Nanchang City, urban and rural residents of basic medical insurance management workflow
In order to standardize the city's urban and rural residents of basic medical insurance work, specially formulated Nanchang City, urban and rural residents of basic medical insurance management workflow.
Nanchang urban and rural residents of the basic medical insurance management workflow
In order to standardize the city's urban and rural residents of the basic medical insurance work, according to the "Nanchang urban and rural residents of the basic medical insurance Interim Measures" (Hongfu Hall issued [2015] No. 37), the development of this workflow.
Departmental responsibilities
The basic medical insurance for urban and rural residents is handled by the city and the counties (districts), development zones (new districts) (hereinafter referred to as counties (districts)), medical insurance agencies, township (township) people's governments (health insurance), street human resources and social security (hereinafter referred to as the Labor Insurance Institute or the People's Insurance Institute) is responsible for the hierarchical level, and the village (community) committees to assist with the process. Specific duties are as follows:
First, the city health insurance agency
(a) is responsible for the city's urban and rural residents of the basic health insurance policy publicity and organization and implementation;
(b) is responsible for the counties (districts) health insurance work to guide the work of the agency;
(c) is responsible for the provincial colleges and municipal colleges and universities in the city of the students enrolled in the insurance premiums, the ordinary (d) responsible for the city's urban and rural residents of the basic medical insurance risk transfer fund collection, management and disbursement;
(e) responsible for the drafting and signing of service agreements with the city's fixed-point medical institutions, the quality of service, the standardization of the management of supervision and inspection;
(f) responsible for the city's urban and rural residents of the major medical insurance agreement signing, funding applications, the standardization of management and supervision;
(f) responsible for the city's urban and rural residents of the major medical insurance agreement signing, funding applications, the standardization of management and the supervision and inspection;
(h) responsible for the city's urban and rural residents of the major disease (F) is responsible for the signing of the city's urban and rural residents of major medical insurance agreements, funding applications, disbursements, and carry out annual assessment.
Second, the counties (districts) medical insurance agency
(a) is responsible for the county (district) urban and rural residents of the basic medical insurance policy publicity and organization and implementation;
(b) is responsible for the county (district) at all levels of medical insurance staff business training;
(c) is responsible for participating in the residents of the verification of insurance information, confirmation, application for the disbursement of the special populations Subsidies;
(d) Responsible for the collection of medical insurance premiums and application for financial subsidies for the insured residents, the management of the hospitalization fund and general outpatient fund; the allocation of risk reserves, major medical insurance premiums, hospitalization fund and general outpatient fund;
(e) Responsible for the hospitalization of the insured residents due to illness, a single medical expense of 5,000 yuan (excluding 5,000 yuan) or more information review and approval of the medical insurance staff;
(f) Responsible for the hospitalization of the insured residents due to illness, a single medical expense of 5,000 yuan (excluding 5,000 yuan) or more information review and approval of the medical insurance staff at all levels of the medical insurance industry. ) or more information on the audit, the payment of medical expenses;
(F) is responsible for the production, management and issuance of social security cards (hereinafter referred to as social security cards) of insured residents;
(G) is responsible for accepting the policy advice of the insured residents, urban and rural residents to carry out research, guidance and management of township (township) health care work;
(H) is responsible for urban and rural residents to provide medical services and medical insurance medical institutions. Medical insurance designated medical institutions to monitor and inspect the quality of medical services, fees, admission and discharge and payment of medical expenses;
(ix) is responsible for the establishment of urban and rural residents medical insurance information management system, the purchase of equipment and routine maintenance.
