Weifang Government issued [2008] No. 12
The people's governments of all counties and municipalities, municipal development zones, the municipal government departments, directly under the institutions, the relevant enterprises, colleges and universities, the people's organizations, Weifang military sub-district:
Weifang City, urban residents of basic medical insurance interim measures has been agreed by the municipal government, is hereby issued to you, please implement it carefully. Interim Measures for Basic Medical Insurance for Urban Residents" has been agreed by the municipal government, is issued to you, please conscientiously implement.
May 30, 2008
Weifang City, urban residents of basic medical insurance interim measures
Chapter I General Principles
Article 1 In order to protect the basic health care needs of urban residents, 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, to formulate the present measures.
Second, these measures apply 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 in the children and other children and young people under the age of 18 years (hereinafter referred to as) (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 The basic medical insurance system for urban residents adheres to the following principles:
(1) the level of medical care and financing standards and the city's level of economic development and the ability of all parties to afford;
(2) low rates, broad coverage, to protect the major illnesses;
(3) the government-guided, voluntary enrollment, and implementation of the local management;
(4) the individual contribution-based, the government to pay for the basic medical insurance, the general urban residents (hereinafter referred to as the general urban residents). 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 The city's basic medical insurance for urban residents to implement a unified policy. At the 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 areas) within the scope of the municipal level, the counties (cities), respectively, and when conditions are ripe, the gradual transition to municipal level.
Article V city, county urban areas, municipal development zones, the municipal department of labor security is responsible for the administration of basic medical insurance for urban residents in the administrative area, the social insurance agency under its specific contractors of basic medical insurance for urban residents.
The urban residents' basic medical insurance business is undertaken by the municipal social insurance agency, the district social insurance agencies 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 good medical assistance; 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 VI of the basic medical insurance for urban residents work required funding, by the same level of finance.
Article 7 The governments at all levels shall strengthen the construction of social insurance agencies and community labor security platforms, ensure that the necessary personnel, equipment and funds to carry out the work, and 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 8 of the basic medical insurance premiums for urban residents in urban areas 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 in accordance with the standard of not less than 80 yuan per person per year for minor urban residents and 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 in accordance with 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 to encourage 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 to pay once a year. November 1 to December 31 each year for the next medical year payment period. Anyone who fails to pay within the payment period will not be processed for enrollment and payment during the year. 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, 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 The collection units should do a good job of collecting basic medical insurance premiums, registration and change of information, and assist the social insurance agency to do a good job of confirming the information and other related work, and timely transfer of urban residents' basic medical insurance premiums to the social insurance agency, and shall not be retained or misappropriated.
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 basic medical insurance treatment
Article 15 of the basic medical insurance for urban residents focus on protecting the insured hospitalization and outpatient medical treatment of serious illnesses, the primary and secondary school students to take into account the accidental injury medical treatment.
Article 16 The scope of medicines, diagnostic and therapeutic items, the scope of medical service facilities and payment standards of the basic medical insurance for urban residents, as well as the management of designated medical institutions, with reference to the relevant provisions of the city's basic medical insurance for urban workers. Children's drugs need to increase the scope of the catalog in accordance with the relevant national and provincial regulations.
Article 17 The urban residents' basic medical insurance fund 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 the insured in the 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 insured persons suffering from malignant tumors radiotherapy, uremia dialysis treatment, organ transplantation anti-rejection treatment, chronic aplastic anemia treatment, as well as minor insured persons 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 payment ratio is 50% for the part from the starting standard to the maximum payment limit. Each county (city) can determine the types of outpatient major illnesses, starting standard and payment ratio.
Article 20 of the primary and secondary school students due to accidents and injuries occurring in the outpatient emergency medical expenses, the basic medical insurance fund to pay 80% of the annual maximum payment of 1,000 yuan.
Article 21 Within a medical year, the eligible inpatient medical expenses 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 The annual maximum payment limit, the starting standard, the types of outpatient diseases and the payment ratio of the basic medical insurance fund for urban and rural residents shall be adjusted by the labor and social security departments in conjunction with the financial departments at the same level in accordance with the balance of the basic medical insurance fund at the appropriate time.
Article 23 The general and elderly urban residents who have not incurred hospitalization and outpatient medical expenses for major illnesses in a medical year and continue to participate in the insurance premiums in the next medical year shall be entitled to a general outpatient medical subsidy of 10% of the amount of the individual premiums paid in the previous medical year. When conditions are ripe, the general outpatient medical expenses will be gradually implemented.
Article 24 of the insured person's condition requires transfer to an overseas hospital for hospitalization, must be issued by the city's tertiary 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 hospitals standard implementation; without the approval of the 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 an emergency hospitalization of medical expenses, the individual first 20%, the remaining part of the treatment in accordance with the measures in the tertiary hospitals standard implementation.
Article 26: Establishment of 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: If an urban resident who has participated in the basic medical insurance for urban residents joins the basic medical insurance for urban workers after working in the city, his/her cumulative contribution period for the basic medical insurance for urban residents within the city shall be converted into one year's contribution period for the basic medical insurance for urban workers for every three years he/she has participated in the basic medical insurance for urban residents (if the calculation is less than one year, it shall be calculated in accordance with the actual time of the conversion).
Article 28 The insured shall pay the basic medical insurance premiums in full and on time; if the payment is interrupted, the basic medical insurance fund shall not pay the medical expenses incurred during the interruption period. Urban residents who are eligible to participate in the insurance premiums in a timely manner, to participate in the following year, from the beginning of the medical year six months before enjoying the basic medical insurance benefits in accordance with the provisions.
