Provisional Provisions on Basic Medical Insurance for Urban Workers in Nanjing
Chapter 1 General Provisions
Article 1: In order to accelerate the establishment of a basic medical insurance system for urban workers and to guarantee basic medical care for them, according to the "Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Workers" (Guofa [1998] No. 44), the "Opinions on the Implementation of the Reform of the Medical Insurance System for Urban Workers in Jiangsu
The implementation of the reform of the medical insurance system for urban workers in Jiangsu Province (Su Zheng Fa [1999] No. 83), as well as the relevant laws
laws, rules and regulations, combined with the actual situation in the city, the formulation of these provisions.
The second establishment of the basic medical insurance system for urban workers shall be guided by the following principles:
(1) the level of basic medical insurance should be compatible with the level of socio-economic development of the city;
(2) all urban employers and their employees are required to participate in the basic medical insurance, and the implementation of the territorial management;
(3) the basic medical insurance premiums shall be borne by both employers and employees;
(4) the basic medical insurance premiums shall be borne by both employers and employees. (c) Basic medical insurance premiums are borne by both the employer and the employee;
(d) The basic medical insurance fund is a combination of social coordination and individual accounts;
(e) Rights and obligations are equal.
Chapter II: Scope and Objects of Implementation
Article 3: All employers in cities and towns within the administrative area of the city, including all types of domestic enterprises, Hong Kong, Macao, Taiwan and foreign-invested enterprises
(except for foreign nationals and personnel stationed in Ningbo from Hong Kong, Macao and Taiwan), organs, institutions, social organizations, private
non-enterprise units and their employees must participate in basic medical insurance in accordance with the present provisions. basic medical insurance.
Ministerial, provincial and foreign units in Ningbo and their employees are required to participate in the city's basic medical insurance in accordance with the principle of territorial management
insurance. The basic medical insurance of the provincial organs and their employees in Ningbo, the implementation of a unified policy, the unit alone management.
The railroads, electric power, ocean shipping and other cross-region, more mobile enterprises and their employees should participate in the city's basic medical insurance in a relatively
centralized manner.
Owners of urban individual economic organizations and their employees, freelancers, township and village enterprises and their employees shall participate in the basic
basic medical insurance in a separate manner.
Chapter III: Collection and Payment of Basic Medical Insurance Premiums
Article 4: Basic medical insurance premiums shall be paid by both the employer and the employee***. The employer shall pay 8% of the total
wage of the employed staff; the employed staff shall pay 2% of their salary income, and the basic medical insurance premiums paid by individuals
will be withheld by the employer on behalf of the employee's salary on a monthly basis.
Total wages are calculated according to the statistical median prescribed by the State.
Article 5: If the average monthly salary of an employee is less than 60% of the average monthly salary of an employee of the previous year in the city, 60% of the salary shall be taken as the base; the portion that exceeds
300% or more shall not be taken as the base for the payment of basic medical insurance premiums.
Basic medical insurance premiums for laid-off workers of state-owned enterprises who enter the re-employment service centers (including unit contributions and individual employee
contributions) shall be paid by the re-employment service centers on the basis of 60% of the average monthly salary of the employees in the previous year in the city
.
Article 6: The basic medical insurance premiums shall be paid monthly by the employer to the Nanjing Medical Insurance Settlement Management Center (hereinafter referred to as the Medical
Insurance Center) or the local tax authorities.
Article 7 of the basic medical insurance premiums paid by the employer, the administrative organs and institutions fully funded by the treasury shall be resolved in accordance with the original
funding channels; fixed-rate or fixed-item management of the nationally owned medical institutions, in accordance with the relevant provisions of the State
execution; other institutions shall be charged from the business income or business revenue extracted from the health care fund; enterprises shall be charged from the
employee welfare fees. p>employee welfare expenses.
Article VIII of the basic medical insurance premiums owed by the bankrupt enterprise shall not be reduced or waived, and the city's average monthly salary of employees in the previous year
as the basis for the prescribed unit contribution rate for the retired (job) a one-time payment of the basic medical insurance premiums for a period of 10 years
. The required funds shall be charged to the liquidated property (including the proceeds from land use right concessions) in accordance with the law, and the competent authorities of the enterprise shall help resolve any shortfall
.