Third, the township (town) people's government (medical insurance), street (labor insurance or human insurance)
(a) is responsible for the jurisdiction of urban and rural residents of the basic medical insurance policy propaganda, consulting, interpretation, as well as participating in the list of insured persons, individual payment of medical insurance fees summarized, reviewed and reported;
(b) is responsible for the review of the basic information of the residents participating in the audit, comparison, entry, change;<
(3) Guiding village (community) committees to carry out the collection of urban and rural residents' basic medical insurance premiums, and issuing payment notices and financial settlement bills;
(4) Being responsible for the collection and issuance of the social security cards of the insured residents;
(5) Being responsible for handling the procedures of transferring, connecting, and terminating the medical insurance relationship of the insured residents;
(6) (F) is responsible for the insured residents of foreign medical (including referral to hospitals), maternity medical expenses, a single medical cost of 5,000 yuan (including 5,000 yuan) or less reimbursement of the review and payment of materials;
(G) is responsible for the insured residents hospitalized for treatment of illnesses in a single medical cost of 5,000 yuan (excluding 5,000 yuan) or more of the relevant information on the preliminary examination and submission of work;
(H) is responsible for Urban and rural residents of special groups of subsidies to apply for the review of relevant information, submitted to the County Health Insurance Bureau for review;
(ix) is responsible for the jurisdiction of urban and rural residents of the entry of medical information, statistics, management and reporting work in the current year before the collection of health insurance premiums to produce a good administrative village participants in the information registration form, to the village committee staff;
(x) is responsible for the payment of the unit of the medical fund accounts (x) Responsible for the accounts of the health insurance fund paid by the unit. (c) responsible for the collection and issuance of social security cards for the insured residents;
(d) responsible for monitoring and checking the reimbursement of medical fees of the insured residents, and regularly publish them on the list to accept the supervision of the public;
(e) responsible for the issuance of receipts for urban and rural residents' medical insurance contributions, and carefully checking, properly retained and reported to the township (township) medical insurance office. The organization to report.
Various categories of people to participate in the premiums
I. General urban and rural residents
(a) urban residents for the first time
urban residents for the first time to participate in the insurance, in the period of October-December each year, according to the following process for the participation and payment of premiums (participation and payment of premiums to enjoy the next year's health insurance benefits):
1. Participants to bring their own household registration book, ID card originals and copies (each a copy of the household register should contain a copy of the first page of the household register and the participant's own page, the same below), and a recent one-inch color photo of a white background, which belongs to the newborn, but also need to provide the original birth certificate and a copy of the same time, to the street labor insurance (human insurance) declaration of insurance;
2, the street labor insurance (human insurance) acceptance and audit, meet the conditions and complete information, receive conditions and complete information, collect the relevant copies for filing, and registration for insurance, generate a personal social security number;
3, participants with personal social security number, go to the designated network of banks to pay health insurance premiums, to receive the bank bill issued by the bank;
4, the streets of the Labor Insurance Institute (Human Insurance Institute) to organize the participants to make the card required information, sent to the county (district) medical insurance bureau to declare the making of the Social security card;
5, county (district) health insurance bureau reported to the provincial social information department to complete the card, receive and forward to the street labor insurance (human insurance), by the street labor insurance (human insurance) issued to the insured individual.
(B) rural residents for the first time to participate in the insurance
belonging to the first time to participate in the insurance of rural residents, in the period from October to December each year, according to the following process for the participation and payment of fees (participation and payment of fees to enjoy the next year's medical insurance benefits):
1, the participants to provide the hukou book, the original ID card and photocopies, and the recent crownless one-inch color photo of the documents in white, one, which belonging to the newborn, but also need to provide the original and copy of the birth certificate, to the village committee staff declaration of insurance;
2, the village committee staff for the initial examination, eligible and complete information, collect the relevant copies, and for the registration of insurance, fill out the registration form of information on the participants (in duplicate), according to the provisions of the collection of medical insurance premiums issued receipts (in triplicate, a copy of one to the Participants, a joint village committee to retain, a joint report);
3, the village committee staff in the village after the collection of all participants in the payment of fees, unified new participants in the information registration form, relevant copies of the information, receipts (a joint), etc. to the township (township) medical insurance;
4, the township (township) medical insurance staff in the report of the participants in the information registration form, medical insurance premiums and After checking the receipts, the registration procedures for participation, entered into the computer system and generate information on the payment of fees, issued by the village committee staff to pay the fees at the bank in accordance with the requirements of the notice;
5, township (township) health insurance according to the village committee to pay the fees of the bank receipts, the issuance of the funds settlement bill, and will be the participants in the registration form of information stamped, and return a copy of the village committee;
6, township (township) health insurance according to the village committee to pay the fees of the bank statement, issued a funds settlement note, and will participate in the information registration form, return a copy of the village committee;
p> 6, the township (township) health insurance to organize the participants to make the card required information, reported to the county (district) health insurance bureau to declare the production of social security cards;
7, the county (district) health insurance bureau sent to the provincial human resources and social information department to complete the card, received and forwarded to the township (township) health insurance, the township (township) health insurance issued to the village committee, the village committee and then issued to the participants of the individual.
