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Participating in urban residents' medical insurance is not required to participate in social pension insurance, to participate in the basic medical insurance of enterprise employees need to participate in pension insurance.
Office of the Hainan Provincial People's Government on the issuance of Hainan Province, the regional integrated area of urban residents of the implementation of basic medical insurance notice Qiongfuban 〔2008〕 No. 31
Cities, counties, autonomous counties people's governments, the provincial government directly under the units:
"Hainan Province, the regional integrated area of urban residents of the implementation of basic medical insurance" has been agreed to by the provincial government is hereby issued to Please earnestly implement them.
March 18, 2008
Hainan Regional Coordination Area
Measures for the Implementation of Basic Medical Insurance for Urban Residents
Chapter I General Provisions
Article 1 According to the "Guiding Opinions of the State Council on the Pilot Work of Basic Medical Insurance for Urban Residents" (Guofa [2007] No. 20), "Hainan Provincial People's Government Issues Regulations on Hainan Provincial People's Government issued the Notice on the Opinions on Doing a Good Job in the Pilot Work of Basic Medical Insurance for Urban Residents" (Qiongfu [2007] No. 35), "Hainan Provincial People's Government Supplementary Circular on Doing a Good Job in the Pilot Work of Basic Medical Insurance for Urban Residents" (Qiongfu [2007] No. 59), and "Approval of the Ministry of Labor and Social Security on the Recognition of the List of Expanded Pilot Cities for Basic Medical Insurance for Urban Residents in 2008" (Ministry of Labor and Social Security Letter [ 2008] No. 24) and so on. 2008] No. 24) and other spirit, combined with the actual situation in our province, the formulation of this approach.
The second in accordance with the "adhere to the low level of the start, focusing on the protection of urban residents of major medical needs, and gradually increase the level of protection" principle, in the regional integrated area (including Wenchang City, Qionghai City, Danzhou City, Wanning City, Wuzhishan City, Dongfang City, Ding'an County, Tunchang County, Chenggao County, Lingao County, Changjiang County, Ledong County Lingshui County, Baisha County, Baoting County, Qiongzhong County and Yangpu Economic Development Zone) to establish a basic medical insurance system for urban residents based on the coordination of major illnesses, and to effectively solve the problem of medical security for urban residents.
Non-agricultural residents of Nongken (hereinafter referred to as Nongken residents) who are not covered by the basic medical insurance system for urban employees participate in the basic medical insurance for urban residents in the cities and counties of the coordinating area of the region where their household accounts are located, in accordance with the principle of territorial management.
Article 3: The regional co-ordination area shall be a co-ordination unit for urban residents' basic medical insurance, and the mode of regional co-ordination of funds, city and county management, and transfer of surplus and shortages shall be implemented. Within the regional co-ordination area, there is a unified financing standard, a unified treatment payment standard, a unified fund management, a unified collection agency, and a unified management agency.
Article 4 of the provincial personnel and labor security department is responsible for working with the relevant departments to study and formulate the regional co-ordination area of urban residents' basic medical insurance regulations. Regional co-ordination area within the scope of the cities and counties (including Yangpu, the same below) personnel and labor security department is responsible for the implementation of the basic medical insurance system for urban residents of the city and county and management and supervision work.
Provincial financial departments are responsible for the regional integrated area of urban residents of basic medical insurance fund transfer funds management. The financial departments of the cities and counties within the regional co-ordination area are responsible for the management of the basic medical insurance fund for urban residents in their own cities and counties.
Provincial local tax departments are responsible for the collection and supervision of urban residents' basic medical insurance premiums in the regional integrated area. The local tax and social insurance premium collection departments of the cities and counties within the regional co-ordination area are responsible for the collection of urban residents' basic medical insurance premiums in their own cities and counties with the assistance of the community labor security service agencies.
The provincial social insurance agency is responsible for monitoring the payment of urban residents' basic medical insurance benefits in the regional integrated area. The social insurance administrative organizations of cities and counties within the regional co-ordination area are responsible for the payment of urban residents' basic medical insurance benefits in their own cities and counties.
The General Administration of Reclamation and its farms and enterprises are responsible for the publicity, registration and payment of urban residents' basic medical insurance. The General Bureau of Reclamation is also responsible for the implementation of the part of the subsidy funds borne by the Bureau.
Health at all levels, publicity, development and reform, education, civil affairs, public security, food and drug supervision, audit, federations of persons with disabilities, and other departments play their respective roles, and actively cooperate with the work of basic medical insurance for urban residents.
