Guo Fa [1998] No.44
People's governments of all provinces, autonomous regions and municipalities directly under the Central Government, ministries and commissions and institutions directly under the State Council:
Accelerating the reform of the medical insurance system and ensuring the basic medical care for employees are the objective requirements and important guarantees for establishing the socialist market economic system. On the basis of summing up the pilot experience of medical insurance system reform in recent years, the State Council decided to carry out the reform of medical insurance system for urban workers nationwide.
I. Tasks and Principles of Reform
The main task of medical insurance system reform is to establish the 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 level of productivity 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.
Second, coverage and payment methods.
All employers in cities and towns, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises, etc.). ), organs, institutions, social organizations, private non-enterprise units and their employees should participate in the basic medical insurance. Whether township enterprises and their employees, owners of urban individual economic organizations and their employees participate in basic medical insurance shall be decided by the people's governments of all provinces, autonomous regions and municipalities directly under the Central Government.
In principle, the basic medical insurance shall be based on the administrative regions at or above the prefecture level (including prefectures and leagues) or counties (cities). In principle, the three municipalities directly under the Central Government, namely Beijing, Tianjin and Shanghai, shall implement overall planning within the city (hereinafter referred to as the overall planning area). All employers and their employees shall participate in the basic medical insurance in the overall planning area in accordance with the principle of territorial management, implement unified policies, and implement unified collection, use and management of basic medical insurance funds. Enterprises with large cross-border production mobility such as railways, electric power and ocean transportation and their employees can participate in basic medical insurance in different places in a relatively centralized way.
The basic medical insurance premium is paid by both the employer and the employee. The employer's contribution rate should be controlled at about 6% of the total wages of employees, and the employee's contribution rate is generally 2% of his salary income. With the development of economy, the contribution rates of employers and employees can be adjusted accordingly.
Three, the establishment of basic medical insurance funds and personal accounts.
It is necessary to establish the basic medical insurance pooling fund and individual account. The basic medical insurance fund consists of overall funds and individual accounts. The basic medical insurance premiums paid by individual employees are all included in individual accounts. The basic medical insurance premium paid by the employer is divided into two parts, one part is used to establish the overall fund, and the other part is included in the personal account. The proportion of individual accounts is generally about 30% of the employer's contribution, and the specific proportion is determined by the overall planning area according to the payment scope of individual accounts and the age of employees.
The overall fund and individual account shall delimit their respective payment ranges, and shall be accounted for separately, and shall not occupy each other. Determine the qifubiaozhun and the maximum payment limit of the overall fund. In principle, the qifubiaozhun is controlled at about 10% of the average annual salary of local employees, and the maximum payment limit is controlled at about 4 times of the average annual salary of local employees. Medical expenses below Qifubiaozhun shall be paid by personal account or borne by individuals. Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid from the overall fund, and individuals also have to bear a certain proportion. Medical expenses exceeding the maximum payment limit can be solved through commercial and industrial medical insurance. The specific Qifubiaozhun, the maximum payment limit and the personal burden ratio of medical expenses above the Qifubiaozhun and below the maximum payment limit of the overall planning fund shall be determined by the overall planning area according to the principle of fixed income and expenditure balance.
Four, improve the basic medical insurance fund management and supervision mechanism.
The basic medical insurance fund shall be included in the financial account management, and shall be used for special purposes and shall not be misappropriated.
The social insurance agency shall be responsible for the collection, management and payment of the basic medical insurance fund, and shall establish and improve the budget and final accounts system; Financial accounting system and internal audit system. The business expenses of social insurance agencies shall not be drawn from the fund, and shall be solved by the financial budgets at all levels.
Bank interest calculation method of basic medical insurance fund: the part raised in the current year will bear interest according to the deposit interest rate; The fund principal and interest carried forward from the previous year shall bear interest at the bank deposit rate of lump-sum deposit for 3 months; The deposited funds deposited in the social security financial special account shall bear interest at the three-year zero deposit and lump-sum savings deposit rate not lower than the interest rate of this grade. The principal and interest of an individual account are owned by the individual and can be carried forward and inherited.
Labor and social security and financial departments at all levels should strengthen the supervision and management of the basic medical insurance fund. Audit departments should regularly audit the fund revenue and expenditure and management of social insurance agencies. In the overall planning area, a medical insurance fund supervision organization with the participation of relevant government departments, employers, medical institutions, trade union representatives and relevant experts should be established to strengthen social supervision of the basic medical insurance fund.
