"Interim Measures for Basic Medical Insurance for Employees in Jiaxing City, Zhejiang"
Chapter I General Principles
Article 1 For the purpose of improving and perfecting the basic medical insurance system for employees, safeguarding the lawful rights and interests of the insured employees, and promoting the harmonious development of the society, according to the "Chinese People's *** and the State Social Insurance Law" and the state, the province of the relevant provisions of the medical security system construction, combined with the city's actual situation, to formulate these measures. The city's actual, the development of this approach.
Article 2 These measures apply to the city within the scope of the various types of enterprises, institutions, institutions, social organizations and private non-enterprise units (hereinafter collectively referred to as the employer) and its employees, as well as self-employed, unemployed persons receiving unemployment insurance premiums for basic medical insurance and related management activities.
Article 3 The basic medical insurance system for employees adhere to the following principles:
(a) the principle of law. All employers and their employees should participate in the basic employee medical insurance in accordance with the law, and the implementation of localized management.
(2) the principle of basic protection. The financing and protection level of basic employee medical insurance should be compatible with the local level of economic and social development to meet the basic medical needs of insured employees.
(C) the principle of reciprocity. Employees basic medical insurance premiums by the employer and the individual employee **** the same burden, the level of treatment and contributions corresponding.
(D) the principle of fairness. Gradually consolidate the type of basic medical insurance for employees, and promote the unification of basic medical insurance treatment for employees.
(V) the principle of sustainability. Employee basic medical insurance fund to determine expenditure, to achieve a balance of income and expenditure, with a slight surplus.
Article 4 The establishment and improvement of supplementary medical insurance system, including major medical insurance, and encourage the development of commercial health insurance connected with basic medical insurance, to meet the needs of the insured multi-level medical protection.
Article 5 The city's human resources and social security administrative department in charge of the city's basic medical insurance for employees; municipal development and reform (price), civil affairs, finance (local tax), health, audit, market supervision and other relevant departments in accordance with their respective responsibilities, *** with the implementation of these measures; Nanhu District Government, Xiuzhou District Government, Jiaxing Economic and Technological Development Zone (International Business District) Management Committee is responsible for the implementation of basic medical insurance within the jurisdiction. Employee basic medical insurance related to the implementation of work.
Article 6 The local tax authorities are responsible for the collection of basic medical insurance premiums.
Article 7 The Municipal Bureau of Social Security Affairs is responsible for the registration of employees' basic medical insurance, record of rights and interests, payment of benefits and audit, construction and maintenance of the information system, day-to-day consultation, business training and guidance, supervision and management of designated medical institutions and designated retail pharmacies.
Chapter II: Collection and Management of Medical Insurance Premiums
Article 8 Employers shall apply for registration of employees for basic medical insurance for their employees within 30 days from the date of employment. Newly established employers, basic medical insurance registration changes or terminated according to law, the employer shall within 30 days from the date of establishment or the occurrence of the relevant circumstances for the account opening, change or cancellation of registration procedures.
Article IX of the basic medical insurance premiums for employees in the urban areas of the previous year, the average salary of all employees on the job as the basis for contributions, respectively, by the employer and the individual employee to the prescribed proportion of monthly **** with the payment.
Article 10 of the basic medical insurance for employees temporarily set up a unified account, unified account two types. Gradually adjust the basic medical insurance for employees unified account one, unified account two contribution ratio and treatment level, in due course, the unified account one transition to unified account two. During the transition period, the specific contribution ratio and treatment level of the unified account one and unified account two of the basic medical insurance of employees, the Municipal Bureau of Human Resources and Social Security in conjunction with the Municipal Bureau of Finance to put forward the views of the municipal government agreed to announce.
In 2015, to participate in the employee basic medical insurance unified account of the first, the employer according to the number of active employees, to pay 3.5% of the contribution base; active employees pay 0.5% of the contribution base of the individual. Participate in the second employee basic medical insurance unified account, the employer in accordance with the number of active employees and retired employees, respectively, to pay 7.5% and 4% of the contribution base; active employees pay 2% of the individual contribution base.