Article 29 The following cases are not covered by the basic medical insurance fund for urban residents:
(1) medical expenses incurred in connection with work-related injuries, occupational diseases, and childbirth of women;
(2) medical expenses incurred during the period in which a participant leaves the country or travels to Hong Kong, Macao, or Taiwan;
(3) medical expenses incurred as a result of traffic accidents, medical and pharmaceutical incidents,
(3) medical expenses incurred as a result of medical and pharmaceutical incidents, and medical and pharmaceutical incidents.
(iv) medical expenses incurred as a result of crime, alcoholism, assault, suicide, self-inflicted injury, etc.;
(v) other medical expenses that are not covered by the basic medical insurance for urban residents as stipulated by the state and province.
Article 30 The medical expenses incurred in the rescue of patients with acute, critical or serious illnesses on a wide scale caused by natural disasters and other factors shall be coordinated by the governments at all levels.
Chapter IV Management of Medical Services
Article 31 The basic medical insurance for urban residents to implement the management of designated medical institutions, the insured person should choose a designated hospital as their nearest inpatient and outpatient hospitals as the designated medical institutions for major illnesses, the service period of one year, the expiration of the service period, the insured person can be changed according to the service situation of 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 The hospitalization of insured persons shall be the first 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 handle the transfer procedure and report it 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 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 regularly.
The basic medical insurance fund will not pay for the medical expenses incurred in the event of non-compliance with the hospitalization procedures.
Article 34 The insured can be hospitalized in the nearest hospital in case of emergency or critical illness. Hospitalization in non-designated medical institutions, should be hospitalized with emergency hospitalization certificate and related information within three working days to the designated medical institutions and social insurance agencies for the record, the hospitalization medical costs incurred, the individual first 5%, and then in accordance with the relevant provisions of these Measures.
Article 35 of the fixed-point medical institutions shall establish and improve the basic medical insurance for urban residents internal management system, the 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 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 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 The social insurance agency shall establish and improve the internal management system, strengthen the basic medical insurance fund for urban residents income and expenditure management, and accept the supervision and inspection of labor security, finance, audit and other departments.
Article 39 The income and expenditure management of the basic medical insurance fund for urban residents shall be regularly reported 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 The collection of basic medical insurance premiums for urban and rural residents of one of the following acts, the Ministry of Labor and Social Security shall order correction; refusal to make corrections, the competent authorities of the principal person in charge of the main person and the person directly responsible for the criticism and education, or administrative sanctions; constitutes a crime, shall be investigated for criminal responsibility.
(a) not in accordance with the provisions of the registration or change of insurance information for participants;
(b) not in accordance with the provisions of the collection of health insurance premiums;
(c) not in accordance with the provisions of the relevant medical management services for the participants;
(d) do not carefully review the relevant documents or fraud, so that the ineligible persons to participate in the insurance or enjoy the government subsidies
(e) retaining or misappropriating medical insurance premiums;
(f) other violations of the laws and regulations on basic medical insurance for urban residents.
Article 41 of the fixed-point medical institutions and their staff, one of the following acts, the labor security department in accordance with the relevant provisions of the treatment; the circumstances are serious, suspension or cancellation of the qualification of the medical institutions fixed-point; constitutes a crime, shall be investigated for criminal responsibility.
(a) the insured medical services are not in place or not timely referrals;
(b) forged medical documents fraudulent medical insurance fund, or do not carefully confirm the identity of the insured resulting in loss of the fund;
(c) will not be eligible for referral of insured patients referral;
(d) violation of the principle of treatment of diseases or the provisions of the relevant, the emergence of (d) Violation of the principle of treating patients according to their illnesses or relevant regulations, such as indiscriminate examination, abuse of medicines, and charging arbitrary fees;
(e) Other violations of the regulations governing the basic medical insurance for urban residents.
Article 42 If an insured person fraudulently obtains medical insurance funds, the labor and social security departments shall order the return of such funds and impose penalties in accordance with the provisions of relevant laws and regulations; if a crime is constituted, the insured person shall be investigated for criminal responsibility according to law.
Article 43 The parties to the labor insurance department of the administrative penalty decision is not satisfied, you can apply for administrative reconsideration or bring an administrative lawsuit. If the party concerned fails to fulfill the administrative penalty decision, the administrative organ that made the administrative penalty decision shall apply to the people's court for compulsory execution in accordance with the law.
Article 44 The labor security department, the social insurance agency and its staff abuse of power, favoritism, dereliction of duty, damage to the legitimate rights and interests of the insured or cause loss of the medical insurance fund, shall be given administrative sanctions according to the law; constitutes a crime, shall be investigated for criminal responsibility.
Article 45 to establish a reporting system. Encourage all sectors of the community on the designated medical institutions in violation of the basic medical insurance management regulations, infringement of the legitimate rights and interests of the insured to report. The basic medical insurance fund involved in the reported cases, once verified, according to the law to recover 10% of the amount of violations of the standard reward to the informer, up to 20,000 yuan; does not involve the basic medical insurance fund, according to a standard of not more than 500 yuan to the informer to give a reward.
Chapter VII Supplementary Provisions
Article 46 of the community health service organizations, retail pharmacies to be ripe, in accordance with the provisions of the basic urban residents gradually into the scope of medical insurance services.
Article 47 The counties (cities and districts) that have launched the basic medical insurance for urban residents ("New City Cooperative") shall be harmonized in accordance with the provisions of these Measures.
Article 48 The municipal labor security department may formulate implementation rules in accordance with these measures.
The county (city) government shall, in accordance with the provisions of these measures, combined with local practice, study and formulate specific comments, reported to the municipal government for approval and implementation.
Article 49 These measures shall June 1, 2008 shall come into force.