Verb (abbreviation of verb) strengthens medical service management
It is necessary to determine the service scope and standard of basic medical insurance. The Ministry of Labor and Social Security shall, jointly with the Ministry of Health, the Ministry of Finance and other relevant departments, formulate the scope, standards and settlement methods of basic medical services, and formulate the national basic medical insurance drug list, diagnosis and treatment items, standards of medical service facilities and corresponding management measures. The administrative departments of labor security of all provinces, autonomous regions and municipalities directly under the Central Government shall, in accordance with the provisions of the state, jointly with relevant departments, formulate corresponding implementation standards and measures in their respective regions.
The basic medical insurance is managed by designated medical institutions (including Chinese medicine hospitals) and designated pharmacies. The Ministry of Labor and Social Security shall, jointly with the Ministry of Health, the Ministry of Finance and other relevant departments, formulate measures for the examination and approval of the qualifications of designated medical institutions and designated pharmacies. Social insurance agencies should, in accordance with the principle of integrating traditional Chinese and western medicine, take into account grass-roots units, specialized departments and comprehensive medical institutions, be responsible for determining designated medical institutions and pharmacies, and sign contracts with designated medical institutions and pharmacies to clarify their respective responsibilities, rights and obligations. When determining the designated medical institutions and pharmacies, we should introduce the competition mechanism. Workers can choose a number of designated medical institutions to seek medical treatment and purchase medicines, or they can buy medicines at a number of designated pharmacies with prescriptions. The State Administration of Pharmaceutical Products shall, jointly with relevant departments, formulate measures for handling drug purchase accidents in designated pharmacies.
All localities should conscientiously implement the spirit of the decision of the Central Committee and the State Council on health reform and development (Zhong Fa [1997] No.3), actively promote the reform of the medical and health system, invest less money, let the people get good medical services, and promote the healthy development of medical and health undertakings. It is necessary to establish a system of separate accounting and management of medicine, form a competitive mechanism between medical services and drug circulation, and reasonably control the level of medical expenses; It is necessary to strengthen the internal management of medical institutions and pharmacies, standardize medical service behavior, and reduce staff and increase efficiency. Reduce the cost of drugs; It is necessary to rationalize the price of medical services, reasonably raise the price of medical technical services and reduce the proportion of drug income in the total medical income on the basis of separate accounting and management of medicines; It is necessary to strengthen professional technical training and professional ethics education to improve the quality and service quality of medical service personnel; It is necessary to rationally adjust the layout of medical institutions, optimize the allocation of medical and health resources, actively develop community health services, and incorporate basic medical services in community health services into basic medical insurance coverage. The Ministry of Health shall, jointly with relevant departments, formulate relevant policies for the reform of medical institutions and the development of community health services. The State Economic and Trade Commission and other departments should seriously cooperate with the reform of the drug circulation system.
Six, properly solve the medical problems of the relevant personnel.
The medical treatment of retired personnel and the old Red Army remains unchanged, and the medical expenses are solved according to the original funding channels. Payment is indeed difficult, by the people's government at the same level to help solve. The medical management authority and laws of retired personnel and the old Red Army shall be formulated by the people's governments of provinces, autonomous regions and municipalities directly under the Central Government.
The medical treatment of disabled revolutionary servicemen above Grade B remains unchanged, and the medical expenses are solved according to the original funding channels. Social insurance agencies set up separate accounts for management: the insufficient payment of medical expenses shall be solved by the local people's government.
Retirees participate in the basic medical insurance, and individuals do not pay the basic medical insurance premium; Appropriate care should be given to the amount of personal accounts of retirees and the proportion of personal medical expenses.
On the basis of participating in the basic medical insurance, national civil servants enjoy the Medicaid policy. Specific measures shall be formulated separately.
In order not to reduce the existing medical consumption level of employees in some specific industries, on the basis of participating in basic medical insurance, as a transitional measure, supplementary medical insurance for enterprises is allowed to be established. The part of enterprise supplementary medical insurance premium within 4% of the total capital shall be paid from employee welfare funds, and the insufficient part of welfare funds shall be included in the cost after approval by the financial department at the same level.
The basic medical insurance premium for laid-off workers of state-owned enterprises, including unit contributions and individual contributions, shall be paid by the re-employment service center according to 60% of the average salary of local employees in the previous year.
