Article 1 According to the "Decision of the State Council on Establishing a Basic Medical Insurance System for Urban Employees" (Guofa [1998] No. 44) and the "Overall Plan for the Establishment of a Basic Medical Insurance System for Urban Employees in Jiangxi Province" (Ganfu Fa [1999] ]27), in order to actively and steadily implement the reform of the medical insurance system for urban employees in our city and in combination with the actual situation of our city, these measures are formulated.
Article 2 The main task of the reform of the medical insurance system is to establish a basic medical insurance system for urban employees, that is, to establish a social medical security system that is adapted to meet the basic medical needs of employees based on the financial, enterprise and personal affordability of the city.
Article 3 Establish a basic medical insurance system for urban employees in our city, and insist that the level of basic medical insurance be consistent with the level of productivity development in our city; all urban employers and their employees must participate in basic medical insurance and implement territorial management; basic medical insurance premiums The basic medical insurance fund is jointly borne by both the employer and the employee. The basic medical insurance fund implements the principle of combining social pooling and personal accounts.
Article 4 All employers in cities and towns across the city, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises, private enterprises, etc.), government agencies, public institutions, social groups, private non-enterprise units and their employees, should participate in basic medical insurance. Township enterprises and their employees, owners of urban individual economic organizations and their employees are not included in the basic medical insurance for the time being, and will be included one by one when conditions are mature.
Article 5 Basic medical insurance shall be implemented as a whole in the city and shall be implemented in accordance with these Measures. At present, the city level and the county (city) are the coordinating units respectively. Zhanggong District is not the coordinating unit and is included in the city level coordinating unit. The city level and each county (city) shall formulate implementation details and related management measures in accordance with these Measures. When conditions are mature, it will gradually transition to city-wide coordination.
Chapter 2 Raising Basic Medical Insurance Funds
Article 6 Basic medical insurance premiums are collected from employers and individual employees in accordance with the following methods.
(1) The employer shall pay 6% of the total monthly salary of its employees, and individual employees shall pay 2% of their monthly salary income. Individual retirees shall not pay basic medical insurance premiums. In the future, with the development of the economy and the operation of the medical insurance fund, the unit and individual contribution rates can be appropriately adjusted with the approval of the provincial government.
(2) If the average monthly salary of employees is 300% higher than the average monthly salary of employees in the city, county (city) where they are located in the previous year, the unit and individual shall pay basic medical insurance based on 300% of the average monthly salary of employees in the city, county (city) where they are located. If the average monthly salary of employees is lower than 60% of the average monthly salary of employees in the city, county (city) where they are located in the previous year, both units and individuals shall pay basic medical insurance premiums based on 60% of the average monthly salary of employees in the city, county (city) where they are located. .
(3) For laid-off employees of state-owned enterprises who have entered the employer's re-employment service center and received basic living allowances, the payment base shall be 60% of the average monthly salary of the previous year in the city, county (city) where they are located, and both unit and individual contributions shall be paid by the center. . Laid-off workers enjoy the same basic medical treatment as current workers.
(4) Private enterprise owners and their employees shall use the average monthly salary of employees in their respective city, county (city) in the previous year as the payment base, and pay basic medical insurance premiums in accordance with regulations.
Employees who have not been re-employed after the termination of the labor contract should continue to participate in basic medical insurance, and the average monthly salary of employees in the city, county (city) in the previous year shall be used as the payment base, and all basic medical insurance premiums shall be paid by individuals.
The basic medical insurance premiums for those who are on long leave, seconded, temporarily employed, or on leave without pay shall be collected and paid by the unit that retains their personnel relations.
When employees are transferred, the transferring unit and the transferring unit shall go to the medical insurance agency in the same month to verify the payment base and payment amount after the personnel change.
(5) Basic medical insurance premiums can be collected by entrusting a bank to withhold (signing-free agreement) or paid in cash, and are not restricted by the starting point of the amount.
Article 7 To ensure the normal operation of the basic medical insurance fund, employers and employees participating in the insurance should pay the basic medical insurance premiums one month in advance.
Article 8 The employer’s payment shall be disbursed through the following channels.