Article 11 The medical insurance premiums paid by the employer shall be expensed in accordance with the channels stipulated by the financial and taxation departments. The medical insurance premiums paid by individual employees shall be withheld and paid by the employer on behalf of the employee.
Article 12 The unemployed who receive unemployment insurance benefits shall participate in the basic medical insurance for employees in accordance with the regulations, and the medical insurance premiums shall be paid by the Unemployment Insurance Fund; the self-employed persons of working age who participate in the basic old-age pension insurance for employees in the co-ordinated area shall participate in the basic medical insurance for employees in accordance with the provisions of Article 10 of the present Measures, and shall pay the basic medical insurance premiums for employees in the ratio of contributions of the employing unit and the individual employee. Employee basic medical insurance premiums.
Article 13 Employers and their employees who pay medical insurance premiums in accordance with the provisions of the basic medical insurance for employees from the month following the payment of premiums to enjoy the basic medical insurance benefits for employees; not in accordance with the provisions of the medical insurance premiums paid from the month following the occurrence of the basic medical insurance benefits for employees to stop enjoying the benefits of the basic medical insurance for employees.
For migrant workers, if they continue to participate in the insurance within 3 months, they can enjoy the basic medical insurance treatment from the next month after they pay the premiums; if it is more than 3 months, it is regarded as an interruption of the insurance, and they have to pay the premiums continuously for 3 months after they continue to participate in the insurance before enjoying the basic medical insurance treatment of the employees.
Retirees should go through the basic medical insurance convergence procedures within 3 months after the approval of retirement and enjoy the basic medical insurance treatment according to the regulations; if it is more than 3 months, they can enjoy the relevant treatment from the following month.
Article 14 When employees reach the legal retirement age and go through the retirement procedures, their basic medical insurance contributions (hereinafter referred to as medical insurance contributions) for a total of 25 years for men and 20 years for women, they can enjoy the corresponding treatment of basic medical insurance for employees in accordance with the provisions of the law. retirement before June 30, 2001, the number of years of medical insurance contributions are not stipulated.
Before the implementation of these measures, the number of years of medical insurance contributions is recognized as the number of years of employees' basic pension insurance contributions; after the implementation of these measures, the number of years of medical insurance contributions is calculated according to the actual number of years of medical insurance contributions. The number of years of health insurance contributions is accumulated on a monthly basis.
Employees retired from the health insurance contribution period is insufficient, can be handled by the year of the basic medical insurance contribution base of 3.5% of a one-time retroactive payment, credited to the health insurance contribution period, do not enjoy the retroactive payment during the basic medical insurance treatment of employees. The employer is responsible for making up for the unpaid contributions, and the employee is responsible for making up for the rest.
Article 15 Participation in the basic medical insurance of the employees of the unified account of the employer, its retirees by the medical insurance agency to confirm that meets the requirements of the number of years of medical insurance contributions, in accordance with the provisions of the basic medical insurance of the employees of the unified account of the treatment; participate in the basic medical insurance of the employees of the unified account of the employer, its retirees by the medical insurance agency to confirm that meets the requirements of the number of years of medical insurance contributions, and according to the provisions of Article 10 of the present measures, the participation of the basic medical insurance of the employees of the employer to pay contributions, can enjoy the benefits of the basic medical insurance. If you pay the contributions, you can enjoy the treatment of the unified account of the employees' basic medical insurance.
Article 16 The employer who participates in the basic medical insurance of employees according to the provisions of Article 10 of these Measures, the retiree who meets the stipulated contribution period of medical insurance can, upon his/her own application and with the consent of the employer, make a one-time lump sum contribution to the age of 75 years (less than 5 years, according to 5 years) with a standard of 1,000 yuan/year according to the management method of one-time handover of medical expenses, and enjoy the treatment of the unified account II of the basic medical insurance of employees from the following month of the payment of contributions. The treatment. 1 January 2015 before the retirement but not in accordance with the specified time to continue to participate in the insurance, need to make up for the interruption of the period of the cost, the specific method according to the interruption of the month × 2112 yuan / month × 5.5% standard calculation, the interruption of the calculation of years of retroactive payment of the time point up to December 2014, do not enjoy the retroactive payment period of health insurance treatment.
