Urban residents medical insurance implementation rules 2014
Chapter I General Provisions
Article 1 In order to protect the basic medical care of urban residents, and to further improve the health insurance system, and to build a harmonious society, according to the State Council's "on the development of urban residents of the basic medical insurance pilot guiding opinions" (Guo Fa [2007] No. 20), Hebei Provincial People's Government "on the establishment of the basic medical insurance system implementation views" (Ji Zheng [2007] No. 99), Hengyang Province People's Government "on the establishment of the basic medical insurance system" (Jizheng [2007] No. 99), and the implementation of the basic medical insurance system of the urban residents. No. 20), Hebei Provincial People's Government "on the establishment of urban residents of the implementation of the basic medical insurance system" (Jizheng [2007] No. 99), Hengshui City, urban residents of the implementation of the basic medical insurance program (Hengzheng [2009] No. 44) and other documents, combined with the actual situation in our county, hereby formulate the implementation of the rules.
Article II of the basic medical insurance system for urban residents, adhere to the principle of low-level, broad coverage, the different levels of groups of medical care to make the appropriate institutional arrangements, according to the level of economic development and the affordability of the various aspects of the reasonable determination of the financing standards and levels of protection, with a focus on the protection of residents of inpatient and outpatient hospitalization and the medical needs of the major illnesses; adhere to the principle of the family as a unit, the masses of people voluntarily, individual contributions and government grants Adhere to the principle of combining family-based, voluntary, individual contributions and government subsidies; adhere to the principle of coordination, unified management, and do a good job of the various types of medical insurance system between the basic policies, standards and management measures.
Article 3 of the basic medical insurance for urban residents to the county as a coordinating unit, the county government is responsible for the unified coordination and management. The county government set up the urban residents basic medical insurance leading group, responsible for the organization and coordination and macro-guidance, research and formulation of related policies and supervise and check the implementation of the policy, coordinate and solve the problems arising from the work. All relevant departments closely cooperate, *** with the work of the basic medical insurance for urban residents.
Article IV County Personnel Labor and Social Security Bureau is the residents of the work of the administrative department in charge of the work of medical insurance, urban residents are responsible for the formulation of basic medical insurance policy, implementation, management and supervision; the county financial bureau is responsible for the budgetary arrangements for financial subsidies and allocation of funds to strengthen the supervision and management of the fund is responsible for the implementation of the supporting funds to ensure that the urban residents of the basic medical insurance agency start-up requirements and included in the Financial budget; County Health Bureau is responsible for the supervision of medical institutions, improve the construction of community health service institutions, for the insured residents to provide quality and affordable basic medical services; County Education Bureau is responsible for publicity and mobilization of organizations in the school primary and secondary school students and nursery school children to participate in the work of the insurance, the implementation of the target responsibility system, the responsibility for the school, the kindergarten to do the insured to ensure that all insured; the county public security bureau is responsible for the identification of the household registration of the participants and the provision of relevant basic data And timely provision of newborns settled information; County Civil Affairs Bureau is responsible for low-income objects and low-income families older than 60 years of age identification, with the Department of Labor and Social Security to do a good job of the special hardship group of data statistics and registration; County Federation of Disabled Persons is responsible for the loss of the ability to work the identity of persons with severe disabilities (1?2), with the Labor and Social Security Department to do a good job of the disabled persons with the registration of the insurance work; townships and townships are responsible for the urban residents within the jurisdiction of the townships and townships to publicize the insurance work. Township government is responsible for the township residents within the jurisdiction of the publicity and mobilization, insurance work; County Development and Reform Bureau, Food and Drug Administration and other departments are responsible for the development of relevant supporting policies and measures to assist in the work of basic medical insurance for urban residents. The above departments should be in accordance with their respective responsibilities to do a good job of urban residents of basic medical insurance start work.
The county medical insurance center is specifically responsible for the county's urban residents basic medical insurance business, and contractors in the county town of urban residents (except schools, kindergartens) to participate in insurance and other work. Township labor security service stations, schools for urban residents of the basic medical insurance agency, under the guidance of the Department of Labor and Social Security, specific contractors residents to participate in the publicity and mobilization, registration, qualification examination, basic information entry, change, summary report and medical insurance, IC card issued and other work.
Chapter 2: Scope of Participation
Article 5 Within the administrative region, non-working urban residents who do not participate in the basic medical insurance for urban workers may voluntarily participate in the basic medical insurance for urban residents. Including:
(a) primary and secondary school students (including vocational education centers, high schools, junior high schools, elementary school students and nursery school children)
(b) 18 years of age (including 18 years of age) of the following non-school residents;
(c) 18 years of age or older, 'non-employed urban residents.
