1,300 yuan in a year, 70% of the outpatient and emergency medical expenses will be paid by mutual aid funds for large medical expenses and 30% will be paid by the individual for those retirees who are less than 70 years of age; for retirees who are more than 70 years of age, 80% of the outpatient and emergency medical expenses will be paid by mutual aid funds for large medical expenses and 20% will be paid by the individual.
(3) The maximum amount of outpatient and emergency medical expenses paid by the mutual aid funds for large medical expenses for employees and retirees is 20,000 yuan in a year.
(4) For hospitalization medical expenses exceeding the maximum payment limit of the basic medical insurance fund (excluding the portion below the starting payment standard and the portion borne by the individual), outpatient medical expenses for radiation therapy and chemotherapy for malignant tumors, kidney dialysis, and anti-rejection drugs after kidney transplantation within a year, the large medical expenses mutual aid fund pays 70% and the individual pays 30%. However, the maximum cumulative amount paid by the mutual funds for large medical expenses in a year is 100,000 yuan.
When the starting standard, payment ratio and maximum payment limit of the large medical expenses mutual aid fund need to be adjusted, the municipal labor security administrative department, together with the municipal finance department, shall propose and report to the municipal people's government for approval.
Article 41 Enterprises and institutions participating in basic medical insurance may establish supplementary medical insurance. The part of the enterprise's supplementary medical insurance premiums within 4% of the total wages of the enterprise's employees shall be included in the costs.
Supplementary medical insurance methods shall be formulated by the municipal labor security administrative department in conjunction with the municipal finance department.
Article 42 of the state civil servants in the basic medical insurance on the basis of the enjoyment of medical benefits, the specific measures shall be put forward by the municipal labor security administrative department in conjunction with the municipal finance department, and reported to the municipal people's government for approval and implementation.
Article 43 for the city's urban residents enjoying the minimum subsistence allowance for families of workers and retirees, in the personal burden of medical expenses are taken care of.
The city has set up funds for medical assistance for persons in special hardship, and the relevant departments shall take measures to raise funds from various sources to solve the difficulties of persons in special hardship caused by excessive expenditure on medical fees.
Chapter VI medical management
Article 44 of the city's medical insurance to implement designated medical system. In accordance with the principle of "proximity, convenient management", employees and retirees can choose three to five designated medical institutions, the unit summarized by the unit, reported to the unit's regional and county social insurance agency, the social insurance agency to determine the overall. The designated specialized medical institutions and designated Chinese medical institutions are the same designated medical institutions for all insured employees and retirees***.
When employees and retirees are sick, they can go to their designated medical institutions with their medical insurance vouchers in accordance with the regulations, and they can also purchase medicines from designated retail pharmacies with prescriptions issued by the treating physicians of the designated medical institutions.
Article 45: Medical institutions and retail pharmacies willing to undertake designated services for basic medical insurance may apply to the administrative department of labor security, and if they meet the conditions, the municipal administrative department of labor security shall recognize them as designated medical institutions and designated retail pharmacies, and shall issue certificates of qualification and make them known to the public. Those who obtain the qualification of fixed-point and are recognized as fixed-point medical institutions and fixed-point retail pharmacies will sign an agreement with the social insurance agency.
Methods for the management of designated medical institutions and designated retail pharmacies shall be formulated by the municipal labor security administrative department in conjunction with the municipal departments of finance, health, Chinese medicine administration and drug supervision.
Article 46 The relevant departments shall implement dynamic management of designated medical institutions and designated retail pharmacies. The designated medical institutions and designated retail pharmacies shall strictly implement the price policy and standards set by the state and the city, the implementation of the relevant provisions of the basic medical insurance system, and the establishment of internal management system compatible with the management of basic medical insurance.
Article 47 of the designated medical institutions shall set up specialized institutions or set up full-time staff responsible for the specific work of basic medical insurance, the strict implementation of the state and the city's management regulations and standards related to medical services, the development and implementation of common disease diagnosis and treatment routines, the establishment of a comprehensive assessment of the effectiveness of the quality of medical care standards, and accurately provide the participants in the basic medical insurance personnel outpatient, emergency, inpatient and single-type of disease and other relevant information. Information.
Article 48 The designated retail pharmacies shall be staffed with personnel responsible for the specific work of the basic medical insurance, abide by the national and municipal regulations on drug management, establish a drug quality assurance system, so that the supply of drugs is safe and effective.
Article 49: The part of outpatient and emergency medical expenses and hospitalization medical expenses paid by individuals, as well as the expenses for purchasing medicines at designated retail pharmacies, shall be settled directly between individuals and designated medical institutions and designated retail pharmacies; medical expenses paid by the integrated fund of the basic medical insurance shall be settled by the social insurance agency with the designated medical institutions after examination and approval. Specific measures shall be formulated separately by the municipal labor security administrative department in conjunction with the municipal finance and health departments.
Article 50 reforms the urban medical and health service system, and vigorously develops community health services to facilitate people's access to medical care. Through the introduction of a competitive mechanism to curb the excessive growth of medical costs, reduce the burden on the people and society. A new classification and management system for medical institutions is being established, with separate accounting and separate management of medicines and a centralized bidding and purchasing system for medicines, and supervision of medical services and drug prices is being strengthened.
Chapter VII: Organization, Management and Supervision
Obviously
Chapter VIII: Legal Liability
Article 58: If an employer fails to pay the basic medical insurance premiums or the mutual aid funds for large medical expenses in accordance with the regulations, resulting in the basic medical insurance fund failing to be transferred to the individual account in accordance with the regulations, and the employees and retirees are unable to enjoy the relevant medical insurance benefits, the employer shall compensate the employees and retirees for the losses thus caused.
