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Basic medical insurance is a social insurance system established to compensate workers for economic losses caused by disease risks. The medical insurance fund is established through the contributions of employers and individuals. After the insured person has medical expenses, the medical insurance agency will give certain economic compensation to avoid or reduce the economic risks caused by illness and treatment.
199865438+in February, the State Council issued the Decision on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44), requiring the establishment of a multi-level medical security system with the basic medical insurance system for urban employees as the core throughout the country. The "Decision" pointed out that the main task of the reform of the medical insurance system is to establish a basic medical insurance system for urban workers, that is, to adapt to the socialist market economic system and to establish a social medical insurance system to ensure the basic medical needs of employees according to the affordability of finance, enterprises and individuals. The principles of establishing the basic medical insurance system for urban workers are: the level of basic medical insurance should be adapted to the development level of productive forces in the primary stage of socialism; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The cost of basic medical insurance shall be borne by both the employer and the employee; The basic medical insurance fund combines social pooling with individual accounts.
95. What is the framework of the basic medical insurance system for urban workers?
According to the requirements of the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44), the framework of the basic medical insurance system for urban employees includes six parts:
One is to establish a reasonable * * * burden and payment mechanism.
The basic medical insurance premium is paid jointly by employers and individuals, which embodies the compulsory characteristics of national social insurance and the unity of rights and obligations. Medical insurance premiums are paid jointly by units and individuals, which can not only expand the sources of medical insurance funds, but more importantly, clarify the responsibilities of units and employees and enhance personal awareness of self-protection. In this reform, China has stipulated the control standards of the employer's contribution rate and individual contribution rate: the employer's contribution rate is controlled at about 6% of the total wages of employees, and the specific proportion is determined by local governments. The contribution rate of employees is generally 2% of their wage income.
The second is to establish overall funds and personal accounts.
The basic medical insurance fund consists of the overall fund used by the society as a whole and the personal account fund dedicated to individuals. All individual contributions are included in individual accounts, about 30% of unit contributions are included in individual accounts, and the rest are set up as a whole fund. Personal account funds are dedicated to my medical expenses, which can be carried forward and inherited, and the principal and interest of personal accounts are owned by individuals.
The third is to establish a single unified account and a clear payment mechanism.
Co-ordinate funds and individual accounts to determine their respective payment ranges. The overall fund mainly pays large and inpatient medical expenses, and the personal account mainly pays small and outpatient medical expenses. In accordance with the principle of "balance of payments", the overall fund shall determine the minimum payment standard and the maximum payment limit according to the actual situation in various places and the affordability of the fund.
The fourth is to establish an effective medical service management mechanism.
The payment scope of basic medical insurance is limited to the medical expenses within the prescribed basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards; Fixed-point management of medical institutions and pharmacies providing basic medical insurance services; Social insurance agencies and basic medical insurance service institutions (designated medical institutions, designated retail pharmacies) shall settle the expenses in accordance with the settlement method agreed in the agreement.
The fifth is to establish a unified socialized management system.
The basic medical insurance is handled by a certain level of social institutions. In principle, the administrative regions at or above the prefecture level (including prefectures, cities and leagues) shall be the overall planning units, and counties may also be the overall planning units. Social insurance agencies in the overall planning area are responsible for the unified collection, use and management of funds, and ensure the full collection, rational use and timely payment of funds.
Sixth, establish and improve an effective supervision mechanism.
The basic medical insurance fund to implement financial accounts management; Social insurance agencies should establish and improve rules and regulations; Overall planning areas should set up social supervision organizations for basic medical insurance and strengthen social supervision. It is necessary to further establish and improve the fund budget and final accounts system, financial accounting system and internal audit system of social insurance agencies.
These contents have basically determined the general framework of the new basic medical insurance system for urban workers, laid the foundation for unifying the national system in the future, and made it convenient for all localities to follow when formulating reform plans, leaving room for local governments to make specific provisions according to local conditions.
96. Which units and employees must participate in the basic medical insurance?
According to the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Workers (Guo Fa [1998] No.44), all employers in cities and towns, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.). ), organs, institutions, social organizations, private non-enterprise units and their employees must participate in the basic medical insurance. That is to say, the units and employees who must participate in the basic medical insurance for urban workers include both government institutions and various urban enterprises, both state-owned and non-state-owned economic units, both enterprises with good benefits and enterprises with difficulties. This is one of the most extensive types of insurance in China's social insurance system at present.