The basic medical insurance premiums of the merged enterprise shall be paid by the merged enterprise.
Article 9: For special hardship enterprises approved by authorized government departments, basic medical insurance premiums shall be paid at the rate of 6% of the total wages
of the in-service employees of the unit, and the full amount shall be credited to the integrated fund. Employees are entitled to medical insurance benefits paid by the integrated fund.
Article 10 of the financial and employer units to provide the necessary basic medical insurance start-up funds. Start-up funds are divided into two parts, the unified
chip fund part of the city's last year by the financial 5.36% of the average monthly salary of employees advanced for a month; personal account
account fund part of the employer in the employee's initial participation in a one-time transfer, transferred to the standard of in-service employees per
person 200 yuan, retired (job) 300 yuan per person.
Chapter IV: Coordinated Fund and Individual Accounts
Article 11: The basic medical insurance fund consists of two parts: the coordinated fund and individual accounts.
(1) the overall fund:
(1) the basic medical insurance premiums paid by the employer after deducting the remaining portion of the individual account;
(2) the late payment fees collected in accordance with the regulations;
(3) interest;
(4) financial subsidies;
(5) other income.
(2) Individual accounts:
(1) basic medical insurance premiums paid by individual employees;
(2) portion of the basic medical insurance premiums paid by the employing organization set aside;
(3) interest;
(4) other income.
Article 12: The basic medical insurance premiums paid by employers shall be transferred to individual accounts in the following proportions:
At the age of 35 and below, 1% of the fund of one's own contribution shall be transferred;
At the age of 35 and above to the age of 45, 1.4% of the base of one's own contribution shall be transferred;
At the age of 45 and above to the pre-retirement age, 1.7% of the base of one's own contribution shall be transferred;
The portion of basic medical insurance premiums paid by employers shall be allocated;
Retired (occupational) personnel at 5.4% of their average monthly pension for the previous year.
Article 13 of the integrated fund and individual accounts according to their respective scope of payment for management, accounting, shall not crowd each other
occupy.
Article 14 of the integrated fund to establish the starting standard and maximum payment limit.
The starting standard is determined according to the grade of medical institutions, and is tentatively set at 1,200 yuan for third-level medical institutions, 800 yuan for second-level
level medical institutions, and 500 yuan for first-level medical institutions (including those below the first level). If an employee is hospitalized several times within a self
renewal year, the starting payment standard will be reduced by 30% each time, but the minimum shall not be less than 300 yuan. Outpatient
The starting payment standard for specific items within a natural year is 1,000 yuan.
The maximum payment limit for medical expenses paid by the integrated fund at one time or cumulatively within a natural year is four times the average social wage of workers in the city in the previous year
.
Article 15 of the integrated fund is mainly used for hospitalization and outpatient specific program costs in line with the basic medical insurance.
Outpatient specific items are temporarily included in the malignant tumor radiotherapy, chemotherapy, uremia dialysis, anti-rejection treatment after kidney transplantation
The three disease items (outpatient specific item management methods are formulated separately).
Article 16: Individual accounts are mainly used for the outpatient expenses of the basic medical insurance, the expenses of purchasing medicines at designated retail pharmacies and the portion of the costs of hospitalization and outpatient specific items for the employees that are borne by individuals, and if the individual accounts are insufficient, the individuals will be paid by the individuals
.
Article 17: The principal and interest of individual accounts are owned by individuals and can be carried forward, transferred and inherited (individual account management
measures to be formulated separately).
Article 18 of the basic medical insurance fund bank interest accruing methods: part of the current year raised, according to the demand deposit interest rate
Interest; the fund carried over from the previous year, principal and interest, according to the three-month period of whole deposit bank deposit interest rate; deposited in the financial account of the social
Social security of the sedimentary funds, according to the three-year period of zero deposit bank deposit interest rate. The interest is merged
into the basic medical insurance fund.
