Article 1 The basic medical insurance for urban residents shall be managed at the municipal level as a whole and at different levels. The unified policy of the whole city stipulates that territorial management shall be implemented, and each county and district (city) shall conduct independent accounting.
Unified establishment of the city's basic medical insurance adjustment system for urban residents (specific measures shall be formulated separately).
Article 2 Scope and object of insurance
Students, children and other non-employed urban residents in primary and secondary schools (including vocational high schools, technical secondary schools, technical schools and special education schools) that are not included in the basic medical insurance system for urban employees within the administrative area of our city may voluntarily participate in the basic medical insurance for urban residents.
Children: refers to urban residents aged 0 to 18 at the time of insurance registration and payment.
Minimum target: refers to the urban residents who enjoy the minimum living guarantee for urban residents as recognized by the county-level civil affairs department.
Severely disabled people who have lost their ability to work: refers to urban residents recognized by the county-level disabled persons' Federation.
Old people over 60 years old in low-income families: refers to urban residents over 60 years old who are identified by the civil affairs department as having no retirement fee, unable to set a supporter or a supporter but unable to bear the obligation of support, and their per capita monthly income is lower than the minimum wage standard for local employees.
Article 3 Insurance procedures
Urban residents who meet the conditions for insurance shall go through the insurance formalities in the town (township) or street labor security office where their household registration is located with their household registration book and 1 recent bareheaded 1 inch photos. If the family members change, they should go through the change formalities at the labor security office within 1 month.
Students in primary and secondary schools (including students from vocational high schools, technical secondary schools, technical schools and special education schools) who meet the conditions for insurance shall fill in the Registration Form of Basic Medical Insurance for Urban Students in Zunyi City (and provide electronic forms at the same time), and go to the town (township) and street labor security office for insurance procedures or go to the social security agency in the county, district (city) where they are located for insurance and payment procedures.
When going through the insurance procedures, the elderly with minimum living allowance and low-income families over 60 years old need to provide relevant certification materials issued by the civil affairs department; Severely disabled persons who have lost their ability to work need to provide relevant certification materials issued by the Disabled Persons' Federation.
Those who paid insurance premiums from 20071October 65438+ to 20081October 65438+ to February 365438+ will pay in the current month and enjoy treatment in the next month. After June 65438+1 October1in 2009, the new participants were given a waiting period of six months, and then they enjoyed corresponding treatment. If the insured person leaves his post after joining the insurance, he should pay part of the personal payment fee during the period of leaving the insurance, and set a waiting period of 6 months, after which he can enjoy the corresponding treatment.
Article 4 Funding criteria
Students and children go to 80 yuan every year, their families go out of 40 yuan, and the government subsidizes 40 yuan. Among them, severely disabled students and children, families pay 30 yuan, and the government subsidizes 50 yuan; Students, children belonging to the minimum living standard, families pay 5 yuan, and the government subsidizes 75 yuan.
Other urban residents are raised in 200 yuan per person per year, and the family pays 160 yuan, and the government subsidizes 40 yuan. Among them, the severely disabled who have lost the ability to work and the elderly over 60 years old from low-income families are paid by the family 100 yuan, and the government subsidy 100 yuan; For residents who belong to the minimum living allowance, the family pays 10 yuan, and the government subsidizes 190 yuan.
Fifth town (township) or street labor and social security office staff in more than 3 people, to establish and improve the financial management system, responsible for the collection of urban residents' basic medical insurance fund. If the staff of the labor security firm is less than 3, the medical insurance premium shall be collected by the finance at the same level and transferred to the income transition households opened by the social security institutions of counties and districts (cities) in designated banks on a monthly basis.
The medical insurance premiums payable by the insured residents shall be paid annually. When applying for insurance for the first time, the expenses for the remaining months of the current year shall be paid in one lump sum, and the expenses for the following year shall be paid in one lump sum in the fourth quarter of each year from the year of insurance.
The medical insurance premiums payable by the insured students in school shall be collected and remitted by the school.
The funds subsidized by governments at all levels shall be included in the financial accounts of the basic medical insurance fund for urban residents in full and on time by the financial department.
After urban residents pay insurance premiums, the medical insurance premiums they pay will not be refunded.