During the transition period, the handover costs (including wholesale fees and interrupted retroactive contributions) were gradually reduced. for the 2015 year, the handover costs were calculated at 90% of the handover costs.
Article 17 of the self-employment status of the retired, by their own application, health insurance agencies to confirm, in line with the provisions of the health insurance contribution period, can be required to enjoy the basic medical insurance for employees unified account one treatment; by their own application, can be compared to the provisions of Article 16 of these measures, a one-time payment of the transfer costs, to enjoy the basic medical insurance for employees unified account two treatment.
Article 18 of the basic pension insurance for employees to defer contributions, according to the standard of self-employed workers to pay monthly employees' basic medical insurance premiums, in accordance with the provisions of the basic medical insurance for employees to enjoy the corresponding in-service treatment.
Chapter III Medical Insurance Individual Accounts and Management
Article 19 Participating in the basic medical insurance for employees, the unified account of the first, do not build individual accounts. For those who participate in the Unified Account II of the Employees' Basic Medical Insurance, individual accounts shall be established according to the following standards:
(1) For active employees (including those who are double-contributing and double-insured): 100 yuan/month for those below 35 years old (inclusive), 120 yuan/month for those above 35 years old and up to 45 years old (inclusive), and 140 yuan/month for those above 45 years old.
(ii) Retirees: 160 yuan/month for those under the age of 75 (inclusive), and 180 yuan/month for those over the age of 75.
The personal account transfer amount changes with the age group, are adjusted from January 1 of the following year.
Article 20 Individual account is divided into current year individual account and calendar year individual account, the current year individual account is mainly used to pay for outpatient (emergency) consultation and purchase of medicines in accordance with the provisions of the basic medical insurance; the funds in the calendar year individual account can be used to pay for the following expenses:
(a) reimbursement of various types of out-of-pocket expenses after meeting the provisions of the basic medical insurance;
(b) medical service items and drug catalogs in accordance with the basic medical insurance. (b) Medical service item costs and drug costs in excess of the prescribed payment limit in accordance with the medical service item and drug catalog of basic medical insurance;
(c) Costs of out-of-pocket services necessary for diagnosis and treatment, including fees for registration, duplication of films, computerized graphic reports, color printing of photographs, color disposable imaging (bola) photographs, dental cleaning, and decoction of medicines;
(d) Preventive service fees other than those of the National Expanded Immunization Program (NEIP). Preventive immunization vaccine fees other than the National Expanded Programme on Immunization: rabies vaccine, various types of pneumococcal vaccine, influenza vaccine.
(e) Other medical expenses in line with national and provincial regulations.
Article 21 The personal account is managed by the medical insurance agency, and interest is accrued once per settlement year at the bank demand deposit rate, and its principal and interest are owned by the individual, and can be transferred and inherited according to law.
Chapter IV Medical Insurance Treatment
Article 22 The basic medical insurance premiums paid by the employer and the individual employee shall be included in the basic medical insurance fund and the individual account of the employee in accordance with the regulations.
Article 23 If you participate in the unified account of the employees' basic medical insurance, the outpatient (emergency) consultation (purchase of medicines) and hospitalization medical fees incurred by the insured in the designated medical institutions (designated retail pharmacies) in a settlement year that meets the scope of payment of the provisions of the basic medical insurance shall be paid in accordance with the following provisions.
