We are forwarding to you the Interim Measures for Basic Medical Insurance for Urban Residents in Weifang City, you focus on the contents of articles 15-30.
Weifang City, Weifang City issued Weifang City, urban residents of basic medical insurance interim measures:
Chapter I General
Article 1 for the protection of urban residents of basic medical needs, the establishment of a sound multi-level medical security system, according to the relevant provisions of the State and the province, in conjunction with the actuality of the city, the formulation of these measures.
Second this approach applies to the administrative area of the city does not belong to the basic medical insurance system for urban workers covered by the city's household registration of the following non-employed urban residents:
(a) primary and secondary school students (including vocational high schools, junior colleges, technical schools, students of special education schools), child care institutions for children enrolled in the child and other children and adolescents under 18 years of age (hereinafter referred to as the) (hereinafter referred to as minor urban residents);
(b) urban residents who are 60 years old for men and 55 years old for women (hereinafter referred to as elderly urban residents);
(c) other eligible non-working urban residents (hereinafter referred to as general urban residents).
Those who participate in the New Rural Cooperative Medical Care cannot also participate in the Basic Medical Insurance for Urban Residents.
Article 3 of the basic medical insurance system for urban residents adhere to the following principles:
(1) the level of medical care and financing standards and the city's level of economic development and the affordability of the various aspects of the city;
(2) low rates, broad coverage, to protect the major illnesses;
(3) the government-led, voluntary enrollment, the implementation of the local management;
(4) Individual contributions, the government appropriate subsidies;
(e) basic medical insurance fund in accordance with the principle of income to determine expenditure, income and expenditure balance, a slight surplus raised and used;
(f) the basic medical insurance for urban residents and the basic medical insurance for urban workers, the new type of rural cooperative medical care and social medical assistance in an integrated and coordinated, interlinked and coordinated development.
Article 4 of the city's basic medical insurance for urban residents to implement a unified policy. Initial stage, Quiwen District, Weicheng District, Fangzi District, Hanting District, High-tech Development Zone, Economic Development Zone, Binhai Development Zone, Xiaoshan Development Zone (hereinafter collectively referred to as the urban area) within the scope of the municipal level, the counties (cities), respectively, and when conditions are ripe, the gradual transition to municipal level.
Article V of the city, county urban areas, municipal development zones, the Department of Labor and Social Security is responsible for the administration of basic medical insurance for urban residents in the administrative area, the social insurance agencies under its specific contractors of basic medical insurance for urban residents.
The urban residents of the basic medical insurance business by the city social insurance agency, the district social insurance agency to assist in the implementation.
Street offices and township governments are responsible for the registration of urban residents for basic medical insurance and other related work.
Development and reform departments are responsible for the basic medical insurance for urban residents into the national economy and social development planning and supervise the implementation of the financial sector is responsible for budgetary arrangements, fund allocation and fund supervision; health departments are responsible for the construction and management of community health care institutions; education departments are responsible for organizing and coordinating the participation of primary and middle school students in urban residents in the work of the basic medical insurance; the civil affairs department is responsible for the identification of low income recipients, the civil affairs department is responsible for the basic medical insurance for urban residents. The identification of low-income objects, organization and guidance of low-income objects to participate in the insurance, supporting the development of medical assistance work; Disabled Persons Federation is responsible for the identification of persons with severe disabilities; public security departments are responsible for the identification of the household registration of the insured residents and the provision of relevant information.
Food and drug supervision, pricing, auditing and other departments, should be in accordance with their respective responsibilities, do a good job of urban residents of basic medical insurance.
Article 6 of the urban residents of basic medical insurance work required funding, by the same level of finance.
Article 7 Governments at all levels shall strengthen the social insurance agencies and community labor security platform construction, to ensure that the work necessary personnel, equipment and funding, establish and improve the basic medical insurance for urban residents to expand the incentives and constraints and supervision and evaluation mechanism.