Chapter II scope of participation and payment methods
Article 5 has a regional coordinating area within the scope of the cities and counties of non-agricultural household registration, is not included in the coverage of the basic medical insurance system for urban workers in schools and colleges and universities (including vocational high schools, junior colleges, technical schools), children and teenagers, and other non-employers of the urban residents can voluntarily participate in the basic medical insurance for urban residents. Schoolchildren are insured in the place where they are enrolled in school.
Article 6: The basic medical insurance for urban residents in regional co-ordination areas is based on a system of regular annual contributions.
The 2008 payment time for the second quarter, Dongfang, Tunchang paid September 2008 to December 2009 premiums, residents enrolled in premiums from September 1, 2008 to December 31, 2009 to enjoy the basic medical insurance for urban residents; other cities and counties (including Yangpu) to pay the premiums July 2008 to December 2009, residents enrolled in premiums from September 1, 2008 to December 31, 2009 to enjoy the basic medical insurance for urban residents; other cities and counties (including Yangpu) to pay the premiums July 2008 to December 2009, residents enrolled in premiums from July 1, 2008 to December 31, 2009 to enjoy the basic medical insurance for urban residents. Residents who enroll and pay premiums will be entitled to basic medical insurance for urban residents from July 1, 2008 to December 31, 2009.
Beginning in 2009, the fourth quarter of each year will be the time for the collection of urban residents' basic medical insurance premiums for the following year. Residents are entitled to basic medical insurance for urban residents from January 1 to December 31 of the following year after enrolling and paying the premiums.
Regional coordinating areas of urban residents of basic medical insurance premium collection methods by the provincial financial departments, in conjunction with the provincial local tax authorities, the provincial personnel and labor security departments to formulate a separate.
Chapter III fund-raising
Article 7 of the regional integrated area of urban residents of basic medical insurance financing standards:
(a) adults per person per year financing standards for 140 yuan, of which 60 yuan of individual contributions, 80 yuan of financial subsidies. Financial subsidies in: the central financial subsidies 40 yuan, the provincial financial subsidies 32 yuan, city and county financial subsidies 8 yuan.
(ii) minors per person per year financing standards for 90 yuan, of which 20 yuan of individual contributions, financial subsidies 70 yuan. Financial subsidies in: the central financial subsidies 40 yuan, the provincial financial subsidies 24 yuan, city and county financial subsidies 6 yuan.
(c) belonging to the low-income objects or severely disabled students and children to participate in the individual contribution required by the central financial subsidy of 5 yuan per person per year; other low-income objects, loss of working capacity of severely disabled, low-income families with disabilities, such as older than 60 years old and other difficult groups of people to participate in the individual contribution part of the central financial subsidy of 30 yuan per person per year. In addition to the central financial subsidies in addition to the shortfall in all by the city and county financial subsidies, and from the city and county urban medical assistance funds.
Not included in the urban employees of the basic medical insurance system coverage of the urban beneficiaries of individual contributions by the city and county financial subsidies, and from the city and county urban medical assistance funds.
The individual contribution required for the participation of disabled people with non-severe disabilities is subsidized 50% by the financial sector, with 80% of the required funds borne by the provincial government and 20% by the municipal and county governments.
(d) The funds required for financial subsidies for Nongken residents to participate in basic medical insurance for urban residents in cities and counties in their regional co-ordination areas shall, in addition to the central financial subsidies, be borne 80% by the provincial treasury and 20% by the General Administration of Nongken.
Reclamation residents of low-income recipients, preferential treatment, persons with severe disabilities and low-income families over the age of 60 years old individual contributions, in addition to the central financial subsidies in addition to the shortfall in all by the local financial subsidies, the funds required from the city, county urban medical assistance funds in the charge; persons with disabilities, individual contributions to the part of the financial subsidy of 50 percent of the funds required to be borne by the provincial financial responsibility for 80%, 20% by the Directorate General of Reclamation. General Administration of the burden of 20%.
Article VIII of the severe disability refers to the China Disabled Persons' Federation "China Disabled Persons Practical Evaluation Standards (Trial)" evaluation of the disability to reach the 1st and 2nd level of disability.
Low-income families are those whose per capita household income, as determined by the civil affairs department, is less than twice the minimum subsistence guarantee standard for the previous year in their area.
Article IX of the conditions of the employer can be subsidized by the employee's family members to participate in insurance contributions. Encourage all kinds of economic organizations, social groups and individuals to donate funds to support the basic medical insurance for urban residents, but shall not be forcibly distributed.