(a) outpatient (emergency) medical expenses incurred by insured persons at community health service centers (stations) implementing the national basic drug system that meet the scope of payment under basic medical insurance shall be paid by the integrated fund at a rate of 70% of the portion of the outpatient medical expenses above the outpatient starting standard and below the outpatient outpatient maximum payment limit; outpatient (emergency) medical expenses incurred by insured persons at other designated medical institutions (designated retail pharmacies) that meet the scope of payment under basic medical insurance shall be paid by the integrated fund at a rate of 70% of the outpatient medical expenses incurred. For outpatient (emergency) consultation (drug purchase) expenses incurred at other designated medical institutions (retail pharmacies) that are within the scope of basic medical insurance, the proportion of 40% of the expenses incurred above the outpatient starting payment standard and below the outpatient maximum payment limit shall be paid by the coordinated fund.
The outpatient starting standard is 500 yuan for active employees and 300 yuan for retirees; the outpatient maximum payment limit is 3,000 yuan, and the portion above the maximum payment limit is borne by individuals.
(b) The hospitalization medical expenses incurred by the insured in the designated medical institutions in line with the scope of payment of the basic medical insurance provisions, above the starting standard to the maximum payment limit of the following part of the integrated fund shall be paid according to the following proportion: 90% of the first level and the following medical institutions (community health service institutions); 85% of the second level (county level) medical institutions; third level (municipal level) medical institutions for 80%.
Retirees will have 5 percentage points added to the above payment ratios.
Article 24: For those who participate in the Employees' Basic Medical Insurance Unified Account II, the outpatient (emergency) consultation (purchase of medicines) and hospitalization medical fees incurred by insured persons at designated medical institutions (designated retail pharmacies) in a settlement year that meets the scope of payment of the provisions of the basic medical insurance shall be paid in accordance with the following provisions.
(a) Participants in the implementation of the national basic drug system in the community health service centers (stations) in line with the basic medical insurance provisions of the scope of payment of outpatient (emergency) medical expenses, first by the current year into the individual account to pay for the current year into the personal account is insufficient to pay for the outpatient outpatient outpatient outpatient outpatient outpatient payment above the standard to the maximum limit of payment of the following part of the proportion of the integrated fund paid at 80%; In other designated medical institutions (retail pharmacies) incurred in accordance with the basic medical insurance provisions of the scope of payment of outpatient (emergency) clinic (purchase of medicines) costs, first by the current year into the individual account to pay, the current year into the personal account is insufficient to pay, in the outpatient outpatient starting standard to the outpatient outpatient maximum payment limit of the following part of the co-ordinated fund at the rate of 50% payment.
The outpatient starting standard is 500 yuan for active employees and 300 yuan for retirees; the outpatient maximum payment limit is 6,000 yuan, and the portion above the maximum payment limit is borne by the individual.
(b) the participants in the designated medical institutions in line with the basic medical insurance provisions of the scope of payment of hospitalization medical costs, above the starting standard to the maximum payment limit of the following part of the integrated fund shall be paid in the following proportions: 90% of the first level and the following medical institutions (community health service institutions); 85% of the second level (county-level) medical institutions; third-level (municipal) medical institutions for the 80%. 80%.
Retirees will have 5 percentage points added to the above payment ratios.
Article 25 The hospitalization medical expenses incurred by insured persons in designated medical institutions in line with the scope of payment of basic medical insurance shall be set according to the level of different medical institutions as the starting standard for hospitalization of the integrated fund: 300 yuan for medical institutions of the first level and below (community health service institutions), 500 yuan for medical institutions of the second level (county level), and 800 yuan for medical institutions of the third level (municipal level).
The hospitalization starting standard is charged on a per visit basis. In a billing year, the hospitalization starting standard is charged at most twice, and there is no starting standard for the third and subsequent hospitalizations; in case of transfer during hospitalization, the starting standard is calculated according to the standard of high-level hospitals.
Article 26 of the basic medical insurance for employees hospitalization (including outpatient prescribed diseases, the same below) the maximum payment limit in principle, according to the previous year, the urban average wage of the whole society in the city to determine about 6 times, temporarily set at 200,000 yuan.