Chapter 5: Basic Medical Insurance Benefits
Article 19: Medical expenses incurred by employees for hospitalization and specific outpatient programs in accordance with the provisions of the basic medical insurance shall be paid by the co-ordinated fund
from their individual accounts or out of their own pockets for expenses up to and including the starting point of the co-ordinated fund, and above the starting point and up to the maximum payment limit shall be paid by both the co-ordinated fund and the individual* in accordance with the principle of "calculation in segments and payment on a cumulative basis. According to the principle of "segmented calculation, cumulative payment", the integrated fund and individual **** with
sharing. The specific sharing ratios are as follows:
Hospitalization medical cost section coordinated fund and individual sharing ratio
The first level of medical machine second level of medical machine third level of medical machine
Coordinated individual coordinated individual coordinated individual coordinated individual
Starting standard to 10,000 yuan 90%10%88%12%86%14%
10001 yuan to 20,000 yuan 92%8%90%10%10%86%14%
10001 yuan to 20000 yuan RMB92%8%90%10%88%12%
More than RMB20,001 96%4%94%6%92%8%
Personal sharing ratio of outpatient medical expenses for specific items is based on the standards of different levels of medical institutions chosen
.
Retired and retired individuals share 70% and 80% of the active employees respectively. Before the founding of the Republic of China to participate in the revolutionary work
retired old workers individual share of 50% of the active employees.
Article 20: If an employee is hospitalized and the cost of treatment items belongs to part of the cost paid by the basic medical insurance, the individual shall first
pay 20% out-of-pocket, and the remainder shall be paid in accordance with the relevant provisions of the basic medical insurance.
If the medical expenses incurred by an employee for the use of "Class A List" drugs are partially paid by basic medical insurance, the individual shall first pay 20% of the expenses out of his own pocket, and the rest shall be paid in accordance with the relevant provisions of the basic medical insurance.
Medical expenses incurred by employees using drugs from the "Class A List" shall be paid in accordance with the provisions of the basic medical insurance.
Medical expenses incurred for the use of "Class B Catalog" medicines shall be paid by the employee as a percentage of his/her own expenses, and the remaining portion shall be paid in accordance with the provisions of the basic medical insurance (the specific percentage of individual out-of-pocket expenses shall be separately formulated).
Article 21 of the employer and the employee interrupted or did not pay the full amount of contributions, the medical insurance center from the next month to transfer
funds to the individual account, and suspend the employee to enjoy the basic medical insurance benefits, the period of arrears in contributions will not be counted as years of contributions. If the employer
unit and the employee make up the arrears and late payment within three months, the medical expenses incurred during the period of arrears will be paid in accordance with the regulations
. If the arrears are more than three months, the employer and the employee can restore the eligibility of the employee for treatment after making up the contributions in accordance with the regulations,
and the individual account will be credited, and the contribution period will be calculated on a continuous basis, but the medical expenses incurred during the period of arrears will not be paid by the coordinating fund.
Article 22 of the employer to participate in the insurance has retired (job) before the personnel do not pay the basic medical insurance premiums. Retirement after participation in the
Personnel in the service of the basic medical insurance premiums paid during the period (hereinafter referred to as the number of years of contributions) must be:
Men for 30 years, women for 25 years. If the number of years is not enough, when applying for retirement procedures, the employer or the employee
individually, based on the city's average monthly salary of employees in the previous year, the unit and the individual combined rate to make up for the difference in
years of basic medical insurance premiums, can enjoy the basic medical insurance treatment for retired persons. The years of continuous service or working experience in accordance with the state regulations before the employee's participation in the insurance can be regarded as the years of contribution.
Article 23 of the employer to participate in the insurance before the employee due to illness, non-work-related disability, total loss of working capacity and other state regulations
processing for early retirement (except for the National Development [1978] No. 104 document stipulates that engaged in special types of early retirement
except for the personnel), in the employer according to the city's last year, 8% of the average monthly wage of employees, for its one-time
Payment of basic medical insurance premiums to the legal retirement age, before enjoying the basic medical
therapeutic insurance treatment for retired (working) personnel.