Chapter IV basic medical insurance treatment
Article 10 in accordance with the provisions of the basic medical insurance premiums paid by urban residents of urban residents (hereinafter referred to as participants), enjoy the integrated fund to pay treatment. If a participant interrupts the payment of contributions, he or she shall cease to enjoy the treatment.
Article 11 of the regional co-ordination area of urban residents basic medical insurance co-ordination fund is mainly used for the participants in line with the Hainan Province urban residents basic medical insurance drug list, disease list and outpatient treatment of special disease list, diagnostic and treatment items, as well as the scope of services and facilities of the medical expenses. There is no individual account in the basic medical insurance for urban residents in the regional co-ordination area.
Article 12 of the medical expenses of the insured in accordance with the regulations, in a settlement year, below the starting standard shall be paid by the individual, and medical expenses above the starting standard and below the maximum payment limit of the coordinated fund shall be borne by the coordinated fund and the insured individually in accordance with the proportion of payment.
Participating residents in difficulty who are eligible for urban medical assistance shall apply for subsidies from the local civil affairs departments in accordance with the relevant regulations.
(I) Starting standard
150 yuan for first-level hospitals, 400 yuan for second-level hospitals, and 600 yuan for third-level hospitals. If you are hospitalized in one billing year, the starting line is calculated cumulatively, and the total amount of the starting payment does not exceed 600 yuan.
(2) Payment Ratio
First-level hospitals: 65% paid by the integrated fund and 35% borne by individuals; second-level hospitals: 55% paid by the integrated fund and 45% borne by individuals; third-level hospitals: 45% paid by the integrated fund and 55% borne by individuals.
The use of the "Class B Catalog" in the "Drug Catalog of Basic Medical Insurance for Urban Residents of Hainan Province" and the "Provisions on the Management of the Diagnostic and Treatment Programs of the Basic Medical Insurance for Urban Residents of Hainan Province" for the diagnostic and treatment programs that are partially covered by the basic medical insurance for urban residents, the insured person shall firstly pay 20% of the cost out-of-pocket, and then pay the cost in accordance with the provisions of this Measures.
(3) The maximum payment limit of the integrated fund
In a settlement year, the maximum payment limit of the integrated fund is RMB 20,000 yuan; for those who have continuously participated in the insurance for more than 3 years, the maximum payment limit of the integrated fund is RMB 23,000 yuan; for those who have continuously participated in the insurance for more than 6 years, the maximum payment limit of the integrated fund is RMB 26,000 yuan; for those who have continuously participated in the insurance for more than 8 years, the maximum payment limit of the integrated fund is RMB 30,000 yuan. The maximum payment limit of the integrated fund is 30,000 yuan.
Dongfang and Tunchang from September 1, 2008 to December 31, 2009 for a settlement year, participants only need to pay the starting standard once, the maximum payment limit of the integrated fund is 27,000 yuan; other cities and counties (including Yangpu) from July 1, 2008 to December 31, 2009 for a settlement year, participants only need to pay the starting standard once, the maximum payment limit of the integrated fund is 30,000 yuan. The maximum payment limit of the fund is 30,000 yuan.
Article 13 of the basic medical insurance for urban residents outpatient treatment of special medical expenses are separately stipulated.
Article 14: The medical expenses for Category A infectious diseases such as cholera and plague shall be fully paid by the integrated fund. The medical expenses for outbreaks and epidemics of infectious diseases recognized by the administrative department of health shall be settled by the people's government through the allocation of special funds.
Article 15: The basic medical insurance fund for urban residents shall not pay for the following expenses:
(1) medical expenses incurred in unauthorized visits to non-designated medical institutions;
(2) expenses incurred during the period of interruption of payment of contributions by a participant;
(3) expenses incurred in cases of suicide, self-inflicted injuries (except for mental illness), fights, assaults, drunkenness, drug addiction, and any other cases arising from crimes or violations of the Law on Punishment of Public Security. violation of the Public Security Administration Punishment Law;
(iv) expenses incurred during the period of going abroad or leaving the country;
(v) expenses incurred for the treatment of cosmetic, orthopedic (except for functional orthopedic), physiological defects, etc.
Fifth: Expenses incurred during the period of going abroad or leaving the country.
Chapter V Medical Service Management
Article 16 of the Basic Medical Insurance for Urban Residents implements the service management of designated medical institutions. Where the medical institutions to obtain a license to practice health care institutions (including the agricultural reclamation health care institutions), by the affiliated municipal and county personnel and labor security administrative departments in conjunction with the health administrative departments to audit, identify, and obtain the qualification of designated medical institutions, by the affiliated municipalities and counties, social insurance agencies and their service agreements. The designated medical institutions shall hang a unified logo.