Article 27 The basic medical insurance for employees prescribed diseases, including malignant tumors radiotherapy, uremia, organ transplantation after anti-rejection treatment, aplastic anemia, systemic lupus erythematosus, hemophilia, severe mental illness, adjuvant treatment of tuberculosis (except for the national free anti-tuberculosis drug treatment), AIDS opportunistic infections (except for the free antiretroviral treatment prescribed by the state) and other nine kinds of diseases. . Specified disease participants in selected medical institutions outpatient targeted treatment costs in line with the scope of payment of basic medical insurance prescribed diseases, can be treated as inpatient medical costs (regardless of the starting standard), paid by the integrated fund in accordance with the proportion of tertiary health care institutions, of which the outpatient targeted herbal treatment costs, according to the maximum payment standard of 50 yuan per post included in the settlement, less than the standard, according to the actual settlement.
Article 28 Participants with one of the following conditions, may apply for the establishment of home hospital beds:
(a) disease-induced paralysis or loss of ability to take care of their own lives patients;
(b) malignant tumors in the late stages of the disease, behavioral difficulties need to support the treatment and alleviate the pain of the patients;
(c) more than three types of surgery (in accordance with the standards of the health administration department to divide the categories) After the recovery period patients;
(D) hospice patients.
The starting standard for family hospital beds is 80 yuan per month; the maximum payment limit is 2,000 yuan per month (which can be used within the time period of the establishment of the bed); the proportion of the integrated fund to pay for medical expenses incurred during the period of the establishment of the bed that are in line with the scope of payment of the basic medical insurance is 70% for the portion of the medical expenses incurred from the starting standard to the part below the maximum payment limit.
Article 29: Old workers who participated in the revolution before the founding of the PRC, the outpatient (emergency) consultation (purchase of medicines) and hospitalization medical expenses incurred in designated medical institutions (designated retail pharmacies) that meet the scope of payment of the provisions of basic medical insurance shall be paid in accordance with the following provisions.
(a) the old workers who participated in the revolution before the founding of the People's Republic of China in the outpatient (emergency) clinic (purchase of medicines) incurred in line with the scope of payment of the basic medical insurance provisions of the medical expenses, first by the current year's personal account, the current year's individual account is insufficient to pay for the portion of outpatient outpatient payment standards (300 yuan), the proportion of the integrated fund paid at 85%.
(2) Old workers who participated in the revolution before the founding of the People's Republic of China incurred inpatient medical expenses at designated medical institutions in line with the scope of payment of the basic medical insurance regulations, after reimbursement of the basic medical insurance regulations, their out-of-pocket medical expenses, and then by the coordinated fund at a rate of 85%.
Article 30: Improvement of the employees' major illness insurance system. Employees' major medical insurance funds are raised at 0.2% of the contribution base, of which 0.15% is borne by the integrated fund and 0.05% is borne by the treasury. Employees' major medical insurance can be entrusted by the medical insurance agency to commercial insurance institutions.
Within a medical insurance settlement year, the hospitalization medical expenses incurred by insured persons at designated medical institutions that meet the payment scope of basic medical insurance and exceed the maximum payment limit for hospitalization will be subsidized by 85% of the employee's major disease insurance, with no ceiling.
Participants in a medical insurance settlement year, in the designated medical institutions in line with the basic medical insurance provisions to pay the scope of inpatient (prescribed types of disease) medical costs, after the basic medical insurance reimbursement (including various types of subsidies), the individual's cumulative out-of-pocket medical expenses more than 15,000 yuan above the part of the subsidy, and then in accordance with the following ratio: 15,000 yuan (excluding) to 50,000 yuan 55%, 50,000 yuan (excluding) part of 70%, and more than 70% of 70%. The proportion of the part above 10,000 yuan (not included) is 70%.