However, whether township enterprises and their employees, owners of urban individual economic organizations and their employees participate in basic medical insurance shall be determined by the people's governments of provinces, autonomous regions and municipalities directly under the Central Government. This is mainly due to the management of this group of people and the particularity of medical insurance itself. If the basic medical insurance is compulsory, the management ability can't keep up, which may lead to uncontrollable medical expenses and increase the risk of fund overrun.
97. How do individuals pay the basic medical insurance premium?
First of all, each overall planning area should determine a personal basic medical insurance contribution rate suitable for the burden level of local employees, which is generally 2% of wage income. Secondly, individuals pay the basic medical insurance premium according to the local individual contribution rate based on wage income. The personal payment base should be based on the statistical caliber of wage income stipulated by the National Bureau of Statistics, that is, all wage income, including all kinds of bonuses, labor income and income in kind, multiplied by the prescribed personal payment rate, is the basic medical insurance premium that I should pay. Third, individual contributions generally do not need to be paid by individuals to social insurance agencies, and are withheld and remitted by the unit from wages.
98. How to establish the basic medical insurance fund and personal account?
According to the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Workers (Guo Fa [1998] No.44), the funds injected into individual accounts come from individual contributions and unit contributions: all individual contributions are credited to individual accounts, and the unit contributions are credited to individual accounts. About 30% of the general unit payment is included in the personal account. However, due to the great difference in the level of medical consumption expenditure of employees of different ages, the age factor should be taken into account when determining the proportion of unit contributions to each employee's account in the overall planning area, and the different proportions of different age grades should be determined. Determine the specific proportion of unit contributions into individual accounts, which shall be determined by the overall planning area according to the payment scope of individual accounts, the age of employees and other factors.
The funds injected into the overall fund mainly come from unit contributions. After the unit payment is transferred to the personal account, the remaining part is the funds of the overall fund.
99. How to deal with the personal accounts of employees participating in basic medical insurance after their death?
The principal and interest of the employee's personal medical insurance account belong to the employee and can be carried forward and inherited. Therefore, after the death of employees participating in the basic medical insurance, there is still a balance in their personal medical accounts, which can be used as inheritance and inherited by their relatives in accordance with the provisions of the inheritance law. At the same time, his personal medical account number and employee medical social insurance manual were withdrawn and cancelled by medical social insurance institutions.
100. How can the insured employees enjoy the basic medical insurance benefits as required?
First of all, the insured person should seek medical treatment and purchase medicines at the designated medical institutions of basic medical insurance, or purchase medicines at designated retail pharmacies according to prescriptions. Medical expenses incurred in seeking medical treatment in non-designated medical institutions and purchasing medicines in non-designated pharmacies shall not be paid by the basic medical insurance fund except in accordance with the provisions on emergency and referral.
Secondly, the medical expenses incurred must conform to the basic medical insurance drug list, diagnosis and treatment items, medical service facilities scope standards and payment standards before they can be paid by the basic medical insurance fund according to regulations. Beyond the part, the basic medical insurance fund will not be paid according to the regulations.
Third, medical expenses that meet the scope of payment by the basic medical insurance fund should be distinguished between those paid by the overall fund and those paid by individual accounts. If the medical expenses that fall within the scope of the overall fund payment exceed the Qifubiaozhun, they shall be paid by the overall fund in proportion, and the highest payment shall be made to the "capping line". Individuals also have to bear part of the medical expenses, and all the expenses above the "capped amount" are paid by individuals or solved by participating in supplementary medical insurance and commercial medical insurance. Medical expenses below Qifubiaozhun shall be settled by personal accounts or paid by individuals. If there is a balance in the personal account, you can also pay part of the medical expenses that should be paid by the individual within the scope of the overall fund payment.
10 1. How do medical insurance workers choose designated medical institutions?
According to the Notice of the Ministry of Labor and Social Security and other departments on Printing and Distributing the Interim Measures for the Administration of Designated Medical Institutions of Basic Medical Insurance for Urban Employees (No.KLOC-0/999 issued by the Ministry of Labor and Social Security), the insured proposed the intention of selecting designated medical institutions for individual medical treatment within the scope of medical institutions with designated qualifications, which was summarized by the unit to which they belong and submitted to the social insurance agency in the overall planning area. Social insurance agencies shall, according to the choice intention of the insured, co-ordinate the determination of designated medical institutions.
In addition to specialized medical institutions and Chinese medical institutions with designated qualifications, the insured can generally choose 3 to 5 medical institutions of different levels, including at least 1 2 primary medical institutions (including first-class hospitals and various hospitals, outpatient departments, clinics, health centers, infirmary and community health service institutions).