Article 6 Other people who are in line with the relevant national and provincial policy regulations and the spirit of the document can voluntarily participate in the basic medical insurance for urban residents. Including:
(a) flexible employment personnel, into the city workers;
(b) the closure of the bankruptcy of the enterprise retirees (including retirees who did not participate in the basic medical insurance for urban workers), the closure of the bankruptcy of the enterprise employees.
Chapter III Funding Standards and Subsidies
Article VII of the participants in addition to the central and provincial financial subsidies, the shortfall will be made up by the county finances.
Article VIII
(a) all types of students, 18 years of age and under, non-school residents, health insurance premium financing standards for each person 160 yuan per year (including large medical insurance premium of 10 yuan), the individual to pay 30 yuan, and the rest of the central, provincial and county finances to make up the difference.
(b) 18 years of age or older urban residents health insurance premium financing standards for each person 300 yuan per year (including large medical insurance premiums of 50 yuan). Individuals pay 170 yuan, and the rest is made up by the central, provincial and county finances. (In 2009, the second half of the collection of residents over 18 years of age medical insurance premiums standard for individuals to pay 85 yuan, including large medical insurance premiums of 25 yuan).
The above people in the low-income recipients, severely disabled (1-2) residents and low-income families in the elderly over 60 years of age health insurance premiums are fully covered by the financial subsidy funds, in addition to the central and provincial financial subsidies, the remaining portion of the county financial subsidies.
Article IX of the conditions of the employer can be subsidized by the employee's family members to participate in the premiums, unit subsidies in the pre-tax.
Chapter IV registration and fund collection
Article 10 of the various types of students, nursery school and kindergarten children by their schools and kindergartens to assign a person as a health care administrator, the unified organization of the insurance procedures. Students, nursery school children for insurance registration to provide ID card number, I small two-inch recent color photographs of two. Schools, kindergartens should be in a timely manner to participate in the basic information, collected on behalf of the medical insurance premiums, unified report to the county health insurance center or designated bank account.
Township residents with a household register, ID card original and a copy of his or her own small two-inch recent crownless color photo 2 (children before kindergarten may not provide a photo), to the county health insurance center, the township labor security service station for the insurance payment procedures. The county health insurance center, the township labor security service station of the residents of the declaration of information review qualified, for the insured residents to print the payment bill, for the relevant registration procedures, the insured residents will be medical insurance premiums paid to the health insurance center designated bank account.
The following people need to hold a low guarantee issued by the Civil Affairs or Disabled Persons' Federation and other departments, a certificate of severe disability (the original and a copy of 1) and other valid certificates of proof, posted by the registration department of the insurance without objection to the county health insurance center to directly apply for the insurance procedures:
(a) Low-income recipients;
(b) urban residents with severe disabilities (including various types of students);
(C) annual per capita income of less than one-third of the annual per capita disposable income of residents of the county in the family over 60 years old (to provide the Civil Affairs Bureau issued a low-income family identification certificate).
Article 11 of the insured residents to the family as a unit, in line with the basic health insurance for urban residents to participate in the conditions of the people must be insured at the same time (has participated in the basic health insurance for urban workers and the new rural cooperative medical personnel, except), all types of students to the school as a unit of the insurance, the collective for the insurance procedures.
Article 12: Newborns should be enrolled within three months from the date of household registration.
Article 13 The urban residents' medical insurance is based on a one-year lump-sum advance payment system, with one year as a period for payment of medical treatment.
(a) All types of students, nursery school children pay fees according to the school year, at the beginning of each school year for registration and change of information related to insurance, payment of the basic medical insurance premiums for the current school year, October 1 of the current year to September 30 of the following year for the payment of medical insurance benefits.
(2) Non-school residents under the age of eighteen and urban residents over the age of eighteen pay annual contributions. From September 1 to October 31 each year, the centralized registration, pre-payment and change of information on residents' health insurance. 2009 collection of half-year health insurance premiums and reimbursement of medical expenses for the second half of the year, January 2010 collection of 2010 annual health insurance premiums, and then every year from September to October collection of health insurance premiums, the following year from January 1 to December 31 for the period of payment of health insurance benefits.
Article 14 of the county health insurance center in November 30 each year, the number of residents enrolled and the amount of financial subsidies reported to the financial sector, the financial sector included in the next year's budget. The financial sector in the following year before the end of January, the financial subsidies will be allocated to the county health insurance center financial account.
Article 15 of the basic medical insurance for urban residents only build a comprehensive fund, not individual accounts.
Article 16 The urban residents basic medical insurance contributions into the integrated fund is not refundable.