Seven, strengthen organizational leadership
The reform of the medical insurance system is highly policy-oriented, involving the vital interests of the broad masses of workers and related to national economic development and social stability. People's governments at all levels should earnestly strengthen leadership, unify their thinking, raise awareness, do a good job in propaganda and political and ideological work, and make the broad masses of workers and all sectors of society actively support and participate in this reform. All localities should carefully organize and implement the basic medical insurance system for urban workers in accordance with the tasks, principles and requirements, combined with local conditions, to ensure a smooth transition between the old and new systems.
The establishment of the basic medical insurance system for urban workers began at the beginning of 1999 and was basically completed at the end of 1999. The people's governments of all provinces, autonomous regions and municipalities directly under the Central Government shall, in accordance with the requirements of this decision, formulate an overall plan for the reform of the medical insurance system and report it to the Ministry of Labor and Social Security for the record. The overall planning area shall, according to the planning requirements, formulate an implementation plan for basic medical insurance, which shall be implemented after being submitted to the people's governments of provinces, autonomous regions and municipalities directly under the Central Government for examination and approval.
The Ministry of labor and social security should strengthen the guidance and inspection of the establishment of the basic medical insurance system for urban workers, and timely study and solve problems in the work. The financial, health and drug supervision and management departments should actively participate, cooperate closely and make joint efforts to ensure the smooth progress of the reform of the basic medical insurance system for urban workers.
December 14th, 1998
Guiding Opinions of the State Council on Piloting Basic Medical Insurance for Urban Residents
(Guo Fa [2007] No.20)
People's governments of all provinces, autonomous regions and municipalities directly under the Central Government, ministries and commissions and institutions directly under the State Council:
The CPC Central Committee and the State Council attached great importance to solving the medical security problems of the broad masses of the people and constantly improved the medical security system. From 65438 to 0998, China began to establish a basic medical insurance system for urban workers, and then launched a new rural cooperative medical system to establish a medical assistance system for urban and rural areas. At present, there is no medical security system arrangement mainly for urban non-employed residents. In order to achieve the goal of basically establishing a medical security system covering urban and rural residents, the State Council decided to launch a pilot program of basic medical insurance for urban residents from this year (hereinafter referred to as the pilot program). All localities and departments should fully understand the importance of this work, regard it as an important task to implement Scientific Outlook on Development and build a harmonious socialist society, attach great importance to it, make overall plans, standardize and guide it, and make steady progress.
I. Objectives and principles
(1) pilot target. In 2007, two or three cities were selected to start the pilot project in qualified provinces, and the pilot project was expanded in 2008. The goal is to reach more than 80% of the pilot cities in 2009, and the pilot cities will be fully promoted throughout the country in 20 10, gradually covering all urban non-employed residents. It is necessary to explore and improve the basic medical insurance policy system for urban residents through pilot projects, form a reasonable financing mechanism, a sound management system and a standardized operating mechanism, and gradually establish a basic medical insurance system for urban residents with serious illnesses.
(2) Pilot principle. The pilot work should start at a low level, reasonably determine the financing level and security standards according to the level of economic development and the affordability of all aspects, focus on ensuring the medical needs of non-employed urban residents for serious illnesses, and gradually improve the level of security; Adhere to the principle of voluntariness and fully respect the wishes of the masses; Clarify the responsibilities of the central and local governments, the central government determines the basic principles and main policies, and the local governments formulate specific measures to implement territorial management of insured residents; Adhere to overall planning and coordination, and do a good job in connecting basic policies, standards and management measures among various medical security systems.
Second, the scope of insurance and financing level.
(3) Insurance coverage. Students, children and other non-employed urban residents in primary and secondary schools (including vocational high schools, technical secondary schools and technical schools) not covered by the basic medical insurance system for urban workers may voluntarily participate in the basic medical insurance for urban residents.
(4) Financing level. According to the local economic development level and the basic medical consumption needs of different groups such as adults and minors, the pilot cities should comprehensively consider the affordability of local residents' families and finances and appropriately determine the financing level; Explore the establishment of a mechanism linking the level of financing, payment period and treatment level.
(5) Payment and subsidies. The basic medical insurance for urban residents is mainly based on family contributions, and the government gives appropriate subsidies. Insured residents are required to pay the basic medical insurance premium and enjoy the corresponding medical insurance benefits. Conditional employers can subsidize employees' families to pay insurance premiums. The state formulates preferential tax policies for individual contributions and unit subsidy funds.
