Chapter I General Principles
Article 1 In order to establish and improve the multi-level medical security system and ensure the basic medical needs of urban residents, these measures are formulated in accordance with the relevant provisions of the Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No.20) and the Implementation Opinions of Shanxi Provincial People's Government on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Jin [2007] No.37), combined with the actual situation of our city.
Article 2 From 2008, it will take three years to gradually establish a basic medical insurance system covering all urban residents in the city.
Article 3 The establishment of the basic medical insurance system for urban residents shall follow the following principles:
Adhere to the principle of combining family contributions with government subsidies;
(two) adhere to the principle of voluntary participation by the masses and government guidance;
(three) adhere to the principle of revenue and expenditure, balance of payments;
(four) adhere to the principle of equality of rights and obligations;
(five) adhere to the principle of low rates, wide coverage, serious illness as a whole.
Article 4 The basic medical insurance for urban residents in our city shall be co-ordinated at the municipal level, handled at the city and county levels, and managed in a unified way.
Article 5 The municipal labor and social security department is the administrative department in charge of the basic medical insurance for urban residents, and is responsible for the organization, implementation, supervision and management of the basic medical insurance for urban residents in this Municipality. The municipal medical insurance agency is responsible for the daily handling of the basic medical insurance for urban residents. The labor and social security departments of counties, cities and districts are responsible for the identification of urban residents within their respective jurisdictions, insurance registration, and insurance premium collection.
Finance, health, civil affairs, education, food and drug supervision, price and other departments at all levels shall, in accordance with their respective responsibilities and the relevant provisions of these measures, do a good job in the basic medical insurance for urban residents.
Sixth basic medical insurance institutions for urban residents are located in streets, communities and schools (kindergartens). All streets, communities and schools (kindergartens) should set up special personnel to undertake agency business.
Chapter II Insurance Scope and Object
Article 7 The insured persons referred to in these Measures are students, children and other non-employed urban residents of primary and secondary schools (including vocational high schools, technical secondary schools and technical schools) who have urban hukou in this Municipality and are not included in the basic medical insurance system for urban workers in this Municipality.
Eighth people who meet the conditions of participating in the basic medical insurance for urban residents shall provide valid documents such as household registration book, resident identity card and school registration certificate to go through the insurance formalities; People who enjoy urban subsistence allowances, severely disabled people who have lost their ability to work, elderly people over 60 years old from low-income families and other difficult urban residents shall provide valid certificates and certification materials issued by relevant departments when handling insurance registration.
Chapter III Payment Standards and Financial Subsidies
Ninth basic medical insurance for urban residents personal payment and financial subsidy standards are as follows:
(1) Students in school and non-school urban residents under the age of 18 are entitled to 100 yuan per person per year, in which: individuals pay 20 yuan, the central government subsidizes 40 yuan, the provincial financial subsidizes 20 yuan, and the city and county financial subsidizes 20 yuan (the municipal government subsidizes Pingshun County, Qinxian County and Licheng County by 50%, the urban area by 80%, and other counties and cities are fully subsidized by finance).
(2) The minimum living allowance or severely disabled students and children are 100 yuan per person per year, of which: 45 yuan is subsidized by the central government (including 5 yuan, which is subsidized by families), 25 yuan is subsidized by the provincial government, and 30 yuan is subsidized by cities and counties, and individuals do not pay fees.
(3) 260 yuan per person per year for other non-employed urban residents, including: individual contributions 120 yuan, central financial subsidies for 40 yuan, provincial financial subsidies for 20 yuan, and municipal and county financial subsidies for 80 yuan.
(4) Non-student children's minimum living allowance target is 260 yuan per person per year, in which: individual pays 40 yuan, central financial subsidy 70 yuan (including subsidized family payment 30 yuan), provincial financial subsidy 50 yuan, and city and county financial subsidy 100 yuan.