Chapter V: Management of Medical Insurance Services
Article 31 The basic medical insurance for employees implements the system of designated medical institutions and designated retail pharmacies. Medical institutions approved by the administrative department of health and obtaining the Medical Institution Practice Permit, and retail pharmacies approved by the market supervision department and holding the Drug Operation Permit and industrial and commercial business license may apply for fixed-point qualification in accordance with the regulations.
Medical institutions and retail pharmacies that have obtained the qualification of fixed-point medical insurance can only provide services to insured persons after signing the medical insurance service agreement with the medical insurance administration organization.
Article 32 Participants can choose to seek medical treatment and purchase medicines at designated medical institutions and designated retail pharmacies within the city according to the regulations. Participants are encouraged to seek medical treatment at grassroots community health service organizations. The city level within the implementation of network settlement, the insured person with their own social security - citizen card for medical treatment, the medical costs incurred by the insured person should be personally borne by the insured person (including out-of-pocket expenses, self-payment) by the insured person directly to the designated medical institutions (retail pharmacies) to pay; should be paid for by the fund, by the designated medical institutions (retail pharmacies) in accordance with the agreement with the health insurance agency to pay on a monthly basis.
In case of failure to settle the payment by credit card due to transferring to another hospital or information system malfunction (except for designated retail pharmacies), the insured person should, within 3 months after advancing the corresponding medical expenses in cash, present the special settlement vouchers for medical expenses (original invoices), lists, and discharge summaries, etc., and then go to the medical insurance agency to settle the medical expenses.
By the end of the settlement year, if the insured person has been hospitalized for 6 consecutive months, he/she should be settled.
Article 33 The insured person's medical condition, in accordance with the relevant provisions of the basic medical insurance registration procedures, transferred to Hangzhou, Shanghai, the local basic medical insurance designated tertiary care institutions for treatment, or due to temporary out of the medical institutions outside of the city emergency, rescue, the incurred in line with the provisions of the basic medical insurance scope of payment of the medical costs, by the individual out-of-pocket expenses of 10%, and then settled in accordance with the provisions; If you are transferred to a local designated tertiary medical institution outside of Shanghai or Hangzhou for treatment according to the regulations, you will have to pay 20% of the medical expenses out of your own pocket, and then settle the bill according to the regulations.
Participants who do not apply for registration and filing procedures in accordance with the provisions of the basic medical insurance outside of the city or other designated medical institutions for treatment, the medical expenses incurred in accordance with the basic medical insurance provisions of the scope of payment, by the individual out-of-pocket expenses of 30%, and then reimbursement of the employee's basic medical insurance provided by the tertiary health care institutions to settle the ratio.
Article 34 For those who live abroad for a long time after retirement or need to be stationed abroad for more than 3 months for work reasons, they can apply to the medical insurance agency of the insured place to apply for the filing procedures for relocation, and the medical expenses incurred in the designated medical institutions in the place of residence (4 institutions can be selected) are regarded as the expenses incurred in the designated medical institutions in the city, and reimbursement will be made as per the regulations. If you have applied for the record of relocation, it can be revoked only after 3 months.
Article 35 The medical service items and the scope of medication of the basic medical insurance for employees shall be implemented in accordance with the Catalogue of Medical Service Items of Basic Medical Insurance of Zhejiang Province, the Catalogue of Medicines of Basic Medical Insurance, Work Injury Insurance and Maternity Insurance of Zhejiang Province, the Manual of Prices of Medical Services of Zhejiang Province, as well as the relevant provisions of the state, province and city. Participants in the coordinated area outside the medical (including relocation, transfer treatment, etc.), the scope of drug use in the "Zhejiang Province, basic medical insurance, industrial injury insurance and maternity insurance drug catalog" shall prevail; really belong to the basic medical insurance in the place of medication, can be included in the scope of payment, according to the treatment of Class B drugs; diagnostic and treatment items, service facilities and standards in accordance with the provisions of the city.