Chapter II fund-raising
Article VIII of the urban residents of basic medical insurance premiums in accordance with the following standards:
(a) 80 yuan per person per year for minor urban residents. Among them, the individual to pay 20 yuan, the government subsidy of 60 yuan; belonging to the low-income objects or severely disabled, the individual to pay 10 yuan, the government subsidy of 70 yuan.
(2) 280 yuan per person per year for general urban residents. Among them, individuals pay 200 yuan, the government subsidy 80 yuan; belonging to the low-income objects or the severely disabled, individuals pay 20 yuan, the government subsidy 260 yuan.
(3) 280 yuan per person per year for elderly urban residents. Among them, individuals pay 140 yuan, the government subsidies 140 yuan; belonging to the low income or severely disabled, individuals pay 20 yuan, the government subsidies 260 yuan.
The basic medical insurance premiums for urban residents in all counties (cities) are raised according to the standard of not less than 80 yuan per person per year for minor urban residents, and not less than 240 yuan per person per year for general and elderly urban residents. Of which the government subsidies at a rate of not less than 40 yuan, 60 yuan, 100 yuan per person per year; belonging to the low-income objects or severely disabled people, respectively, at a rate of not less than 60 yuan, 180 yuan, 180 yuan per person per year to give subsidies.
Article IX of the basic medical insurance financing standards for urban residents and government subsidies can be adjusted at the appropriate time according to the level of economic development, the labor and social security departments in conjunction with the financial sector to put forward the views of the government at the same level for approval and implementation.
Article X of the government subsidies, in addition to financial subsidies above the provincial level, the municipal financial subsidies in accordance with a certain percentage of some counties and municipalities. Among them, 50% of the urban subsidies, Anqiu City, Changle County, Linqu County, 15% subsidies, Qingzhou City, Gaomi City, Changyi City, 10% subsidies, the rest of the municipal governments in the counties to bear the financial burden. Government subsidies are included in the annual financial budget, the financial sector directly into the urban residents' basic medical insurance fund financial account.
Article 11 encourages the conditions of the employer's family of urban residents in the employee's personal contributions to subsidize the part. Individual contributions and unit subsidies for the implementation of the State's tax incentives.
Article XII of the basic medical insurance premiums for urban residents pay once a year. November 1 to December 31 each year for the next medical year payment period. Anyone who fails to pay the contributions within the payment period, the year will no longer apply for participation in the payment procedures. The period from January 1 to December 31 of each year is a medical year.
Article XIII of the basic medical insurance premiums for urban residents by the following units are responsible for the collection:
(1) primary and secondary school students, by the education department is responsible for organizing the collection of payment on behalf of;
(2) other people in the family as a unit of their domicile by the streets, townships and townships of the labor security service agencies are responsible for the collection of payment on behalf of.
Article 14 of the collection unit should do a good job of basic medical insurance premiums, registration and change of information, to assist the social insurance agency to do a good job of participating in the information confirmation and other related work, and timely transfer of basic medical insurance premiums for urban residents to the social insurance agency, shall not be retained, misappropriation.
Social insurance agencies shall establish contribution and payment records for urban residents, and shall be responsible for providing information inquiry for the insured.
Chapter III of the basic medical insurance treatment
Article 15 of the basic medical insurance for urban residents focuses on the protection of hospitalization and outpatient medical treatment of the insured, the primary and secondary school students to take into account the accidental injury medical treatment.
Article 16 of the basic medical insurance for urban residents of the scope of medication, diagnostic and treatment items, the scope of medical services and facilities and payment standards, as well as the management of designated medical institutions with reference to the city's urban workers in the implementation of the relevant provisions of the basic medical insurance. Children's drugs need to increase the scope of the catalog in accordance with the relevant provisions of the national and provincial implementation.
Article 17 of the basic medical insurance fund for urban residents to pay the annual maximum payment limit system. Urban participants in each medical year, the maximum payment limit, minor urban residents for 48,000 yuan, other urban residents for 30,000 yuan. Each county (city) maximum payment limit of not less than 30,000 yuan.