Chapter V Medical Insurance Treatment
Article 17 The basic medical insurance for urban residents implements the relevant provisions of the Hebei Provincial Urban Workers' Basic Medical Insurance Drug Catalog, Diagnostic and Therapeutic Items Catalog, and Medical Service Facilities and Standards, based on which, the varieties and ranges of medicines used by children will be increased appropriately. In addition to the part of the costs incurred by the hospitalization of the individual part of the direct settlement with the designated medical institutions, the remaining part of the county medical insurance center and the designated medical institutions settlement.
Article 18 The scope of payment of the unified fund includes:
(1) Payment of hospitalization expenses of non-student urban residents in accordance with the provisions of the basic medical insurance for urban residents and outpatient radiotherapy for malignant tumors, outpatient dialysis for uremia and outpatient expenses incurred for anti-rejection medicines after liver and kidney transplants;
(2) Payment of hospitalization expenses for all types of students, non-school residents aged 18 years old and younger, illnesses and accidental injuries, malignant tumor outpatient radiation therapy, outpatient dialysis and anti-rejection medicine after liver and kidney transplantation. (b) Payment of outpatient expenses incurred by students, non-school residents aged 18 years and below for hospitalization for diseases and accidental injuries, outpatient radiotherapy for malignant tumors, outpatient dialysis for uremia and taking anti-rejection medicines after liver or kidney transplantation, and outpatient expenses incurred by aplastic anemia and hematological disorders during the remission period of leukemia.
Article 19 The urban insured residents have to bear a certain amount of medical fees, i.e. the starting standard, for each hospitalization. The starting standard is determined according to the different levels of medical institutions: 300 yuan for first-level designated medical institutions (including designated community health centers), 500 yuan for second-level designated medical institutions, and 700 yuan for third-level designated medical institutions.
The hospitalization reimbursement rate for insured residents is: 70% for first-level designated medical institutions (including designated community health centers) above the starting standard, 60% for second-level designated medical institutions, and 50% for third-level designated medical institutions.
The maximum annual payment limit of the unified fund is 30,000 yuan per person.
Article 20 of the urban residents of the basic medical insurance to pay part of the cost of diagnostic and treatment items, as well as the use of urban residents of the basic medical insurance drug list? The individual first pays 10% out-of-pocket. The individual will pay 10% of the cost and the remaining 90% of the cost will be paid by the individual and the integrated fund in accordance with the stipulated ratio.
Article 21 The insured residents suffering from malignant tumors outpatient radiotherapy, uremia outpatient dialysis and liver, kidney transplantation after taking anti-rejection drugs (all types of students and non-school residents aged 18 years and under, including aplastic anemia, leukemia remission of blood disorders) need outpatient treatment, with their own medical insurance (IC card), the second level or above the designated medical institutions recent diagnostic certificates, inpatient medical records, and relevant tests, laboratory tests and laboratory tests. A copy of the medical certificate (IC card), recent diagnostic certificate of the designated medical institution above the second level, hospitalized medical record, and relevant test and laboratory reports, etc., shall be submitted to the Labor and Social Security Department for recognition, and then receive the "Outpatient Medical Certificate for Special Diseases of Urban Residents' Basic Medical Insurance", and then go to the designated medical institution with the certificate for medical treatment, and the outpatient treatment shall be included in the scope of the payment of the Urban Residents' Basic Medical Insurance Fund, with a starting standard of RMB 500 yuan per year. The hospitalization of the relevant provisions of the implementation.
Article 22 The number of years of contribution is linked to the medical insurance treatment. For every five years of continuous contributions, the urban residents' basic medical insurance fund will increase the payment ratio by 3%, with a cumulative maximum of 9%. If the insured residents interrupt the payment of contributions, they will recalculate the number of years of contribution according to the new insured people.
Article 23 With reference to the operation of large medical insurance for urban workers, large medical insurance for urban residents is integrated at the municipal level, and the municipal medical insurance agency will unify and insure the insurance with commercial insurance companies. The part of the hospitalization and outpatient expenses of the insured exceeding the maximum payment limit of the urban residents' basic medical insurance co-ordination fund, the medical expenses conforming to the provisions of the basic medical insurance shall be paid 75% by the large medical insurance and 25% by the individual, and 10% by the individual, and 10% by the individual in the second category, and then paid according to the same proportion. The maximum payment limit for large medical insurance in a settlement year is 70,000 yuan.
Chapter 6 Medical Management
Article 24 of the basic medical insurance for urban residents to implement designated medical management. When the insured residents need to seek medical treatment due to illness, they should hold their medical insurance IC card and medical certificate to choose among the designated medical institutions of medical insurance announced by the labor and social security departments.