Article 17 of the implementation of designated medical service organizations access and exit mechanism. Municipal and county personnel and labor security administrative departments, in conjunction with the health administrative departments of the designated medical institutions to organize regular inspections, to meet the conditions, confirm the retention of its designated qualifications, by the municipal and county social insurance agencies to continue to sign a service agreement with them, for those who do not meet the conditions, to cancel the designated qualifications, termination of the service agreement.
Article 18 of the fixed-point medical institutions shall strictly implement the pricing policy, the urban residents of the basic medical insurance basic medication catalog and basic medical service prices and so on to be publicized.
Article 19 of the designated medical institutions of medical personnel should be based on the treatment of disease, adhere to the principle of reasonable examination, reasonable treatment, reasonable referral, in strict accordance with the provisions of the technical specifications of the medical diagnosis and treatment, to provide good medical services for the insured.
Article 20 of the insured person with the "Hainan Province, urban residents of basic medical insurance medical insurance card" (hereinafter referred to as "medical insurance card") in accordance with the provisions of the designated medical institutions to enjoy the urban residents of basic medical insurance treatment.
Article 21: The medical expenses incurred by the insured in the designated medical institutions, which are in accordance with the relevant provisions of the basic medical insurance for urban residents, shall first be directly recorded by the designated medical institutions in accordance with the provisions, and then be examined and settled by the municipal and county social insurance administrative organizations and the designated medical institutions in accordance with the provisions. The designated medical institution shall provide the hospitalized participant with a list of expenses, which shall be confirmed by the signature of the patient himself/herself or the relevant agent or attesting person. Any medical expenses not confirmed by the signature of the integrated fund shall not be paid.
Article 22 of the insured person should be the first in the city, county designated medical institutions, such as the condition needs to be transferred to the next level of designated medical institutions to continue to receive treatment, by their own application, the city, county designated medical institutions to put forward the views of the city, county social insurance agencies and approved by the municipal and county social insurance agencies can be transferred to the next level of designated medical institutions. If there is no proof of referral procedures, the integrated fund will not pay.
Article 23 of the critical emergency patients sent directly to the next level of emergency hospitalization of designated medical institutions, should be admitted within 10 working days (including the 10th working day) to the city or county social insurance agency report, while making up the referral procedures.
Article 24 of the approved medical expenses incurred in non-designated medical institutions shall be advanced by the insured first, and then reimbursed to the municipal and county social insurance agencies in accordance with the provisions of the review and reimbursement after discharge from the hospital. The medical insurance card, referral application form, certificate of discharge (with official seal), list of expenses, invoice and other relevant supporting materials shall be presented for reimbursement of expenses.
Article 25: Participants residing outside the insured cities and counties (including Yangpu Economic Development Zone) may, on their own application, choose two designated hospitals in their place of residence, and the municipal and county social insurance agencies shall approve the application and go through the relevant procedures. The medical expenses incurred will be handled in accordance with the provisions of these Measures. If the relevant procedures are not carried out in accordance with the provisions, the integrated fund will not pay.
Article 26 of the temporary out of acute hospitalization in a foreign hospital rescue, within 10 working days (including 10 working days) should be reported to the municipal and county social insurance agencies, and handle the relevant procedures. The medical expenses incurred shall be handled in accordance with the provisions of this Measures. If the relevant procedures are not carried out in accordance with the regulations, the integrated fund shall not pay.
Article 27 The designated medical institution shall refer the participant to the medical institution when the following situations occur:
(1) difficult diseases that cannot be diagnosed after examination and consultation;
(2) critical diseases that do not have the conditions for diagnosis and treatment and resuscitation;
(3) lack of necessary examination, diagnostic and therapeutic items and facilities;
(4) clear diagnosis, the participant requests to be transferred to a lower level of the social insurance fund. The participant requests to be transferred to a lower-level designated medical institution for further treatment.
Chapter VI Fund Management and Supervision
Article 28: The financial management and accounting of the urban residents' basic medical insurance fund of the municipalities and counties within the scope of the regional coordinating area shall be implemented with reference to the current system and provisions of social insurance, and a transfer system of the urban residents' basic medical insurance fund of the regional coordinating area shall be established.
Article 29: The basic medical insurance fund for urban residents of cities and counties within the regional co-ordination area shall consist of city and county co-ordination funds and transfer funds:
(1) The city and county co-ordination funds shall consist of the residual portion of all subsidies and individual contributions made by all levels of finances to the urban residents of the cities and counties participating in the insurance scheme, minus the transfer funds. The municipal and county funds are mainly used to pay for the medical expenses of the insured urban residents of the city or county in accordance with the regulations.