Article 59: Where an employer fails to pay basic medical insurance premiums in accordance with the regulations, or fails to declare the wage base for basic medical insurance premiums in accordance with the regulations, resulting in the omission or underpayment of such premiums, or fails to withhold basic medical insurance premiums on behalf of the employer in accordance with the regulations, the administrative department of labor and security shall order payment of such premiums by a specified period of time. A late payment fee of two thousandths of a percent shall be added from the date of non-payment.
Article 60: If an employer fails to participate in basic medical insurance and pay basic medical insurance premiums in accordance with the provisions of the State Council's Provisional Regulations on the Collection and Payment of Social Insurance Premiums, the administrative department of labor security shall impose penalties in accordance with the provisions of the Provisional Regulations on the Collection and Payment of Social Insurance Premiums.
Article 61 If an employer fraudulently obtains expenditure from the medical insurance fund, the fraudulent fund shall be recovered by the social insurance agency, and the employer shall be fined by the administrative department of labor security not less than one and not more than three times the amount of the fraud by the employer; and if the circumstances are serious enough to constitute a crime, the employer shall be held criminally liable in accordance with the law.
Article 62: If an individual who participates in medical insurance fraudulently obtains medical insurance treatment, or resells medicines reimbursed by the medical insurance fund for undue benefits, resulting in a loss of the medical insurance fund, the administrative department of labor and security shall order the return of the funds, and impose a fine of not less than one but not more than three times the amount of money that was fraudulently obtained from the medical insurance fund on the individual; if the circumstances are serious enough to constitute a crime, the individual shall be held criminally liable in accordance with the law.
If the acts in the preceding paragraph do not result in losses to the medical insurance fund, the administrative department of labor security may impose a fine of not more than 1,000 yuan on the individual.
Article 63 of the designated medical institutions have one of the following acts, resulting in losses to the basic medical insurance fund, shall compensate for the losses, and the administrative department of labor security shall order rectification, and may impose a fine of 5,000 yuan or more than 20,000 yuan or less; if the circumstances are serious, cancel the designated medical institutions for basic medical insurance qualification:
(a) the medical costs of the people who are not enrolled in the medical insurance fund or the large amount of money from the basic medical insurance fund or the large amount of money. basic medical insurance co-ordination fund or large medical expenses mutual aid funds;
(ii) the medical expenses that should be borne by individuals are paid by the basic medical insurance co-ordination fund or large medical expenses mutual aid funds;
(iii) the costs of non-emergency and rescue patients are included in the payment of emergency and rescue items;
(iv) patients that do not meet the criteria for inpatient (d) hospitalizing patients who do not meet the criteria for hospitalization, or intentionally prolonging a patient's hospitalization, or hospitalizing a patient under a name or making false medical records;
(e) misappropriating another person's personal account;
(f) falsifying or switching medicines;
(g) adopting other means of fraudulently obtaining medical insurance benefits.
If one of the acts in the preceding paragraph is committed but does not result in a loss of the medical insurance fund, the labor security administrative department may impose a fine of up to 5,000 yuan on the designated medical institution.
Article 64: If a designated retail pharmacy commits any of the following acts, the administrative department of labor security shall impose a fine of not less than 1,000 yuan and not more than 20,000 yuan; if the circumstances are serious, the qualification of the designated retail pharmacy shall be canceled:
(1) Selling medicines not in accordance with the outwardly dispensed prescription;
(2) Dispensing medicines not in accordance with the dosage of the outwardly dispensed prescription;
(3) Switching the medicines used in the outwardly dispensed prescription to other medicines. (C) exchanging medicines for other items with out-dispensing prescriptions.
Article 65 If a designated medical institution or a designated retail pharmacy violates the regulations on medical care, medicines and prices, the administrative department of labor security shall bring the matter to the attention of the relevant departments for handling; if the situation is serious, the qualification of the designated institution shall be revoked.
Article 66 The staff of the social insurance agency violates the provisions of medical insurance, resulting in the loss of the medical insurance fund, the administrative department of labor security shall order them to recover; in serious cases, administrative sanctions shall be imposed according to law.
Article 67 If a staff member of a social insurance agency fails to perform his duties or pay medical insurance benefits in accordance with the regulations, the administrative department of labor security shall criticize him and order him to make corrections; if serious consequences are caused, he shall be given administrative sanctions in accordance with the law.
Article 68 If the staff of a labor security administrative department or a social insurance agency abuses their powers, practices favoritism, or neglects their duties, resulting in a loss of the medical insurance fund, the labor security administrative department shall recover the lost medical insurance fund; if the loss constitutes a crime, it shall be held criminally liable in accordance with the law; and if it has not yet constituted a crime, it shall be given an administrative sanction in accordance with the law.
Article 69: Any unit or individual who misappropriates the medical insurance fund shall be dealt with in accordance with the provisions of Article 28 of the State Council's Provisional Regulations on the Collection and Payment of Social Insurance Premiums.
Chapter IX Supplementary Provisions
Article 70 of the retirees, the Old Red Army, the second grade B or above, the revolutionary disabled soldiers medical treatment remains unchanged, the medical expenses are resolved in accordance with the original funding channels. Specific measures shall be formulated by the municipal labor security administrative department in conjunction with the relevant departments and reported to the municipal people's government for approval.
Seventy-one individual urban industrial and commercial households and their employees with reference to the implementation of these provisions.
Article 72 These provisions shall come into force on April 1, 2001 onwards.
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