Article 36 The insured person suffering from the specified diseases need outpatient targeted treatment, can be applied to the health insurance agency in accordance with the provisions of the application, after review and approval, into the specified disease settlement range, every 2 years, 1 time to validate.
Participants can choose a second-class and above designated medical institutions as the prescribed disease treatment hospital; need to be targeted treatment of Chinese herbal medicine, you can choose an additional designated medical institutions (not limited to the level) as the treatment hospital. The hospital selected for treatment of prescribed diseases shall not be changed within one year.
Article 37 of the insured need to set up a home hospital bed, by their own application, the admission of medical institutions, reported to the health insurance agencies to review and agree to be included in the home hospital beds settlement range, every health insurance settlement year, should be settled once. The maximum time for a home hospital bed to be built is not more than one year.
In principle, family hospital beds are responsible for the admission and provision of medical services by the community health service organizations in the place of residence of the insured.
Article 38 The fixed-point medical institutions and fixed-point retail pharmacies shall strictly implement the relevant provisions to provide safe, effective and reasonably priced medical services and medicines for the insured; if there is a need to provide services and medicines outside the scope of payment of the basic medical insurance regulations, the consent of the insured person or his/her immediate family should be obtained in advance.
The fixed-point medical institutions and fixed-point retail pharmacies should strictly control the amount of Chinese and Western medicines prescribed in accordance with national and provincial regulations on prescription management. Western medicine (proprietary Chinese medicine) prescription volume, acute diseases not more than 3 days, general diseases not more than 7 days, chronic diseases not more than 15 days (perennial medication is relaxed to 30 days). Herbal medicine prescription quantity is generally not more than 7 posts; prescribed disease outpatient herbal medicine prescription quantity is not more than 14 posts, of which for special reasons need to be transferred to out-of-city herbal medicine treatment, the highest not more than 30 posts.
For the national prescription drugs and non-prescription drugs classification and management provisions, can be sold according to the sales registration system of prescription drugs, can be in the conditions of the designated retail pharmacies on a trial basis according to the sales registration system. The specific implementation of the medical insurance agency in conjunction with the relevant departments to formulate a separate.
Article 39 The following medical expenses shall not be included in the scope of payment by the Employees' Basic Medical Insurance Fund:
(1) those that should be paid from the Workers' Compensation Insurance Fund;
(2) those that should be borne by a third party;
(3) those that should be borne by public **** health;
(4) those that seek medical treatment outside of the country;
(5) those that Intentional crime caused by their own injuries occur;
(F) beauty, plastic surgery and other non-basic medical needs occur;
(G) non-basic medical insurance designated medical institutions (designated retail pharmacies) occur;
(H) other laws and regulations provide for non-payment.
Chapter VI Supervision and Administration of Medical Insurance
Article 40 The basic medical insurance fund for employees is unified into the financial account of the social security fund, the implementation of the two lines of management of income and expenditure, the implementation of the social insurance fund budgeting system and financial accounting management system. No department, unit or individual shall encroach on, squeeze and misappropriate the fund, and shall not be used to balance the financial budget.
Article 41 The municipal human resources and social security departments shall, in accordance with the relevant provisions of the state and province to develop and improve the basic medical insurance policy system, and in conjunction with the relevant departments and units to establish and improve the designated medical institutions, designated retail pharmacy supervision and management and management of the medical insurance physician and other supporting systems.
The medical insurance agency should, according to the relevant provisions of the national, provincial and municipal basic medical insurance, scientifically and reasonably formulate the service agreement of designated medical institutions and designated retail pharmacies, strengthen the daily supervision and management, regulate the behavior of their basic medical insurance services, and deal with the violation of the law; promote the reform of the basic medical insurance settlement system, and implement a variety of settlement modes under the control of the total amount of money, so as to effectively control the medical costs and reduce the burden of the insured. The government has also promoted the reform of the basic medical insurance settlement system and the implementation of various settlement methods under total control, so as to effectively control the excessive growth of medical costs and reduce the burden of insured persons.