Article 18: The hospitalization medical expenses incurred by insured persons in designated medical institutions in accordance with the regulations shall be included in the scope of payment of the basic medical insurance fund for urban residents. According to the different levels of hospitals to determine the corresponding starting standard and payment ratio. For hospitalized medical expenses incurred in first-, second- and third-level hospitals, the starting standard in urban areas is 300 yuan, 500 yuan and 700 yuan, respectively; and the proportion of payment from the starting standard to the maximum payment limit is 60%, 55% and 50%, respectively. Each county (city) can determine the starting standard and payment ratio.
Article 19 of the establishment of outpatient major medical system. Urban participants suffering from malignant tumors radiotherapy, uremia dialysis treatment, organ transplantation anti-rejection treatment, chronic aplastic anemia treatment, as well as minor participants suffering from hepatitis B, type I diabetes mellitus, systemic lupus erythematosus, active tuberculosis, epilepsy, rheumatic fever and bronchial asthma requiring outpatient treatment, approved by the municipal social insurance agency, in the designated outpatient major medical institutions, outpatient The outpatient medical expenses for major diseases can be included in the scope of payment by the basic medical insurance fund. The starting standard for outpatient medical expenses for major diseases in urban areas is 600 yuan; the proportion of payment from the starting standard to the maximum payment limit is 50%. Each county (city) can determine the types of outpatient major illnesses, the starting standard and the payment ratio. Article 20 of the primary and secondary school students due to accidental injury occurs without responsibility for outpatient emergency medical expenses, the basic medical insurance fund to pay 80%, the annual maximum payment of 1000 yuan.
Article 21: Within a medical year, eligible inpatient and outpatient medical expenses incurred by an insured person shall be calculated together, and the basic medical insurance fund shall not pay more than the annual maximum payment limit.
Article 22 of the basic medical insurance fund for urban residents, the annual maximum payment limit, the starting standard, outpatient diseases, the payment ratio, the labor security department in conjunction with the financial sector at the same level in accordance with the balance of the basic medical insurance fund adjusted in due course.
Article 23 of the general and elderly urban residents in a medical year did not incur inpatient and outpatient medical expenses for major diseases, and the next medical year continue to participate in the insurance premiums, you can enjoy the last medical year, 10% of the amount of individual contributions to the general outpatient medical subsidies. When conditions are ripe, the general outpatient medical expenses will be gradually implemented.
Article 24 of the insured person's condition requires the transfer of overseas hospitals for inpatient treatment, must be issued by the city's third-level hospitals or municipal specialized hospitals, and reported to the social insurance agency for approval. After the approval of the transfer of hospitalization medical costs incurred, the individual first 10%, the remaining part of the treatment in accordance with this method in the tertiary hospital treatment standards; unauthorized transfer of hospitalization medical costs incurred, the basic medical insurance fund will not pay.
Article 25 of the insured person for visiting relatives, travel and other reasons in a foreign place in the emergency hospitalization of medical expenses, the individual first 20%, the remaining part of the treatment in accordance with the measures in tertiary hospitals in accordance with the implementation of the standard treatment.
Article 26 establishes a mechanism to link the number of years of contributions with the enjoyment of medical treatment. Urban residents continuously pay basic medical insurance premiums for every five years, hospitalization medical costs of basic medical insurance fund to increase the proportion of payment by 1 percentage point.
Article 27 of the general urban residents to participate in the basic medical insurance of urban residents, the employment of urban workers to participate in the basic medical insurance, their participation in the basic medical insurance of urban residents in the city of the cumulative contribution period of every 3 years for the basic medical insurance of urban workers to pay 1 year (conversion less than 1 year, according to the actual time of the conversion).
Article 28 of the insured shall pay the basic medical insurance premiums in full and on time, the interruption of the payment of premiums, the interruption of the period of medical expenses incurred during the basic medical insurance fund will not pay. Urban residents who are eligible to participate in the insurance premiums in a timely manner, to participate in the following year, six months from the start of the medical year, and then enjoy the basic medical insurance benefits in accordance with the provisions of the regulations.