(C) did not get the household registration of the first time to participate in the insurance
did not get the household registration of the person, in October-December each year, according to the following process for the insurance payment procedures (after the participation and payment to enjoy the next year's health insurance treatment):
Township residents
1, the participant to bring the recent crown-exempt one-inch color photo to the community (street) a colorful photo of the white background to apply, the community (street) The community (street) verified the situation, issued a certificate of identity of the participant, clear the participant's name, date of birth and other relevant information and registration, personal information will be entered into the information system, generating a personal social security number;
2, the participant with a personal social security number, go to the designated network of banks to pay medical insurance premiums, to collect the bill issued by the bank;
Rural residents
1, the participant with a recent crown-free one-inch color photo to the village committee to apply, the village committee to verify the situation, issued by the participant's identity certificate, clear participant's name, date of birth and other relevant information and for registration, fill out the participant's information registration form (in duplicate), in accordance with the provisions of the collection of health insurance premiums and issue a receipt (in triplicate, one to the participant, one to the participant, one to the participant, one to the participant, one to the participant, one to the participant, one to the participant, one to the participant, one to the participant. A joint to the participants, a joint village committee to retain, a joint report);
2, the village committee staff in the village after the collection of all participants in the payment of fees, a unified summary of the participants of the information registration form, receipts (a joint) and so on to the township (township) of the medical insurance (the follow-up procedures in accordance with the normal first-time participation of rural residents to participate in the payment of fees for persons to participate in the program for handling).
Townships (towns), street medical insurance agency will submit the relevant information to the county (district) medical insurance agency, the county (district) medical insurance agency unified production of temporary medical insurance card.
The county (district) health insurance agency will hand over the temporary health insurance card to the township (town), street health insurance agency to issue to the participants.
After enrollment, future annual enrollees will pay normal renewal premiums according to the general urban and rural residents in the place of enrollment.
(D) foreign business or laborers first enrollment
foreign business and laborers and their minor children to the city, living in the city for more than a year and not in the origin of the basic medical insurance, you can apply for enrollment in the city in accordance with the following procedures (enrollment and payment of premiums to enjoy the benefits of the next year's medical insurance):
1, the participant to provide the place of origin of the medical insurance Proof of participation, ID card and its copy, temporary residence permit or township (street) of the certificate, the recent crownless one-inch color photo, to the residence of the county (district) health insurance agency to apply for registration;
2, the county (district) health insurance agency acceptance and audit, eligible and complete information, collect the relevant copies of the archives, and for the registration of participation
3, participants with personal social security number, go to the designated network of banks to pay health insurance premiums, to receive the bank statement issued by the bank;
4, the county (district) health insurance bureau to organize the participants to make the card required information, sent to the provincial social security information department to make the social security card, complete the receipt and distribution to the insured individual.
After enrollment, future annual enrollees are normally renewed according to the general urban and rural residents in the place of enrollment.
(E) urban and rural residents to renew
1, urban residents normal renewal. Urban residents who have been insured, during the annual centralized payment period, with personal social security number, go to the designated network of banks to pay medical insurance premiums, and then receive the bill issued by the bank.
2. Normal renewal of contributions for rural residents
(1) During the annual centralized payment period, the village committee will arrange for the villagers' groups (each group should arrange for more than two staff members) to collect the individual medical insurance premiums payable by the family as a unit, and issue receipts (in triplicate, with one copy for the insured, one copy for the village committee to keep, and one copy for reporting);
(2) After completion of the payment, the villagers' groups will collect the medical insurance premiums payable by the individual. After the completion of the payment, the village group will report the collected premiums and the receipts to be kept to the village committee;
(3) After checking the amount of premiums collected and the documents, the village committee will summarize and register the premiums, fill in the Registration Form of the Participants, and keep one copy of the receipts;
(4) In the stipulated period of time, the registration form of the information on the participation in the premium payment and the receipt (one copy) will be handed over to the township (township) healthcare center for uniformity. (township) medical insurance office;
(5) township (township) medical insurance office of the reported information on the registration form of participants, the payment of fees and receipts after checking, through the information system to generate information on the payment of fees, payment notice issued by the village committee staff in accordance with the requirements of the notification to the bank to pay;
(6) township (township) medical insurance office according to the payment of fees by the village committee of the bank statement, issue a fund transaction Settlement bills, and the participant information registration form will be stamped, return a copy to the village committee to retain.