Article 24 Medical expenses incurred in the following cases shall not be paid:
(1) work-related injuries (including occupational diseases), childbirth and its complications;
(2) injuries caused by violation of laws and discipline;
(3) traffic accidents;
(4) suicide, self-inflicted injuries (except for the mentally ill);
(5) during going abroad or leaving the country
(6) Medical malpractice;
(7) Others are not eligible for payment by basic medical insurance.
Chapter 6: Medical Aid for Major Diseases and Supplementary Medical Insurance
Article 25: All employees participating in the basic medical insurance for urban workers in the city shall participate in the medical aid for major diseases, and the fund for medical aid for major diseases
in principle, the fund for medical aid shall be paid by the employees (including retired and retired personnel) at the rate of RMB 5 yuan per person per month, and it shall be used for solving the problems of basic medical insurance. The main purpose of the fund is to cover medical expenses above the maximum payment limit of the unified fund up to a maximum of 150,000 yuan (the measures for medical assistance for major illnesses are to be formulated separately).
Article 26: On the basis of their participation in basic medical insurance, employers who are in a position to do so may establish enterprise supplementary medical insurance
. The part of the enterprise supplementary medical insurance premiums within 4% of the total wages shall be expended from the employee's welfare expenses
, and the part of the welfare expenses insufficient to be expended shall be included in the costs after approval by the municipal finance and taxation departments.
Chapter VII of the basic medical insurance fee settlement
Article 28 in accordance with the principle of balance of payments of the basic medical insurance fund, according to the different levels and types of designated medical institutions
category, in the settlement of the fee to implement the "total control" as the main, supplemented by the service unit, services, or a variety of ways to
combined with the assessment approach. Specific settlement by the municipal labor security administrative department in conjunction with the municipal finance, health
health departments to develop.
Article 29 employees in the designated medical institutions outpatient clinic, medicine or with the dispensing prescription in the designated retail pharmacy medicine, the use of individual
personal account to pay for the medical costs of the "medical insurance card" account, medical insurance center according to the individual account actually issued
generated medical costs and designated medical institutions or designated retail pharmacy settlement.
Article 30: The medical expenses incurred by an employee hospitalized in a designated medical institution shall be settled between the employee and the designated medical institution if the expenses are paid by the individual, and between the medical insurance center and the designated medical institution if the expenses are paid by the integrated fund.
Article 31: First-aid and rescue hospitalization medical expenses incurred by an employee during a business trip or leave of absence on official business shall be settled between the employee's home institution and the medical insurance center in accordance with the regulations.
Article 32: Retired employees who are resettled in other places or insured employees who have been stationed abroad for more than six months for work and study must
attend medical treatment at the local designated medical institutions they have declared. Their inpatient and outpatient specific item medical expenses shall be summarized by the unit they are
in and settled with the medical insurance center in accordance with the regulations.
Chapter VIII Management of Medical Services
Article 33 of the basic medical insurance implements the management of designated medical institutions and designated retail pharmacies. Medical institutions and retail pharmacies established with the approval of the administrative departments of health and drug supervision and management
can apply to the administrative department of labor security to
run the medical service business of basic medical insurance. After examination and obtaining the qualification of fixed-point, the labor security administrative department
issues the certificate of fixed-point qualification.
Article 34: The medical insurance centers shall reasonably determine the designated medical institutions and designated retail pharmacies in accordance with the choice intention of the employees and the distribution of health resources, and shall sign agreements with the designated medical institutions and designated retail pharmacies respectively, specifying
the respective responsibilities, rights and obligations, and shall be responsible for supervising and checking the fulfillment of the agreements.
Article 35 Employees may be outpatient or hospitalized at three or more fixed-point comprehensive medical institutions of different levels selected by them. Traditional Chinese medical institutions and specialized medical institutions that have been granted
designated medical institution status may serve as designated medical institutions for all employees
structures.
Employees with external prescriptions can purchase medicines at designated retail pharmacies in the city.