Administrative agencies shall be arranged by the finance department at the same level, and public institutions provided by the finance department shall be arranged by the finance department at the same level based on financial subsidies and business income. Other public institutions shall list expenses in the medical funds drawn from business income or operating income, and enterprises shall make expenditures in employee welfare fees. List of items.
Article 9 When an employer is divided, merged or terminated, it must first pay off the basic medical insurance premiums in arrears, and go through the registration change or deregistration procedures with the medical insurance agency within 10 days from the date of approval; after the change, , the party that leases, contracts, merges or accepts the operation shall bear all the basic medical insurance responsibilities of the original unit and its employees. When a bankrupt enterprise liquidates its property, it should pay off the arrears of basic medical insurance premiums in the first order and pay in full the basic medical insurance premiums for employees who have been employed for 1 years.
Article 10 Employers and employees must pay basic medical insurance premiums in full on a monthly basis. The basic medical insurance premiums payable by individual employees shall be withheld from their salary income by their units. If the payment is overdue, the medical insurance benefits paid by the unified fund for employees and retirees of the unit will be suspended, and penalties will be imposed in accordance with the relevant provisions of the "Interim Regulations on the Collection and Payment of Social Insurance Premiums". It will be reinstated after resubmission. Medical expenses incurred during the suspension period that should be paid by the unified fund will not be paid.
Chapter 3 Establishment and use of personal medical insurance accounts
Article 11 Medical insurance agencies shall establish lifelong personal medical insurance accounts for employees participating in basic medical insurance.
The personal medical insurance account consists of the individual payment amount and the amount credited according to the following proportion.
Employees under the age of 35 (including 35 years old) are entitled to 0.8% of their monthly salary income; employees between 35 and 45 years old (including 45 years old) are entitled to 1% of their monthly salary income; employees over 45 years old are entitled to 1% of their monthly salary income. 1.2% of his/her monthly salary income. Retirees are credited with 3.4% of the monthly basic pension of the previous year.
Article 12 The principal and interest of the personal medical insurance account belong to the individual employee and can be carried forward for use and inheritance.
Article 13 The personal medical insurance account is mainly used to pay the outpatient medical expenses of the employee, the inpatient medical expenses below the threshold and the medical expenses that should be borne by the individual within the payment scope of the overall fund.
Chapter 4 Establishment and Use of Medical Coordination Fund
Article 14 The remainder of the basic medical insurance premiums paid by the employer for its employees, after deducting them from the personal medical insurance account, shall be included in the medical overall fund, and shall be determined by the medical insurance agency according to the principle of revenue-based expenditures and balance of expenditures. Concentrated use.
The scope of medical expenses paid by the overall pool fund should be in line with the spirit of relevant national and provincial documents.
Article 15 The minimum payment standard for medical expenses paid by the medical pooling fund for employees’ medical expenses for the first hospitalization in this year is 10% of the average annual salary of employees in the city, county (city) in the previous year; for the second hospitalization, it is 8%; The rate for hospitalizations more than three times was 6%. The maximum payment limit is four times the average annual salary of employees in the city, county (city) to which it belongs in the previous year. Medical expenses below the minimum payment standard shall be paid by personal medical accounts or by individuals, and medical expenses above the maximum payment limit shall be settled through the urban employee mutual medical insurance measures (specific measures will be formulated separately).
Medical expenses above the minimum payment standard and below the maximum payment limit are mainly paid by the overall fund, and individuals should bear a certain proportion: above the minimum payment standard to 8,000 yuan, active employees personally bear 20%, and retirees personally bear 18%; 8,000 +—13000 yuan, the personal burden of active employees is 18%, and the personal burden of retirees is 16%; 13001—17000 yuan, the personal burden of active employees is 16%, and the personal burden of retirees is 1 4%; 17001 yuan up to the maximum payment limit, the personal burden of current employees is 14%, and the personal burden of retirees is 12%. In the future, with the increase in the average salary of employees and the operation of the medical co-ordination fund, the amounts of the four payment periods will be adjusted accordingly.
For medical expenses that are approved to be transferred outside the coordinated area or hospitalized for business trips, the proportion of personal burden shall be increased by 20 percentage points based on the second paragraph of this article.