The insured may request to change the designated medical institutions after 1 year, and the social insurance agency in the overall planning area shall handle the change procedures.
102. Can employees of enterprises be reimbursed for medical expenses because they are too late to go to designated medical institutions for medical treatment due to illness?
According to the Notice of the Ministry of Labor and Social Security and other departments on Printing and Distributing the Interim Measures for the Administration of Designated Medical Institutions of Basic Medical Insurance for Urban Employees (No.KLOC-0/999 issued by the Ministry of Labor and Social Security), the insured can purchase drugs at designated medical institutions or at designated retail pharmacies with prescriptions. In addition to emergency and first aid, the expenses incurred by the insured in non-selected designated medical institutions shall not be paid by the basic medical insurance fund. Therefore, if employees really can't go to the selected hospital for treatment, they will go to a nearby hospital for treatment and hold a hospital emergency certificate, and their medical expenses can be paid by the basic medical insurance fund according to regulations.
103. What is the medical period? What are the regulations on the medical treatment period for employees who are sick or injured at work?
According to the provisions of the Provisions on Medical Treatment Period for Enterprise Employees Suffering from Illness or Non-work-related Injury issued by the former Ministry of Labor 1994, the medical treatment period refers to the period during which the employees of the employing unit stop working for treatment and rest due to illness or non-work-related injury, and the employing unit may not terminate the labor contract.
The Provisions on the Medical Treatment Period for Enterprise Employees Suffering from Illness or Non-work-related Injury issued by the former Ministry of Labor 1994 mainly stipulates the medical treatment period as follows:
(1) If employees of an enterprise need to stop medical treatment due to illness or non-work-related injuries, they shall be given a medical treatment period of 3 months to 24 months according to their actual working years. If the actual working experience is less than 10 year, it is 3 months if you have worked in this unit for less than 5 years; More than five years is six months. If the actual working experience is more than 10 years, it will be 6 months if you have worked in this unit for less than 5 years; More than 5 years/kloc-0 and less than 9 months; More than 10 years and less than 15 years is 12 months; 15 to 20 years is 18 months; More than 20 years is 24 months.
(2) If the medical treatment period is 3 months, the accumulated sick leave time within 6 months shall be calculated; For 6 months, calculate the accumulated sick leave time within 12 months; 9 months, calculate the accumulated sick leave time within 15 months; 12 months, calculate the accumulated sick leave time within 18 months; 18 months is calculated according to the accumulated sick leave time within 24 months; For 24 months, calculate the accumulated sick leave time within 30 months.
(3) During the medical treatment period, the sick pay, disease relief and medical insurance benefits of enterprise employees shall be implemented according to the provisions of relevant departments.
(IV) If the employees of an enterprise are disabled due to non-work-related injuries and suffer from diseases that are difficult to be treated by doctors or medical institutions, and they can't engage in their original jobs or other jobs arranged by the employing unit after medical treatment, the labor appraisal committee will conduct labor ability appraisal with reference to the Appraisal Standard for Disability Degree of Work-related Injuries and Occupational Diseases (since April 5, 2002) and on the basis of the Appraisal Standard for Disability Degree of Employees Due to Non-work-related Injuries or Diseases (Trial) (issued by the Ministry of Labor and Social Affairs). The labor contract shall not be terminated during the medical treatment period identified as Grade 5 to Grade 10.
(5) If the employees of an enterprise are disabled due to non-work-related injuries or suffering from diseases, and the medical treatment period expires, the labor appraisal committee will conduct the labor ability appraisal with reference to the Appraisal Standard of Disability Degree of Work-related Injuries and Occupational Diseases (since April 5, 2002, based on the Appraisal Standard of Disability Degree of Employees Due to Non-work-related Injuries or Diseases (Trial) (No.8 issued by the Ministry of Labor and Social Affairs [2002]). Those who are recognized as Grade I to Grade IV will quit their posts, terminate their labor relations, go through retirement and resignation procedures and enjoy retirement and resignation benefits.
(6) For those who have not recovered after the expiration of medical treatment, the issue of economic compensation for the termination of the labor contract shall be implemented in accordance with relevant regulations.
104. Do migrant workers participate in basic medical insurance?
The Ministry of Labor and Social Security's Notice on Implementing the Two Regulations, Expanding Social Security Coverage and Strengthening Fund Collection (No.KLOC-0/999 issued by the Ministry of Labor and Social Security) stipulates that farmers' contract workers participate in the social insurance of their units, and social insurance agencies set up individual accounts for their employees. After the termination or rescission of the labor contract, the social insurance agency may issue the personal account of the basic medical insurance to me at one time.