Sixth people who participate in the basic medical insurance for urban residents shall not participate in the basic medical insurance for urban workers and the new rural cooperative medical system at the same time. Employees of various enterprises and institutions and staff of state organs cannot participate in the basic medical insurance for urban residents.
For those who participate in the basic medical insurance for urban workers and transfer to the basic medical insurance for urban residents, the payment period for participating in the basic medical insurance for urban workers after June 65438+1October 2007 can be calculated as the payment period for participating in the basic medical insurance for urban residents. Those who participate in the basic medical insurance for urban residents are transferred to the basic medical insurance for urban employees, and the payment period for participating in the basic medical insurance for urban residents cannot be calculated as the payment period for the basic medical insurance for urban employees.
Article 7 The medical management of the basic medical insurance for urban residents shall be implemented with reference to the relevant provisions of the national and provincial basic medical insurance for urban employees, such as the list of medicines, the list of diagnosis and treatment items, the standard of medical service facilities and the basic medical insurance for urban employees in our city. The designated medical institutions of basic medical insurance for urban workers within the scope of our city are the basic medical insurance service institutions for urban residents.
Eighth insured urban residents need hospitalization due to illness, should hold the "Zunyi basic medical insurance card for urban residents" and ic card, to the designated medical institutions for hospitalization. For hospitalization in designated hospitals at different levels, insured residents need to pay different minimum payments: tertiary hospital 450 yuan, secondary hospital 300 yuan, township hospitals and community medical and health service institutions 80 yuan. The affiliated hospital of Zunyi Medical College and Zunyi Hospital shall pay 45% of hospitalization expenses above Qifubiaozhun by the medical insurance fund; In 34 17 hospital, county, district (city) people's hospital, traditional Chinese medicine hospital and all kinds of designated medical institutions, according to the county-level guidance price of medical service price in Guizhou Province, 55% will be paid by the medical insurance fund. The medical insurance fund pays 65% of the hospitalization and observation expenses in township hospitals, community medical and health service institutions, and various designated medical institutions charged according to the standard of "Zunyi Township and Community Medical Service Price". According to the national and provincial basic medical insurance "Drug Catalogue", "Diagnosis and Treatment Project Catalogue" and "Medical Service Facilities Standard", the medical insurance fund will not pay the fees, and the residents will pay.
When the insured residents go through the discharge formalities in the designated medical institutions, the expenses that should be paid by the residents according to the regulations shall be settled by the residents and the designated medical institutions; The expenses that should be paid by the medical insurance fund according to the regulations shall be settled by the social security agency and the designated medical institution.
For urban residents who participate in basic medical insurance, after five years of continuous payment, the proportion of hospitalization reimbursement will increase by 3%; After continuous payment 10 years, the reimbursement ratio will increase10%; After 20 years of continuous payment, the reimbursement rate will increase by 20%.
Insured residents suffering from malignant tumor, tuberculosis, psychosis, renal failure or kidney transplantation, bone marrow transplantation, coronary heart disease stent implantation, heart valve replacement, with the relevant disease diagnosis data, disease certificate and treatment plan issued by the designated hospitals at or above the county level to the social security agencies for review and filing.
Medical expenses of radiotherapy for malignant tumor in outpatient department, expenses of chemotherapy drugs and expenses of leukopenia caused by radiotherapy and chemotherapy; The cost of anti-tuberculosis drugs for tuberculosis outpatient chemotherapy and antipsychotic drugs for psychiatric outpatient treatment; The medical expenses of hemodialysis and peritoneal dialysis in outpatient department of renal failure and erythropoietin drugs needed for renal anemia shall be reimbursed according to the hospitalization review.
The expenses of outpatient anti-rejection drugs after kidney transplantation and bone marrow transplantation, and the expenses of outpatient anti-coagulation drugs after coronary heart disease stent implantation and heart valve replacement shall be reimbursed by the medical insurance fund for 50%.
The maximum payment limit of the basic medical insurance fund for urban residents is 45,000 yuan per person per year.
Ninth insured residents need to go to the county, district (city) for medical treatment because of their illness, and they need to be approved by the county, district (city) social security agency. Residents living in different places for a long time should fill in the "Selection Form of Designated Medical Institutions for Basic Medical Insurance for Urban Residents in Zunyi City" when insured, and should go to the selected designated medical institutions for treatment due to illness. Go out to visit relatives, work, etc. , because of sudden illness in different places need on-site first aid and rescue, should be within 3 days after admission (legal holidays postponed) reported to the county, district (city) social security agencies for the record.