(5) 260 yuan per person per year, such as severely disabled people who have lost their ability to work, and elderly people over 60 years old from low-income families. Among them, the central government subsidizes 70 yuan (including 30 yuan), the provincial government subsidizes 50 yuan, and the city and county government subsidizes 140 yuan. Individuals do not pay fees.
Article 10 For those who enjoy financial subsidies, their subsidies cannot be repeated, and the specific subsidy standards shall be based on the principle of high or low.
Eleventh people who have participated in the basic medical insurance for urban workers can use the balance of their personal accounts to pay for their family members. The specific measures shall be determined separately. Conditional employers can give appropriate subsidies to employees' families for insurance.
Article 12 The insurance year of the basic medical insurance for urban residents is from July 6, 0 to June 30 of the following year.
The insured persons of basic medical insurance for urban residents shall pay the basic medical insurance premium for urban residents in one lump sum from May to June 30th every year, and enjoy the basic medical insurance benefits for urban residents from July to June 30th the following year. If the payment is made continuously in accordance with the regulations in the next year, you will enjoy the treatment continuously from July 1 day of the next year.
After the implementation of these measures, urban residents who concentrate on insurance registration and payment within the specified time shall enjoy the basic medical insurance benefits for urban residents from the second month of insurance payment; If the insured person exceeds the prescribed centralized payment time, he can enjoy the basic medical insurance benefits for urban residents after 6 months from the month of payment.
Thirteenth basic medical insurance for urban residents only to establish a unified fund, not to establish a personal account. The basic medical insurance premium for urban residents will not be refunded once paid.
Chapter IV Medical Treatment
Fourteenth urban residents' basic medical insurance fund (hereinafter referred to as the overall fund) should be used in accordance with the basic medical insurance drug list, diagnosis and treatment project list and medical service facilities in Shanxi Province. It is also used to pay the hospitalization expenses of the insured residents of the basic medical insurance for urban residents (hereinafter referred to as the insured residents) and the eligible outpatient chronic disease expenses (the measures for the management of chronic diseases in outpatient clinics shall be formulated separately) and the emergency outpatient expenses for accidental injuries of students in schools (the measures for the management of accidental injuries of students in schools shall be formulated separately).
Article 15 The insured residents shall meet the prescribed hospitalization and outpatient medical expenses for chronic diseases and the emergency outpatient expenses for accidental injuries of students at school, and the overall fund shall be controlled by Qifubiaozhun and the maximum payment limit. The medical expenses below the Qifubiaozhun and above the maximum payment limit for chronic diseases in inpatient and outpatient departments shall be borne by the insured residents, and shall not be paid by the overall fund.
Article 16 When insured residents are hospitalized, the minimum threshold for pooling funds is: tertiary hospital 400 yuan, secondary hospital 300 yuan, primary hospital 200 yuan, community health service center 100 yuan. Insured residents hospitalized many times in an insurance year, the first and second hospitalization Qifubiaozhun shall be borne by the individual, and the third and above hospitalization Qifubiaozhun shall be paid by the overall fund. In an insurance year, the cumulative maximum payment limit of the overall fund is 20 thousand yuan.
For hospitalization expenses above Qifubiaozhun, 50% of the overall fund is paid by tertiary hospitals, 55% by secondary hospitals, 60% by primary hospitals and 70% by community health service centers. For urban residents who have paid for two consecutive years, the treatment payment can be increased by 1% every year from the third year, with a maximum increase of 5%. Emergency and rescue patients can be hospitalized in nearby non-designated medical institutions. After the condition is stable, it must be transferred to a designated medical institution for hospitalization. In line with the scope of the overall fund to pay emergency and rescue expenses, with relevant information to pay 50% to the medical insurance agency.
Insured residents who need to go to other places for medical treatment due to illness must be transferred to hospitals by designated medical institutions, and can be transferred to hospitals only after being approved by medical insurance agencies. In the overall fund payment range of hospitalization expenses, the overall fund payment ratio is reduced by 5% according to the above standards.