Article 42 The fixed-point medical institutions, fixed-point retail pharmacies in violation of the agreement signed with the medical insurance agency, in accordance with the relevant agreements to pursue its responsibility for breach of contract. If the circumstances are serious, the fixed-point qualification will be canceled.
Participants who violate the basic medical insurance regulations and cause losses to the basic medical insurance fund, the medical insurance agency to recover the medical insurance premiums already paid, and can be notified to the employer.
Article 43 If the basic medical insurance fund expenditure is cheated by fraud, falsification of supporting documents or other means, according to the provisions of Article 87 and Article 88 of the Social Insurance Law of the People's Republic of China, the fraudulent medical insurance premiums shall be ordered to be returned, and the fraudulent amount shall be subject to a fine of not less than two times and not more than five times of the amount cheated. If it belongs to a medical insurance service organization, the service agreement shall be terminated; if the directly responsible supervisors and other directly responsible personnel have a license to practice, their license shall be revoked in accordance with the law. Suspected of committing a crime, transferred to the judicial authorities in accordance with the law.
Article 44 The medical insurance administrative departments, collection agencies, agencies and their staff in violation of the provisions of the basic medical insurance, in accordance with the "Chinese People's *** and the State Social Insurance Law", Article 89, Article 90, Article 91, Article 92, Article 93, Article 94 of the relevant provisions of the treatment.
Chapter VII Others
Article 45 The employees referred to in these Measures include active employees (including those who have made double contributions and double insurance) and retirees (including those who have retired).
Out-of-pocket expenses refer to the medical and other expenses that are not included in the scope of payment under the basic medical insurance for employees and are to be borne by the insured individuals.
Out-of-pocket expenses refer to the part of the starting payment standard, the part of personal expenses after reimbursement according to the proportion, and the part above the outpatient maximum payment limit, which are included in the scope of payment of basic medical insurance for employees and should be borne by the insured person according to the regulations.
The maximum payment limit refers to the maximum amount of medical expenses included in the scope of payment of the basic medical insurance fund.
The settlement year of basic medical insurance for employees is a natural year.
Article 46 Before the implementation of these measures, the retirees who have transferred their medical expenses to the management of the one-time standard of 1000 yuan / year, shall enjoy the treatment of basic medical insurance for employees in accordance with the provisions of the Unified Account II.
Article 47 Employers can choose a type of participation in the basic medical insurance of employees in the transition period in accordance with the provisions of Article 10 of these Measures. If the employer needs to change the type of insurance, in principle, it will be centralized once in December every year.
Article 48 Improvement of civil servants' medical subsidies, enterprises and institutions medical subsidy policy. Encourage all types of employers to set up a medical subsidy system through self-construction and purchase of commercial health insurance and other forms, to reduce the burden of medical care on the insured.
Article 49 The medical subsidies for retired cadres, military personnel with revolutionary disabilities of the sixth grade and above, and model workers at the municipal level and above shall be implemented in accordance with the relevant provisions.
Article 50 The counties (cities) in accordance with the "Jiaxing Municipal People's Government on the unification of the city's employees health insurance policies related to the implementation of the views" (Jia Zheng Fa [2008] No. 59), "Jiaxing Municipal People's Government on the implementation of the work of Jiaxing Municipal Social and Basic Medical Insurance municipal level of co-ordination" (Jia Zheng Fa [2009] No. 106), and other documents, in conjunction with the methods to be implemented.
Fifty-first.
Article 51 These measures shall be implemented on a trial basis from 2015. The original "Jiaxing City, urban workers basic medical insurance interim provisions" (Jia Zheng Fa 〔2001〕 No. 112), "Jiaxing City, urban workers basic medical insurance interim provisions of the relevant supporting documents notice" (Jia Zheng Ban Fa 〔2001〕 No. 113, in addition to Annexes 7-9) shall be repealed at the same time. The city's original basic medical insurance for workers related provisions are inconsistent with these Measures, the Measures shall prevail.
;