Article 29 of the following cases do not fall within the scope of the basic medical insurance fund for urban residents:
(1) work-related (public) injuries, occupational diseases, and women's maternity incurred medical expenses;
(2) the insured person to go abroad, or go to Hong Kong, Macao, Taiwan, incurred during the period of medical expenses;
(3) due to traffic accidents, and medical and pharmaceutical accident, medical costs.
(iv) medical expenses incurred as a result of crime, alcoholism, assault, suicide, self-inflicted injuries and other medical expenses;
(v) other medical expenses that are not covered by the basic medical insurance for urban residents as stipulated by the state and the province.
Article 30 due to natural disasters and other factors caused by a wide range of emergency, critical, serious patients rescue medical expenses incurred, the government at all levels to coordinate the solution.
Chapter IV medical service management
Article 31 of the basic medical insurance for urban residents to implement designated medical institutions, the insured should be the nearest choice of a designated hospital as their own inpatient and outpatient major medical institutions, the service period of one year, the expiration of the service period, the insured person can be based on the service to change the designated medical institutions.
Except for the cases stipulated in Articles 24, 25 and 34 of these Measures, the basic medical insurance fund shall not pay for the medical expenses incurred in non-designated medical institutions.
Article 32 of the hospitalization of the insured person should first be hospitalized in the designated medical institutions. If the condition of the patient requires transfer to a hospital within the city, the designated medical institution shall, in accordance with the patient's condition, promptly complete the transfer procedures and report them to the social insurance agency for the record.
The basic medical insurance fund will not pay for the hospitalization medical expenses incurred without the transfer procedures of the designated medical institutions.
Article 33 of the insured person in the designated medical institutions, should hold the relevant documents for hospitalization procedures, after the end of medical treatment, in accordance with the standards set out in these measures, the insured person and the hospital should only be individually responsible for the part of the settlement, the rest of the cost of the social insurance agency and the medical institutions to settle on a regular basis.
The basic medical insurance fund will not pay for the medical expenses incurred by the participant who is not hospitalized according to the regulations.
Article 34: In the event of an emergency or critical illness, the insured person may be hospitalized in the nearest hospital. Hospitalization in non-designated medical institutions, should be hospitalized with proof of emergency hospitalization and related information within three working days to the designated medical institutions and social insurance agencies for the record, incurred hospitalization medical costs, the individual first 5%, and then in accordance with the relevant provisions of these Measures.
Article 35 of the designated medical institutions shall establish and improve the basic medical insurance for urban residents internal management system, strict implementation of the relevant policies and regulations and medical service agreements, with a full-time (part-time) management personnel to do a good job of the basic medical insurance for urban residents of internal management.
Chapter V Fund Management and Supervision
Article 36 of the basic medical insurance fund for urban residents to implement the two lines of income and expenditure, into the financial account management, separate accounts, any unit or individual shall not be squeezed, misappropriation.
Article 37 of the basic medical insurance fund for urban residents to implement a unified social insurance fund budgeting system, financial accounting system and internal audit system.
Article 38 of the social insurance agencies shall establish and improve the internal management system, strengthen the urban residents of the basic medical insurance fund income and expenditure management, and accept the supervision and inspection of the departments of labor security, finance, audit.
Article 39 of the basic medical insurance fund for urban residents of income and expenditure management, shall regularly report to the social security supervisory committee at the same level, and regularly publicized to the community to accept social supervision.
Chapter VI rewards and punishments
Article 40 of the basic medical insurance premiums for urban residents of the collection unit of one of the following acts, the Ministry of Labor and Social Security department shall order correction; refusal to make corrections, by the competent departments of the principal person in charge and the person directly responsible for the criticism of the education or administrative sanctions; constitutes a crime, shall be investigated for criminal responsibility.
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