For the insured residents in the pilot cities, the government will give subsidies according to the standard of not less than 40 yuan per capita every year. Among them, since 2007, the central government has given subsidies to the central and western regions according to the standard of 20 yuan per capita. On this basis, the government shall, in principle, subsidize the part of family contributions required for students and children with minimal living allowance or severe disabilities to participate in the insurance, and the central government shall subsidize the central and western regions according to the per capita 5 yuan; For other low-income households, severely disabled people who have lost their ability to work, elderly people over the age of 60 from low-income families and other residents in need of insurance payment, the government gives subsidies every year according to the standard of not less than 60 yuan per capita. Among them, the central government gives subsidies to the central and western regions according to the per capita 30 yuan. The central government will give appropriate subsidies to the eastern region with reference to the subsidy measures for the new rural cooperative medical system. The specific scheme of financial subsidies is determined by the financial department, labor and social security, civil affairs and other departments, and the subsidy funds are included in the financial budgets of governments at all levels.
(6) Payment of expenses. The basic medical insurance fund for urban residents is mainly used for the hospitalization and outpatient medical expenses of insured residents, and areas with conditions can gradually try out the outpatient medical expenses as a whole.
The use of the basic medical insurance fund for urban residents should adhere to the principle of fixed income and expenditure, balance of payments and slight balance. It is necessary to reasonably formulate the minimum payment standard, payment ratio and maximum payment limit of the basic medical insurance fund for urban residents, improve the payment method, and reasonably control the medical expenses. Explore medical services and payment methods suitable for the economic affordability of non-employed residents in difficult towns, and reduce the burden of medical expenses. The basic medical insurance fund for urban residents is used to pay medical expenses within the prescribed scope, and other expenses can be solved by supplementary medical insurance, commercial health insurance, medical assistance and social charitable donations.
Third, strengthen management and service.
(7) organization and management. The management of the basic medical insurance for urban residents shall, in principle, refer to the relevant provisions of the basic medical insurance for urban workers. All localities should make full use of the existing management service system, improve management methods and improve management efficiency. Encourage qualified areas to combine the basic medical insurance for urban workers and the actual management of new rural cooperative medical care, and further integrate the management resources of basic medical security. It is necessary to explore the establishment and improvement of social supervision organizations for medical insurance composed of representatives of government agencies, insured residents, social organizations and medical service institutions, and strengthen supervision over the management, service and operation of basic medical insurance for urban residents. Establish medical insurance professional technical standards organizations and expert consultation organizations, and improve medical insurance service management professional technical standards and business norms. According to the needs of the development of medical insurance, strengthen the construction of medical insurance management service institutions and teams. Establish and improve the management system, improve the operation mechanism, and strengthen the construction of medical insurance information system.
(8) Fund management. The basic medical insurance fund for urban residents should be included in the unified management of the financial accounts of social security funds and accounted for separately. Pilot cities should strictly implement the financial system, strengthen the management and supervision of basic medical insurance funds, and explore the establishment and improvement of fund risk prevention and adjustment mechanisms in accordance with the relevant provisions of social insurance fund management to ensure the safety of funds.
(9) Service management. The medical service management of the basic medical insurance for urban residents shall refer to the relevant provisions of the basic medical insurance for urban workers in principle, and the specific measures shall be formulated by the labor and social security department of the pilot city in conjunction with the departments of development and reform, finance and health. It is necessary to comprehensively consider the basic medical needs of the insured residents and the affordability of the basic medical insurance fund, and reasonably determine the scope of medical services. Through the conclusion and performance of the designated service agreement, the management of designated medical institutions and designated retail pharmacies will be standardized, and the rights and obligations of medical insurance agencies and designated medical institutions and retail pharmacies will be clarified. Medical insurance agencies should simplify examination and approval procedures to facilitate residents' participation in insurance and reimbursement of medical expenses; Clarify the settlement method of medical expenses and settle with medical institutions in a timely manner according to regulations. Strengthen the management of medical expenses and explore the establishment of a reward and punishment mechanism for medical insurance management services. Actively promote the payment of medical expenses according to diseases and the total amount in advance, and explore ways to determine the standard of medical expenses by agreement.
(ten) give full play to the role of urban community service organizations. Integrate, upgrade and broaden the functions of urban community service institutions, strengthen the construction of community service platforms, and do a good job in the management and service of basic medical insurance. Vigorously develop community health services and bring qualified community health service institutions into the designated scope of medical insurance; For the medical expenses incurred by insured residents in community health service institutions, the proportion of medical insurance fund payment shall be appropriately increased.