Article 16 A hospitalization refers to the entire process of a patient's admission and discharge procedures. If emergency rescue and hospitalization are continuous, it will be regarded as one hospitalization. If the transfer is approved and the transfer process is within 5 days, two hospitalizations can be regarded as one hospitalization. If a hospitalization or emergency rescue process spans multiple years, the settlement year will be determined based on the end time of diagnosis and treatment.
Article 17 For special examinations and special treatments during hospitalization and emergency rescue, the individual shall bear 20% first, and the remaining 80% shall be subject to the provisions of Article 15. If the drugs used by employees during hospitalization or emergency rescue belong to the "Category B Catalog" of the "Drug Catalog", the individual shall bear 10% first, and the remaining 90% shall be subject to the provisions of Article 15. In the future, if the country and province have new regulations, they shall be subject to the new Provisions are enforced.
Article 18 The overall fund will not pay the medical expenses incurred by persons participating in medical insurance due to illegal crimes, alcoholism, fights, suicide and self-mutilation, traffic accidents and medical accidents.
Article 19: Retirees resettled in other places shall be subject to fixed quota management of medical expenses. The funds in the personal account are allocated to the individual, and the hospitalization medical expenses that should be paid by the overall fund shall be based on the per capita hospitalization medical expenses of the retirees in the original retirement city or county (city) in the previous year.
Standard, annual quota management is implemented, and 50% of the balance of the individual's fixed medical expenses for the current year will be awarded to the individual, and the overspending will not be reimbursed.
Chapter 5 Basic Medical Insurance Fund Management and Supervision
Article 20 Basic medical insurance funds shall be uniformly raised, managed and used by municipal and county (city) medical insurance agencies respectively.
Article 21 The basic medical insurance fund shall be incorporated into a separate social insurance fund financial account at the same level, and management shall be implemented on two lines of revenue and expenditure. The funds shall be earmarked for exclusive use and shall not be misappropriated by any unit or individual. The business expenses of medical insurance agencies shall not be withdrawn from the fund and shall be settled by the fiscal budget at the same level.
Medical insurance funds and interest are not included in taxes and fees.
Article 22: The bank interest calculation method for the basic medical insurance fund: the part raised in the current year is calculated at the interest rate of current deposits; the principal and interest of the fund carried forward from the previous year is calculated at the interest rate of bank deposits in three-month lump sums; Precipitated funds deposited into the special social security fiscal account will be charged interest based on the three-year zero-sum savings deposit rate.
Article 23 Medical insurance agencies must establish and improve budget and final accounting systems, financial accounting systems and internal audit systems.
Article 24 The labor and finance departments shall supervise and manage basic medical insurance funds, and the audit department shall regularly audit the fund income and expenditure and management of medical insurance agencies. The Fund Medical Insurance Supervision Committee supervises and inspects the management of basic medical insurance funds.
Article 25 Employees participating in medical insurance have the right to supervise the implementation of basic medical insurance policies and fund management. Employees' complaints and reports against relevant units and personnel are protected by law.
Article 26 The employer shall regularly announce the payment status of employees’ basic medical insurance premiums to employees. Employees have the right to inquire about their total wages and the income and expenditure of their personal accounts from their employers and basic medical insurance agencies. The medical insurance agency shall be authorized by the labor administrative department at the same level to audit the employer's relevant accounts, statements, wages, retirement payment amounts, employee rosters, insured persons and payment bases.
Chapter 6 Medical Service Management
Article 26 Basic medical insurance shall be managed by computer network. Use uniformly issued IC cards, medical insurance cards, and medical records.
Article 28 Medical insurance agencies are responsible for identifying designated medical institutions and designated pharmacies, and signing agreements with designated medical institutions and designated pharmacies in accordance with the spirit of relevant national and provincial documents to clarify the responsibilities, rights and obligations of both parties.
Article 29 Employers and their employees can, with the approval of the medical insurance agency, choose 2 to 3 designated medical institutions to seek medical treatment and purchase medicines with their IC cards, medical insurance certificates, and medical records. They can also purchase medicines at designated pharmacies with prescriptions. .
Article 30 Designated medical institutions and designated pharmacies should set up computer terminals in accordance with the requirements for basic medical insurance computer network construction, and the operators should be certified to work after being trained by the medical insurance agency.