If insured residents who are approved to seek medical treatment outside the city or residents living in different places seek medical treatment in designated medical institutions of their own choice, and sudden diseases in different places need on-site first aid and rescue, the medical expenses incurred shall be paid in advance by themselves. After the medical treatment, the social security agency shall review and reimburse according to the provisions of the reimbursement ratio of different levels of hospitals in our city. The social security agency shall not reimburse the medical expenses incurred in seeking medical treatment outside the city or in non-selected medical institutions without approval.
Article 10 Designated medical institutions shall conscientiously implement the relevant national and provincial policies and regulations, consciously standardize medical service behaviors, strictly implement prescription limits and drug administration regulations, adhere to reasonable inspection, rational drug use and reasonable treatment on the premise of ensuring basic medical care, and ensure the rational use of urban residents' medical insurance funds.
Eleventh designated hospitals should carefully check the medical guarantee and IC card of urban residents, accurately record the outpatient medical records, strictly control the hospitalization standards, and put an end to the phenomenon of nominal hospitalization or false hospitalization.
Designated hospitals should respect patients' or their families' right to know. When using self-funded drugs, medical consumables and medical treatment items, the consent of patients or their relatives should be obtained in advance. Medical institutions at or above the county level should take the initiative to provide a detailed list of daily medical expenses so that patients or their relatives can understand the expenses.
Twelfth designated medical institutions should be announced to the public diagnosis and treatment services and fees, accept the supervision and inspection of the insured and the relevant departments.
Thirteenth labor and social security administrative departments and social security agencies have the right to consult the prescriptions, medical records, doctor's orders, diagnosis and treatment reports, receipts and other related materials of designated medical institutions for the diagnosis and treatment of insured patients, and designated medical institutions shall actively cooperate. The social security agency shall not pay the medical, service or drug expenses that exceed the limits set by the designated medical institutions.
Fourteenth the following expenses shall not be paid by the medical insurance fund:
1. Medical expenses incurred abroad or in Hong Kong, Macao and Taiwan;
2. Medical expenses incurred in pregnancy and family planning (contraceptive operation);
3 other insurance and other medical expenses that should be paid within the scope of responsibility;
4. Medical expenses incurred due to drug abuse, fighting and other illegal and criminal acts;
5 medical expenses incurred during the unpaid period or during the surrender period;
6 other expenses that are not paid according to the national and provincial medical insurance policies.
Fifteenth urban residents who participate in the basic medical insurance shall fulfill the following obligations:
1. Pay medical insurance premiums in full and on time;
2 with the designated medical institutions, according to the provisions of the settlement should be paid by my medical expenses;
3. Do not lend the medical insurance card and IC card to others for use;
4 abide by the provisions of the basic medical insurance for urban residents and the management system formulated by the relevant departments.
Article 16 The basic medical insurance fund for urban residents (including interest income) shall be divided into two lines of revenue and expenditure, which shall be included in the financial special account management of social insurance funds, and shall be used for special purposes and shall not be misappropriated.
Seventeenth social security agencies should establish and improve the budget and final accounts system, financial accounting system and internal management system of the basic medical insurance fund for urban residents, and implement the early warning report system for fund overruns. The administrative departments of finance and labor security shall strengthen the management of fund revenue and expenditure, and accept the supervision and inspection of supervisory organs and auditing organs at the same level.
Eighteenth the establishment of designated medical institutions supervision and assessment system. The administrative department of labor and social security shall, jointly with the departments of health, finance, price and drug administration, assess the implementation of the basic medical insurance policies and regulations for urban residents and the performance of designated service agreements by designated medical institutions, and reward or punish them according to the assessment results.
Nineteenth insured urban residents provide or forge false certificates, materials or bills, cancel the qualification of insurance, and recover all the expenses paid; If a crime is constituted, criminal responsibility shall be investigated according to law.
Twentieth due to serious natural disasters, sudden epidemic diseases and other sudden factors caused by a wide range of urgent, dangerous and serious medical expenses, by the government funding to solve.
Article 21 The Zunyi Municipal Bureau of Labor and Social Security shall be responsible for the interpretation of these Detailed Rules.