(2) The transfer fund shall be withdrawn by the cities and counties in accordance with a certain percentage of the total annual funding of the basic medical insurance for urban residents. The management method of the transfer fund shall be formulated separately by the provincial financial department in conjunction with the provincial personnel and labor security department.
Article 30 of the municipalities and counties to set up by the supervision, audit and other departments and the National People's Congress deputies, CPPCC members and representatives of the participants of the urban residents of the basic medical insurance supervision committee, of which the representatives of the participants should be no less than 20% of the total number of people. The Supervisory Committee is responsible for supervising the income, expenditure and management of the fund.
Chapter 7: Rewards and Punishments
Article 31: Departments, designated medical institutions and related staff with remarkable achievements in the work of basic medical insurance for urban residents shall be commended by the people's governments of cities and counties. Specific methods of commendation shall be formulated by the municipal and county people's governments themselves.
Article 32 of the social insurance agency and its staff have one of the following acts, by the relevant departments in accordance with the relevant provisions; suspected of committing a crime, transferred to the judicial organs:
(a) dereliction of duty or violation of financial and economic discipline, resulting in losses of the basic medical insurance fund for urban residents;
(b) embezzlement, misappropriation of the basic medical insurance fund for urban residents or soliciting or accepting bribes, neglect of duty, abuse of power, or favoritism;
(3) unauthorized approval of the portion of the reimbursement program that does not belong to the basic medical insurance for urban residents;
(4) unauthorized changes in the treatment of the insured;
(5) interception or misappropriation of the basic medical insurance fund for urban residents;
(6) other violations of the relevant provisions of the basic medical insurance for urban residents. medical insurance regulations.
Article 33 of the designated medical institutions and their staff have one of the following behaviors, depending on the severity of the circumstances, shall be dealt with in accordance with the relevant provisions; suspected of committing a crime, transferred to the judicial organs to deal with:
(a) the urban residents of the basic medical insurance work management measures are not in place, irregularities occur from time to time, affecting the work of the urban residents of the basic medical insurance work normally;
(b) the urban residents of the basic medical insurance work; and p>(b) not strictly implement the basic medical insurance for urban residents in Hainan Province, the catalog of drugs, disease catalog and outpatient treatment of special disease catalog, diagnostic and treatment items, as well as the scope of services and facilities, decomposition of charges, indiscriminate charging, and do not strictly implement the national pricing policy;
(c) not strictly implement the provisions of the diagnosis and treatment, shifting the blame to the patient, arbitrarily referral, arbitrary relaxation of the indications for admission to the hospital, arbitrary examination;
(4) detaining patients who must be transferred to a higher-level designated medical institution for treatment due to their condition;
(5) not strictly implementing the relevant policies and regulations on basic medical insurance for urban residents, and making false invoices, resulting in the loss of the basic medical insurance fund for urban residents;
(6) not verifying or registering the consultations by medical staff, or providing convenience for those who seek medical treatment in an impostor's name;
(vii) violating the regulations on the use of medicines for urban residents' basic medical insurance by issuing large prescriptions or false prescriptions;
(viii) taking advantage of their work to prescribe medicines on a ride-along basis, or joining hands with patients in forgery, and stringing together self-financed medicines, health care products, and daily necessities for medicines within the basic catalog;
(ix) other violations of the regulations on the management of basic medical insurance for urban residents.
Article 34 If a participant commits any of the following acts, in addition to recovering the medical expenses already paid by the integrated fund, he shall be criticized and educated, depending on the seriousness of the case; if he is suspected of committing a crime, he shall be transferred to the judicial organs for handling:
(1) falsely issuing invoices and prescriptions for medical expenses, and fraudulently obtaining the basic medical insurance fund for urban residents;
(2) lending his Resident's Medical Insurance Certificate to
(iii) altering medical expense invoices, medical records, prescriptions, inspection reports, or illegal inspections, or authorizing medical personnel to make false statements;
(iv) illegally reselling medicines prescribed by a designated medical institution;
(v) violating the regulations on the administration of basic medical insurance for urban residents.
Chapter VIII Supplementary Provisions
Article 35: The basic medical insurance financing standards for urban residents in the regional co-ordination areas and the standards for payment of benefits may be adjusted by the provincial personnel and labor security departments in conjunction with the provincial financial departments in accordance with the level of economic and social development and the actual operation of the fund.
Article 36 of these measures by the provincial personnel and labor security departments responsible for the interpretation.
Article 37 of these measures shall be implemented from the date of publication.