In order to protect the basic medical needs of the insured, standardize and strengthen the supervision and management activities of basic medical insurance, and safeguard the security of the basic medical insurance fund, these Measures are formulated in accordance with the Law of the People's Republic of China on Social Insurance and other laws and regulations, and in light of the actual situation of the city. Article 2 (Scope of Application)
These Measures are applicable to the supervision and management activities of the designated medical institutions for basic medical insurance (hereinafter referred to as designated medical institutions), the designated retail pharmacies for basic medical insurance (hereinafter referred to as designated retail pharmacies), and the individuals' compliance with the provisions of the city's basic medical insurance.
The basic medical insurance referred to in these measures includes basic medical insurance for employees and basic medical insurance for urban and rural residents.
Supervision and management of the implementation of the city's maternity insurance system and long-term care insurance system with the basic medical insurance fund as the financing channel shall be carried out in accordance with the relevant provisions of these Measures. Article 3 (Supervision and Management of Medical Insurance)
The Municipal Medical Insurance Bureau is the administrative department in charge of basic medical insurance in the city, and is responsible for the supervision and management of basic medical insurance in the city. The district medical insurance bureaus are responsible for the supervision and management of basic medical insurance within their jurisdiction.
The Municipal Health Insurance Supervisory Organization, in the name of the Municipal Health Insurance Bureau, specifically implements basic health insurance supervision and inspection and other administrative law enforcement work, and according to the needs of supervision and management, enrich and strengthen the supervision and inspection force.
Development and reform, health, market supervision, drug supervision, finance, audit, public security, civil affairs, human resources and social security departments shall, within their respective areas of responsibility, cooperate in the supervision and management of basic medical insurance. Article 4 (Medical Insurance Information System)
The Municipal Medical Insurance Bureau shall establish and improve the information system for medical practitioners of designated medical institutions and the basic medical insurance expense settlement system, monitor the basic medical insurance expenses incurred by designated medical institutions and their medical practitioners in the process of providing medical services in real time, regulate the medical service behaviors of medical practitioners of designated medical institutions and supervise the supervision and management of medical practitioners found to have violated the law. The medical practitioners who are found to have violated the rules are subject to a demerit point management.
Designated medical institutions and designated retail pharmacies shall, in accordance with the requirements of the city's basic medical insurance network settlement, be equipped with the necessary networking equipment, comply with the basic medical insurance information technology norms and information security regulations, and upload the basic medical insurance fee settlement and other relevant information in a timely and accurate manner. Article 5 (Service Agreements)
The Municipal Health Insurance Business Management Center is the basic medical insurance operator of the city, and in accordance with the relevant provisions of the State and the city, it signs service agreements with designated medical institutions, designated retail pharmacies, as well as designated assessment institutions for long-term care insurance (hereinafter referred to as designated assessment institutions) and designated nursing institutions for long-term care insurance (hereinafter referred to as designated nursing institutions).
The Municipal Health Insurance Business Management Center may suspend the service agreement or terminate the service agreement if the designated medical institution, the designated retail pharmacy, and the designated assessment agency and the designated nursing agency violate the provisions of these Measures or the service agreement. Article 6 (Internal Management)
Designated medical institutions and designated retail pharmacies shall abide by the provisions of the national and municipal basic medical insurance as well as the service agreement, and establish and improve the internal management system of basic medical insurance.
Tertiary and secondary medical institutions shall set up departments specializing in the management of basic medical insurance, with the necessary management personnel; other medical institutions shall be equipped with full-time (part-time) personnel to manage the work of basic medical insurance.
Designated retail pharmacies shall be equipped with specialized (part-time) personnel to manage basic medical insurance. Article 7 (Management of Medical Insurance Expenses)
Specified medical institutions shall implement the city's basic medical insurance payment budget management, total prepaid expenses management of the relevant provisions of the basic medical insurance to protect the basic medical needs of the insured, and standardize the use of basic medical insurance funds. Article 8 (Requirements for services provided by designated medical institutions)
Designated medical institutions shall, according to the conditions of the insured persons, reasonably select diagnostic and therapeutic items and reasonably determine the use of medicines in accordance with the provisions of the basic medical insurance regarding diagnostic and therapeutic items, medical service facilities, prescription management and the scope of medicines.
The designated medical institutions shall comply with the provisions of the basic medical insurance on diagnostic and treatment items, medical service facilities, scope of medication, price management and payment standards in providing medical services to the insured, and shall provide the insured with the medical expense settlement documents.
Designated medical institutions shall, in accordance with the relevant provisions of the State and the city, provide direct settlement services for medical expenses incurred by non-city insured persons in the city. Article 9 (Requirements on the Services Provided by Designated Retail Pharmacies)
Designated retail pharmacies shall not settle basic medical insurance expenses for prescriptions that do not comply with the regulations on the use of medicines for basic medical insurance when they provide participants with prescription medicines for dispensing and over-the-counter medicines for self-acquisition; and they shall not violate the regulations on the scope, varieties, and quantities of medicines for use for basic medical insurance when providing over-the-counter medicines for the participants. The non-formulary drugs provided to the insured shall not violate the scope, variety and quantity of drugs used in basic medical insurance.
Designated retail pharmacies shall comply with the relevant provisions on price management and payment standards in providing dispensing services to the insured persons, and provide the insured persons with relevant expense settlement documents. Article 10 (Real-time Monitoring)
The municipal health insurance supervisory organization shall carry out real-time monitoring of the monthly cumulative number of outpatient and emergency visits of the insured persons at the designated medical institutions and the basic health insurance expenses incurred by them, as well as the monthly cumulative basic health insurance expenses incurred by the designated retail pharmacies for dispensing medicines. Based on the real-time monitoring, the district medical insurance bureaus and the municipal medical insurance supervisory organizations can temporarily change the basic medical insurance fee accounting and settlement methods for outpatient emergency visits or dispensing of medicines for those whose medical visits and dispensing of medicines are out of the scope of the regulations.
To take measures to temporarily change the accounting and settlement of basic medical insurance expenses, the district medical insurance bureau and the municipal medical insurance supervisory organization shall notify the insured person and promptly audit the situation of medical treatment and dispensing of medicines. Participants should cooperate with the audit, explain the situation and provide relevant materials as required.
After the audit, no violation of the basic medical insurance provisions of the participant is found, the district medical insurance bureau, the city health insurance supervisory body shall, on the day of the completion of the audit and inspection, to restore the basic medical insurance fees recorded settlement.
After the audit, found that participants have violated the provisions of basic medical insurance behavior, the city, district medical insurance bureau in accordance with the provisions of Article 15, paragraph 2, or Article 19 of this approach to deal with.