Article 31 Employees’ transfers must be approved by designated medical institutions and transferred step by step. They can also be transferred to specialized hospitals in this city, but effective measures should be taken to strictly control transfers.
Article 32: Establish a medical supervision system. Medical insurance agencies must conduct regular supervision and inspection of designated medical institutions and designated pharmacies.
Chapter 7 Settlement of Medical Expenses
Article 33 The medical expenses incurred by employees using personal medical insurance accounts at designated medical institutions or designated pharmacies and the medical expenses paid by the medical insurance for the treatment of discharged patients with severe diseases listed in the "Catalogue of Diseases" in the current month shall be paid by the medical insurance The handling agency is responsible for reviewing relevant information and settling accounts with designated medical institutions and designated pharmacies once a month.
Article 34: The medical insurance agency shall formulate quota standards with reference to the average length of hospitalization of employees, average hospital bed-day cost and number of hospitalizations in the previous year, as well as the number of employees and retirees of insured units, and submit it to the medical reform leading group for approval. For designated medical institutions Implement total medical expense control and quota management.
Chapter 8 Management Organization and Responsibilities
Article 35 The city’s leading group for the reform of the basic medical insurance system for urban employees is responsible for studying and formulating the overall plan for the reform of the city’s medical insurance system and relevant policies and regulations.
The office of the Municipal Leading Group for the Reform of the Basic Medical Insurance System for Urban Employees is located in the Municipal Labor Bureau. It is responsible for the implementation of the city’s medical insurance system, supervision and inspection of the implementation of medical insurance policies and regulations by relevant units, and solving related problems during the implementation process.
Establish a medical insurance supervision committee led by the labor and social security administrative department and participated by departments such as structural reform, finance, auditing, price, health, medicine, People's Bank of China, and labor unions. Supervise and inspect the receipts and expenditures, operations, management and services of basic medical insurance funds by medical insurance agencies, and announce them to the public on a regular basis.
Each county (city) shall establish a coordination and management agency accordingly and clarify its responsibilities.
Chapter 9 Supplementary Provisions
Article 36 Medical expenses incurred by employees due to work-related injuries or maternity shall be governed by the relevant provisions of work-related injury and maternity insurance. Those who do not participate in work-related injury or maternity insurance will be settled according to the original funding channels.
Article 37: At the same time as these measures are implemented, insured units and employees will no longer implement the original publicly funded medical care and labor insurance medical care. Before the implementation of this measure, the medical expenses of active employees and retirees (including those whose medical treatment has not been terminated) will still be settled through the original channels.
Article 38: The medical treatment of retired personnel and veteran Red Army personnel shall remain unchanged, and medical expenses shall be settled according to the original fund channels. If there are any difficulties in payment, the people's government at the same level shall help solve the problem. The medical treatment for disabled revolutionary servicemen of Class B and above will remain unchanged, and medical expenses will be settled according to the original funding channels. The local people's government will help solve the insufficient payment of medical expenses, but management should be strengthened to prevent waste (specific management measures will be formulated separately).
Article 39 On the basis of participating in basic medical insurance, state civil servants enjoy medical subsidy policies in accordance with the relevant regulations of the Provincial People's Government.
Existing specific industries (units) with high medical consumption levels can establish corporate supplementary medical insurance for employees on the basis of participating in basic medical insurance. The part of the enterprise's supplementary medical insurance premiums within 4% of the total salary shall be deducted from employee welfare fees. The part of the welfare fees that is insufficient shall be included in the cost after approval by the financial department at the same level.
Article 40 Family members of employees and students in ordinary secondary and higher education institutions are temporarily not included in the basic medical insurance, and their medical expenses will be properly settled according to the original method.
Article 41: For employees with low income and difficult family life, if excessive medical expenses affect the basic life of the family, the employer where the employee works shall provide subsidies from welfare fees.
Article 42: Medical expenses incurred in the treatment of large-scale critical and serious patients caused by force majeure factors such as sudden epidemic diseases and natural disasters shall be comprehensively coordinated and settled by the local government.
Article 43 The municipal labor and social security administrative department is responsible for the interpretation of these Measures.
Article 44 These Measures shall come into effect from the date of promulgation. If the provisions of these Measures are inconsistent with other previous provisions, the provisions of these Measures shall prevail.