Fourth, deepen relevant reforms.
(eleven) continue to improve the medical security system. Further improve the basic medical insurance system for urban workers and take effective measures to bring mixed ownership, non-public economic organizations and flexible employees into the basic medical insurance for urban workers; Vigorously promote migrant workers to participate in the basic medical insurance for urban workers, focusing on solving the problem of serious illness; Continue to focus on solving the medical security problems of employees and retirees such as state-owned enterprises with difficulties and closed bankrupt enterprises; Encourage urban residents of working age who have the ability to work to find jobs in various ways and participate in the basic medical insurance for urban workers; Further standardize the current payment policy of basic medical insurance for urban workers and strengthen the management of medical services. Accelerate the implementation of the new rural cooperative medical system. Further improve the urban and rural medical assistance system. Improve the multi-level medical security system and do a good job in the connection of various medical security systems.
(twelve) to promote the reform of the medical and health system and the drug production and circulation system. In accordance with the overall requirements of deepening the reform of the medical and health system, we should coordinate the reform and system convergence of medical and health care, drug production and circulation and medical security system, and give full play to the role of medical security system in raising medical funds, improving medical quality and controlling medical expenses. Further transform government functions, strengthen regional health planning and improve the medical service system. Establish and improve the health industry standard system, and strengthen the supervision of medical services and drug markets. Standardize medical service behavior, and gradually establish and improve technical standards such as clinical operation norms, clinical diagnosis and treatment guidelines, clinical medication norms, and admission standards. Accelerate the construction of urban community health service system, give full play to the role of community health service and Chinese medicine service in medical services, and explore the implementation of graded medical care for insured residents in areas where conditions permit.
Verb (abbreviation of verb) strengthens organizational leadership
(thirteen) the establishment of the State Council urban residents basic medical insurance inter ministerial joint conference system. Under the leadership of the State Council, the Inter-Ministerial Joint Conference on Basic Medical Insurance for Urban Residents in the State Council is responsible for organizing, coordinating and guiding the pilot work, studying and formulating relevant policies, supervising and inspecting the implementation of policies, summarizing and evaluating the pilot work, coordinating and solving the problems in the pilot work, and submitting reports and suggestions to the State Council on major issues.
(fourteen) choose to determine the pilot city. The provincial people's government may choose 2 to 3 pilot cities according to local conditions and report them to the inter-ministerial joint meeting for approval. The implementation plan of pilot cities shall be reported to the office of the inter-ministerial joint meeting for the record and approved by the people's governments of all provinces (autonomous regions and municipalities).
(fifteen) to formulate supporting policies and measures. The labor and social security department shall formulate relevant supporting policies and measures in conjunction with relevant departments such as development and reform, finance, health, civil affairs, education, drug supervision, and Chinese medicine management. All departments should cooperate with each other according to their respective responsibilities and accelerate various supporting reforms. Mobilize all social forces to create a good environment and provide strong support for promoting the reform of the medical insurance system, and ensure the smooth progress of the pilot work.
(sixteen) carefully organized and implemented. Local people's governments at all levels should fully understand the great significance of the pilot work and earnestly strengthen organizational leadership. The people's governments at the provincial level shall make overall plans according to the pilot objectives, tasks, basic policies and work steps stipulated in this guidance, and actively and steadily promote the pilot work in their respective administrative areas. Pilot cities should formulate pilot implementation plans and carefully organize their implementation on the basis of full investigation, careful calculation and multi-party demonstration. Cities that have carried out basic medical insurance should sum up experience in time, improve their systems, and further explore more practical basic medical insurance systems and mechanisms.
(seventeen) do a good job in public opinion propaganda. The establishment of the basic medical insurance system for urban residents is directly related to the vital interests of the broad masses of the people and is a major livelihood project with strong policy. All localities should adhere to the correct guidance of public opinion, strengthen the publicity of the significance, basic principles, principles and policies of the pilot work, and strengthen the summary and popularization of good practices and experiences in the pilot work, so that this policy of benefiting the people will be deeply rooted in the hearts of the people and truly gain the understanding and support of the broad masses and all sectors of society, so that the pilot work will become a practice in which the broad masses actively participate.
All localities should pay attention to the study of new situations and problems in the pilot process, actively explore solutions, and properly handle the relationship between reform, development and stability. In case of important circumstances, report to the inter-ministerial joint meeting in time.
the State Council
July 2007 10