Article 25 If an insured resident is hospitalized due to illness and needs to be transferred for treatment, the transferring hospital shall fill in the "Anping County Urban Resident Transfer Approval Form" and report it to the county health insurance center for approval for the record before transferring to another hospital; if the resident needs to be hospitalized in a non-designated hospital due to an emergency, the resident shall notify the county health insurance center of the transfer for the record within 3 days after the hospital admission. If the patient is transferred to a non-designated hospital for hospitalization or treatment, the patient shall be discharged from the hospital with the approval procedure of the county medical insurance center, a copy of the hospitalization medical record, a diagnosis certificate, a detailed fee schedule and valid expense documents, and shall be reimbursed in accordance with the regulations before the 10th day of each month at the county medical insurance center. The county health insurance center will not accept all medical expenses incurred by the hospitalization without following the procedures.
Article 26 of the medical expenses incurred by the insured residents, one of the following circumstances, the basic medical insurance fund for urban residents will not be paid:
(a) treatment abroad or Hong Kong, Macao, Taiwan;
(b) suicide, intentional self-injury, self-inflicted injuries;
(c) assault, alcoholism, drug abuse and other injuries and illnesses caused by illegal or criminal behavior;
(a) the use of drugs, alcoholism, drug addiction and other illegal or criminal behavior;
(b) the use of drugs, alcoholism, drug addiction and other illegal or criminal behavior;
(c) the use of drugs, alcoholism, drug addiction and other illegal or criminal behavior.
(d) Traffic accidents, medical accidents, accidental injuries (except for students), work-related injuries, or medical expenses for which the other party bears the responsibility;
(e) Other cases for which payment will not be made in accordance with the relevant regulations.
Article 27 The county health insurance center shall sign a designated service agreement with the designated medical institutions to clarify the rights and obligations of both parties and regulate supervision and management. Violation of the provisions of the agreement, the recovery of illegal funds and impose liquidated damages, liquidated damages can be used for incentives, publicity and other expenditures; the circumstances are serious, terminate the agreement.
Article 28 The labor security department of the organization's financial, health, pricing and other departments to strengthen the supervision and inspection of the services and management of the designated medical institutions. For violation of the provisions of the designated medical institutions, the labor security department depending on the circumstances, ordered to make corrections within a certain period of time, or notification of criticism, or cancel the qualification of the designated.
Article 29 The insured residents make false statements, take concealment, fraud and other means of cheating residents of the medical insurance fund, medical insurance agencies will not pay; has been paid, to be recovered; constitutes a crime, transferred to the judicial organs.
Chapter VII Fund Management and Services
Article 30 The basic medical insurance fund for urban and rural residents is composed of the medical insurance premiums paid by the insured residents, the subsidy funds at all levels of finance, the fund's interest and value-added income, as well as other channels of raising funds.
Article 31 The basic medical insurance fund for urban residents into the financial account, while the medical insurance center to set up income accounts, expenditure accounts, the implementation of two-line management, separate accounts, separate accounting, dedicated to the basic medical insurance for urban residents, the implementation of a unified social insurance budgeting system, financial accounting system and audit, supervision system.
Article 32 The basic medical insurance fund for urban residents shall be exempted from taxes and fees in accordance with state regulations.
Article 33 The Ministry of Labor and Social Security and the financial sector, to strengthen the supervision and management of the basic medical insurance fund for urban residents, and regularly audit the income and expenditure of the basic medical insurance fund for urban residents and management.
Article 34 The Department of Labor and Social Security, in conjunction with the financial sector, according to the social and economic development and financial and residential income and the operation of the urban residents of the basic medical insurance fund, the urban residents of the basic medical insurance contribution standards, financial subsidies and medical
medical insurance treatment and other adjustments to be reported to the county government for approval and implementation.
Article 35 The medical insurance agency according to the number of residents enrolled in the proportional increase in personnel, the use of re-employment of public welfare jobs indicators equipped with medical insurance coordinator.
Article 36 The county financial department of the medical insurance agency to give start-up funds, and according to the number of urban residents enrolled in the medical insurance center, township labor security service stations, schools, kindergartens to give financial subsidies, subsidies standard 2 yuan / person per year, the start-up costs and subsidies by the county financial expenditure, included in the county's annual budget.
Article 37 The labor security department is responsible for the management of health insurance coordinators, business training and payroll.
Chapter VIII Supplementary Provisions
Article 38 The medical expenses incurred due to major epidemics, disasters and emergencies shall be coordinated by the county government.
Article 39 The implementation of the rules by the county labor security department is responsible for interpretation.
Article 40 These Implementing Rules shall come into force on July 1, 2009 .
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