3, urban and rural residents interrupted to make up contributions
urban and rural residents did not pay the required contributions within the period of enrollment, the interruption of contributions to renew the insurance need to make up for the period of interruption of the individual health insurance premiums payable. Urban and rural residents interrupted contributions, in October to December each year in accordance with the relevant identity group contribution process to make up the costs, since the make-up costs of the next year to enjoy the basic medical insurance benefits.
Second, the college students
(a) the first enrollment
(1) in the centralized enrollment payment period, college students with ID cards and photocopies, recent crownless one-inch color photo, fill out the enrollment registration form for the class as a unit of unified registration;
(2) the school summary of the registration form and the enrollment registration of the relevant information, uniformly sent to the Nanchang City
(3) Nanchang health insurance agency audit, registration procedures, entered into the information system to generate a list of college students to participate in the accounting subsidies, according to the school affiliation were reported to the provincial and municipal finance departments to declare the subsidy funds;
(4) the financial sector will be college students to participate in the subsidies allocated to the college students' basic health insurance financial account. Nanchang health insurance agency in a timely manner for the registration procedures;
(5) the city health insurance agency to organize the insured college students card information, sent to the provincial social information department to produce social security cards; production is completed, received and forwarded to the school to be issued to the participants.
(b) normal renewal
(1) has been insured students in the centralized insurance payment period, by the school according to the municipal health insurance agency notification, fill out the information registration form for the classroom, the school summary and verification of the correctness of the report of the municipal health insurance agency;
(2) the municipal health insurance agency audit, and the information system to participate in the information verification, audit, confirmation in the system
(3) the city health insurance agency summary of the situation, to generate a list of college students to participate in the subsidy funds allocated, according to the school affiliation were reported to the provincial and municipal financial departments to allocate college students to participate in the subsidy funds and timely transfer to the college students of basic health insurance financial account.
Third, the special people
(a) financial help to contribute to the object
According to the policy, the insured urban and rural residents belonging to the minimum subsistence guarantee objects, students and children with severe disabilities, loss of working capacity of the disabled, low-income families in the minors and elderly people aged 60 years old and above, has been unemployed and not included in the basic health insurance for urban workers in 14 categories of retired soldiers, key preferential objects, rural areas, and the people with disabilities, and the people who have not been included in the basic health insurance for urban workers. Soldiers, key beneficiaries, rural five guaranteed dependent objects, urban "three have-nots" objects, orphans, the family as a whole to participate in the insurance of the elderly over 70 years of age (including 70 years of age), as well as other persons in line with the provisions of the 11 categories of special personnel, individual contributions to help bear the financial part of their participation in the payment of contributions according to the following process:
1, urban residents in the overall participation of the family in the 70-year-old
(1) in the annual participation in the payment period, by himself or relatives with his social security card, ID card and a copy of the household register and all members of the household register in the participation in the payment voucher, to the participation of the county (district) health insurance agency to declare;
(2) the county (district) health insurance agency acceptance and audit
2, rural residents in the overall participation of the family in the 70-year-old
(1) in the annual participation in the payment period, by themselves or relatives with their social security card, ID card and a copy of the household register and all members of the household register in the participation in the payment vouchers, to the village committee to declare;
(2) the village committee of the initial examination, the eligibility, collection of the declaration of information and registration, the Reported to the township (town) health insurance review, and then by the county (district) health insurance agency review;
(3) county (district) health insurance agency acceptance and review of eligible, in the information system, registration confirmation;
(4) county (district) health insurance agency to generate a roster of such participants, the amount of subsidies accounted for the amount of funds, unified to the county (district) financial applications for disbursement.
3, the other 10 groups
In addition to the "family as a whole to participate in the insurance 70-year-old", low income objects and other 10 categories of special people, subject to review and approval by the civil affairs department. The specific process is as follows:
(1) participants in the centralized participation in the payment period, with the enjoyment of treatment materials or relevant documents, household registers, identity cards and their copies, the first time to participate in the insurance must also provide a recent crown-free one-inch color photo, to the village (community) committee to declare;
(2) the village (community) committee after the initial review, the conditions are met, to collect the Declaration information and registration, reported to the township (town), street civil affairs department audit, and then reported to the county (district) civil affairs department review;
(3) by the audit eligible, by the county (district) civil affairs department to confirm and confirm the operation of the health insurance system; at the same time, the list of such persons electronic version and paper version of a list of the county (district) medical insurance agency;
(4) county (district) medical insurance The agency summarizes the information of the personnel, generates a list of financial subsidies allocated funds, reported to the same level of the financial sector to allocate funds, and timely allocation of funds allocated to the urban and rural residents of the basic medical insurance financial account.