Article 36 of the fixed-point medical institutions and fixed-point retail pharmacies to develop and improve the necessary management system, to provide low-priced
cheap, high-quality services. And accept the supervision and inspection of the relevant departments.
Chapter IX Basic Medical Insurance Fund Management and Supervision
Article 37 of the basic medical insurance fund to implement the financial account management, earmarked for special purposes, any unit or individual shall not be squeezed
misappropriation. The basic medical insurance fund and its interest are exempt from taxes and fees.
Medicare centers of business expenses, the financial budget, shall not be extracted from the medical insurance fund and listed
expenditure.
Article 38 The administrative department of labor security and the financial department shall strengthen the management and supervision of the basic medical insurance fund. The auditing
accounting departments shall regularly audit the income, expenditure and management of the fund.
Article 39 establishes the Basic Medical Insurance Fund Supervisory Committee with the participation of representatives of the relevant government departments, representatives of employers, representatives of medical institutions, representatives of labor unions and relevant
experts to strengthen the social
supervision of the Basic Medical Insurance Fund.
Chapter X Medical Treatment of the Personnel Involved
Article 41 The medical treatment of retired personnel and the Old Red Army shall remain unchanged, and medical expenses shall be resolved in accordance with the original channels of funding, and the people's government at the same level shall assist in the resolution of any difficulties in payment. (Specific administrative measures will be formulated separately)
Article 42: The medical treatment of soldiers with revolutionary disabilities of grade B or above (including grade B) shall remain unchanged; medical expenses shall be settled in accordance with the original funding channels; and the people's government at the same level shall help to settle any shortfall in the payment of medical expenses. (Specific
management methods are to be formulated separately)
Article 43: The medical expenses of immediate family members supported by employees shall remain in accordance with the original methods, with the funds to be resolved through the original channels.
Article 44: The medical expenses of students enrolled in ordinary institutions of higher education who are now entitled to publicly-funded medical treatment shall remain in accordance with the original measures, with the funds
resolved through the original channels.
Article 45: Medical expenses incurred by the unemployed during the period of receiving unemployment insurance benefits shall be implemented in accordance with the provisions of Su Zheng Fa [1999] No. 107
.
Chapter XI Rewards and Penalties
Article 46 gives appropriate commendations or rewards to designated medical institutions
structures, designated retail pharmacies and their staffs that provide excellent services, are well managed, and have achieved remarkable results in controlling medical expenses, to the satisfaction of the employees.
Article 47: If an employer fails to apply for social insurance registration and change or deregistration procedures in accordance with the regulations, and fails to declare the basic medical insurance contribution wage base in accordance with the regulations, the municipal labor security administrative department shall impose penalties in accordance with the "Interim Regulations on the Collection and Payment of Social Insurance
Charges".
Article 48 If an employee commits any of the following acts, resulting in a loss to the basic medical insurance fund, the medical insurance center shall recover
the medical expenses incurred in violation of the regulations in full, and the administrative department of labor security shall impose a fine of more than 1,000 yuan and less
than 5,000 yuan on the person directly responsible, and if the act constitutes a crime, the employee shall be held criminally liable according to law:
1. Medical Insurance Card to a non-employee;
2. Falsification, alteration of prescriptions, cost documents and other vouchers;
3. False declaration or fraudulent claim of medical expenses;
4. Other acts in violation of the provisions of the basic medical insurance administration.
Article 49: If a designated medical institution and its staff commit any of the following acts, the medical insurance center shall recover the medical expenses paid in violation of the regulations
, and the administrative department of labor security shall impose a fine of 5,000 yuan or more than 20,000
yuan on the designated medical institution, and a fine of 1,000 yuan or more than 5,000 yuan on the person directly responsible; If the situation is serious
, the qualification of designated medical institutions shall be canceled; if the situation constitutes a crime, criminal responsibility shall be investigated according to law:
1. Failure to carefully check the Medical Insurance Card when diagnosing and treating and keeping accounts, and inclusion of the medical expenses of non-participating objects and the costs of
non-basic medical insurance items in the scope of payment of basic medical insurance;
2. Failure to carry out the stipulated charges for medical services and drug prices, and arbitrary increase in charges standards and drug prices, and arbitrarily increase charges;
3. hospitalizing patients under a name or breaking down the number of hospitalizations;
4. other acts in violation of the provisions of basic medical insurance management.