On the basis of participating in the basic medical insurance, urban residents can also voluntarily participate in supplementary medical insurance, and the specific measures shall be formulated separately.
Seventeenth students who participate in the basic medical insurance for urban residents have accidental injuries. After the treatment, 60% of the emergency outpatient expenses exceed 100 yuan, and the maximum payment limit of the overall fund is 5000 yuan per year.
Eighteenth insured residents in any of the following circumstances, the overall fund will not be paid:
(a) in the city's non designated medical institutions (except emergency);
(2) Transferring to an overseas medical institution for treatment without approval;
(three) does not meet the basic medical insurance drug list, diagnosis and treatment project list, medical service facilities in Shanxi Province;
(four) to change the prescription without permission or to make a prescription;
(5) being treated abroad or in Hongkong, Macao Special Administrative Region or Taiwan Province Province;
(six) treatment caused by illegal crimes, fighting, alcoholism, self-mutilation, suicide, drug abuse, traffic accidents, medical accidents and other injuries;
(seven) in accordance with the provisions of the state and the province should be paid by individuals.
Chapter V Management of Medical Services
Nineteenth basic medical insurance for urban residents is managed by designated medical institutions. Designated medical institutions shall be determined by the labor and social security departments of cities and counties (cities, districts) in accordance with the principles of market competition, openness, fairness and convenience for insured residents. City, county (city, district) medical insurance agencies shall sign a medical service agreement with them to clarify their respective rights and obligations.
Twentieth designated medical institutions shall establish and improve the internal management system of basic medical insurance for urban residents, and strictly implement the basic medical insurance policies and medical service agreements for urban residents. Equipped with full-time (part-time) management personnel to do a good job in the internal management of the basic medical insurance for urban residents.
Twenty-first medical insurance agencies and designated medical institutions medical expenses specific settlement measures shall be formulated by the municipal labor and social security department.
Twenty-second set up by the relevant government departments, insured residents, social organizations, medical service institutions and other representatives to participate in the social supervision organization of medical insurance, strengthen the supervision of the management, service and operation of the basic medical insurance for urban residents.
Twenty-third the development of designated medical institutions supervision and assessment system. Labor and social security departments shall organize medical insurance agencies to assess designated medical institutions, and reward or punish them according to the assessment results. The assessment and reward measures shall be formulated separately by the municipal labor and social security department.
Twenty-fourth establish a reward system for reporting. The municipal labor and social security department shall set up a telephone number and a report box, and shall promptly investigate and verify the complaints and cases that violate the provisions of the basic medical insurance for urban residents and handle them in accordance with relevant regulations. Chapter VI Fund Management.
Twenty-fifth basic medical insurance fund for urban residents consists of the following items:
(a) the basic medical insurance for urban residents paid by the insured residents;
(2) government subsidies at all levels;
(3) funds supported and funded by all sectors of society;
(four) the interest income of the basic medical insurance fund for urban residents;
(five) other income as prescribed by laws and regulations.
Article 26 The basic medical insurance fund for urban residents shall be included in the financial special account, and shall be managed by two lines of revenue and expenditure, with special funds for special purposes, separate accounts and independent accounting, and shall not be misappropriated or misappropriated.
Twenty-seventh medical insurance agencies should establish and improve the internal management system, strengthen the management of fund revenue and expenditure, and accept the supervision and inspection of audit, finance, labor and social security departments.
Twenty-eighth medical insurance agencies need funds from the financial budget. In order to ensure the development of basic medical insurance for urban residents, the municipal finance arranges special funds for basic medical insurance for urban residents according to the standard of 4 yuan per person directly under the municipal government, and the county (city, district) finance arranges special funds for basic medical insurance for urban residents according to the standard of 5 yuan per person. May not be withdrawn from the fund.
Chapter VII Supplementary Provisions
Twenty-ninth matters not covered in these Measures shall be implemented with reference to the relevant provisions of the basic medical insurance for urban workers in Changzhi City.
Thirtieth these Measures shall come into force as of June 6, 2008+0.
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