(B) newborns enrolled in the same year
The date of birth of the newborn is deemed to participate in the basic health insurance for urban and rural residents, but need to be within six months of birth for registration and payment procedures (enrollment and payment of fees from the year of birth to start enjoying health insurance benefits). The specific process is as follows:
urban residents
1, the parents of the insured person with their household registration, birth certificate original and photocopies, a crown-free one-inch color photo, to the household registration county (district) medical insurance agency declaration of insurance;
2, the county (district) medical insurance agency acceptance and audit, in line with the conditions of participation and complete information. Receive the relevant information and registration for participation, generate personal social security number;
3, participants with personal social security number, go to the designated network bank to pay health insurance premiums, receive the bank statement;
4, the county (district) health insurance bureau to organize the participants to make the card required information, sent to the provincial social security information department to make social security cards, complete the receipt and distribution to the insured individual
Rural residents
1, the parents of the insured person to bring their own household register, the original birth certificate and photocopies, a crown-free one-inch color photo, to the registered seat of the village committee staff declaration of insurance;
2, the village committee staff to accept and audit, meet the conditions of participation and complete information, collect the relevant information and registration of the insurance, fill out the Participants information registration form (in duplicate), according to the provisions of the medical insurance premiums and issue receipts (in triplicate, one to the participant, a village committee to retain, a report);
3, the village committee staff in the village after the collection of all the participants in the payment of fees, within a certain period of time a unified summary of the information of the new participants in the registration form, the receipts (in duplicate), etc., to the township (township) medical insurance office. (Subsequent procedures in accordance with the normal rural residents for the first time to participate in the insurance payment procedures).
(C) Veterans, college students returning to the region after graduation, newcomers with foreign household registration, expatriates returning to the country, newborns, people disqualified from low-income insurance, unemployed again after employment, people who have completed their sentence of correctional labor, newcomers with foreign household registration, and people over 70 years of age free of charge to enroll in insurance for the current year
Veterans, college students returning to the region after graduation, newcomers with foreign household registration, newcomers with foreign household registration, newborns, people with low income and unemployed again after employment, people who have completed their sentence of labor reform, people with foreign household registration, free of charge for the year The newborns, those who have been disqualified from low income insurance, those who are unemployed again after being employed, those who have completed their sentence of reform through labor, those who have newly moved in from other provinces, and those who are over 70 years old and free of charge, should apply for the insurance procedures in three months for the current year. Specific procedures are as follows:
1, the insured person to bring their own hukou book, the original ID card and photocopies, and the recent crownless one-inch white color photo, in addition to (1) veterans to provide a discharge certificate, (2) graduating college students to provide a university diploma, (3) the original non-Nanchang City household registration of the new move into the person to provide the basis for moving into the material, (4) return to the country of the expatriate personnel to provide the return of visa, (5) the released persons to provide the sentence of imprisonment, (7) the new people to provide the new people to provide the new people to provide the basis for moving into the material. Ex-prisoners to provide evidence of release, (6) employment again unemployed persons need to provide proof of unemployment, (7) newborns need to provide birth certificates, to the domicile of the county (district) health insurance agency declaration of insurance;
2, county (district) health insurance agency acceptance and audit, in line with the conditions of participation and complete information, collect the relevant copies of the archives, and apply for insurance Registration, generate a personal social security number;
3, participants with personal social security number, to the designated network of banks to pay health insurance premiums, to receive the bank statement;
4, county (district) health insurance bureau to organize the participants to make the card required information, submitted to the provincial information center for the production of social security cards, complete the receipt and distribution to the insured individuals.
Fourth, the insured residents enrollment changes
(a) basic information changes
1. The insured residents enrolled in the need to change the name, identity card number, contact phone number, and other basic information, with a household registration, social security card and the department of the proof of the information to the insured township (township), street health insurance agencies;
2. Township (township), the streets of medical insurance After reviewing the information, change the information in the computer system of the residents to participate in the insurance, the change of name, nationality and ID number, the replacement of the new social security card.
Replacement of the new card, by the township (town), street health insurance agency to collect the required materials, unified report county (district) health insurance agency in accordance with the card-making process.