Article 50 of the designated retail pharmacies and their staff have one of the following behaviors, the medical insurance center to recover the violation of the provisions of the
payment of medical expenses, and by the labor security administrative department of the designated retail pharmacies with a fine of more than 5,000 yuan to 20,000 yuan
following; on the direct responsibility of the person to be sentenced to more than 1,000 yuan to 5,000 yuan following the fine; If the situation is serious
, its qualification as a designated retail pharmacy shall be canceled; if it constitutes a crime, it shall be held criminally liable according to law:
1. Not dispensing medicines strictly in accordance with the prescribed dosage;
2. Confusing self-financed medicines with medicines reimbursed by the basic medical insurance for billing purposes;
3. Exchanging prescribed medicines for health care products, daily necessities and so on, which will be issued to patients;
4. Not implementing the relevant regulations on the price of medicines, which will cause the basic medical insurance to be reimbursed. Enforce the relevant regulations on drug prices, resulting in losses to the basic medical insurance fund;
5. Provide patients with counterfeit, shoddy or expired medicines;
6. Other behaviors in violation of the regulations on the management of basic medical insurance.
Article 51 The relevant government administrative departments, medical insurance centers and their staff shall be held administratively or criminally liable by the relevant ministries
depending on the seriousness of the case for one of the following acts:
1. Violating the regulations on the management of the basic medical insurance fund and causing losses to the fund;
2. Embezzlement or misappropriation of the basic medical insurance fund;
3. Other behaviors that violate the regulations on the management of basic medical insurance.
Article 52 If the party concerned is not satisfied with the decision on punishment, it may, within 60 days from the date of receipt of the decision on punishment, apply for administrative reconsideration to the next higher level of administrative
departments or the people's government at the same level. If the administrative reconsideration decision is not accepted, an administrative lawsuit may be filed with the People's Court within 15 days from the date of receipt of the
administrative reconsideration decision; for those who do not apply for reconsideration after the expiration of the time limit, do not file a lawsuit, and do not issue a penalty decision, the administrative organ that made the penalty decision may apply to the
people's court for compulsory execution.
Chapter XII Supplementary Provisions
Article 53 Class A infectious diseases, large-scale outbreaks, epidemics of infectious diseases, or due to natural disasters and other irresistible factors
cause of emergency, critical and serious patients of the medical expenses incurred in the treatment of people's governments at the same level to coordinate the solution.
Article 54: In the event of a dispute over medical
insurance between the insured unit, the employee, the designated medical institution, the designated retail pharmacy and the medical insurance center, the dispute shall be resolved by the municipality directly under the control of the two disputing parties; in the event of failure to reach a settlement through negotiation, the dispute may be referred to the administrative department of the Ministry of Labor and Social Security for adjudication.
Article 55 of the provisions of the contribution rate, the individual account accounting ratio, the integrated fund starting standard, the maximum payment limit and
individual out-of-pocket ratio of the need to be adjusted, the administrative department of labor security and reported to the municipal people's government for approval, and then announced to the
society.
Article 56 The administrative department of labor security is responsible for the organization and implementation of urban workers' medical insurance in the city. Finance, health
Health, prices, audit, taxation, drug supervision and management departments shall, in accordance with their respective responsibilities, cooperate with the labor
Mobile security administrative departments to do a good job in the formulation of relevant supporting documents and other medical insurance-related work.
Article 57 implements integrated management at the municipal and county levels. Jiangning, Jiangpu, Liuhe, Lishui, Gaochun five counties in accordance with the provisions of this provisional
provisions, combined with the local actuality of the implementation of the measures, reported to the Municipal People's Government for approval and implementation of the organization.
Article 58 of these provisions shall be interpreted by the municipal labor security administrative department.
Article 59 of these provisions shall come into force on the date of publication.
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