Article 1 for the protection of urban residents basic medical needs, the establishment of a sound multi-level medical security system, according to the relevant provisions of the state and the province, combined with the actuality of the city, the formulation of these measures.
Article 2 of this approach applies to the administrative area of the city does not belong to the urban workers covered by the basic medical insurance system with 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), nursery institutions for children and other children and adolescents under the age of 18 years (hereinafter referred to as) Minor urban residents);
(b) urban residents aged 60 for men and 55 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 participate in the basic medical insurance for urban residents at the same time.
Article 3 of the basic medical insurance system for urban residents adhere to the following principles:
(a) the level of medical care and financing standards and the city's level of economic development and the ability of all parties to afford;
(b) low rates, broad coverage, to protect the major illnesses;
(c) the government-led, voluntary participation in the implementation of the territorial management;
(d) Individual contributions, the government appropriate subsidies;
(e) basic medical insurance fund in accordance with the principle of income to determine expenditure, revenue 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 rural cooperative medical care and social medical assistance in an integrated and coordinated manner, convergence and coordinated development.
Article 4 of 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 referred to as urban areas) within the scope of the implementation of municipal co-ordination, the counties (municipalities), respectively, the operation of the conditions are ripe for gradual transition to municipal co-ordination.
Article V 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 region, the social insurance agencies under its specific contractors of basic medical insurance for urban residents.
The urban residents of the urban 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.
The 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; the financial sector is responsible for budgetary arrangements, fund allocation and fund supervision, etc.; the health sector is responsible for the construction and management of community health care institutions; the education sector is responsible for organizing and coordinating the participation of urban primary and middle school students in the work of urban residents in the basic medical insurance; the civil affairs department is responsible for the identification of low income objects, the civil affairs department is responsible for the urban residents in the basic medical insurance work. The civil affairs department is responsible for the identification of low-income objects, organizing and guiding the low-income objects to participate in the insurance, supporting the development of good medical assistance work; the Federation of Disabled Persons is responsible for the identification of persons with severe disabilities; the public security department is responsible for the identification of the household registration of the residents participating in the insurance 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 the basic medical insurance for urban residents.
Article 6 of the basic medical insurance for urban residents work required funding, by the same level of financial commitment.
Article 7 governments at all levels should strengthen the social insurance agencies and community labor security platform construction, to ensure that the work of the necessary personnel, equipment and funding, to establish and improve the basic medical insurance for urban residents to expand incentives and constraints and supervision and evaluation mechanism.
Chapter II fund-raising
Article 8 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.
(ii) general urban residents 280 yuan per person per year. Among them, individuals pay 200 yuan, the government subsidy of 80 yuan; belonging to the low-income objects or severely disabled, individuals pay 20 yuan, the government subsidy of 260 yuan.
(c) 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 objects or severely disabled, individuals pay 20 yuan, the government subsidies 260 yuan.
The counties (cities) urban residents basic medical insurance premiums, in accordance with the minor urban residents per person per year of not less than 80 yuan, general and elderly urban residents per person per year of not less than 240 yuan of the standard raised. Of which the government subsidies per person per year, respectively, not less than 40 yuan, 60 yuan, 100 yuan standard; belonging to the low-income objects or severely disabled, respectively, not less than 60 yuan per person per year, 180 yuan, 180 yuan standard subsidies.
Article 9 of the basic medical insurance financing standards for urban residents and government subsidies can be adjusted in accordance with the level of economic development at the appropriate time, by 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 10 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 the part of the subsidy. Individual contributions and unit subsidies for the implementation of the State's tax incentives.
Article 12 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, the year no longer apply for insurance payment procedures. January 1 to December 31 each year for a medical year.
Article 13 of the basic medical insurance premiums for urban residents by the following units are responsible for the collection:
(a) primary and secondary school students, by the education sector is responsible for organizing the collection of payment;
(b) other people in the family as a unit of their domicile by the streets, townships and townships responsible for the collection of payment of the labor security service agencies.
Article 14 of the collection unit should do a good job of collecting basic medical insurance premiums, registration and change of information, to assist the social insurance agency to do a good job of participating in the confirmation of information and other related work, in a timely manner to the urban residents of the basic medical insurance premiums transferred to the social insurance agency, and shall not be detained, misappropriation.
The social insurance agency shall establish a record of contributions and payments for the insured urban residents, and 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 focus on the protection of hospitalization and outpatient medical treatment of the insured, the primary and secondary school students to take into account the appropriate accidental injuries.
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 basic medical insurance for urban workers and the implementation of the relevant provisions. Children's drugs need to increase the scope of the catalog in accordance with the relevant provisions of the state and the province.
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. Counties (cities) maximum payment limit of not less than 30,000 yuan.
Article 18 of the insured persons in the designated medical institutions incurred in accordance with the provisions of the hospitalization medical costs, included in the urban residents of the basic medical insurance fund to pay the scope. 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. Counties (cities) can determine their own 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 require 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) may decide on its own 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 In a medical year, the eligible inpatient medical expenses and outpatient medical expenses incurred by the insured person are combined, and the basic medical insurance fund will 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, by 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 at the right time.
Article 23 of the general and elderly urban residents in a medical year did not incur hospitalization and outpatient major medical expenses, and the next medical year to continue to participate in the insurance premiums, you can enjoy the general outpatient medical subsidies of 10% of the amount of the individual contributions for the previous medical year. When the conditions are ripe, the gradual implementation of general outpatient medical expenses.
Article 24 of the insured person's condition requires the transfer of foreign hospitals for hospitalization, must be issued by the city's tertiary hospitals or municipal specialized hospitals to transfer procedures, and reported to the social insurance agency for approval. Approved by the hospitalization medical costs incurred after the transfer, the individual first 10%, the remaining part of the treatment in accordance with this method in the three hospitals standard implementation; 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 standard implementation.
Article 26 of the establishment of the number of years of contributions and the enjoyment of medical treatment mechanism. 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 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, its participation in the city of urban residents in the basic medical insurance of urban residents of the cumulative contribution period of every 3 years of basic medical insurance for the urban workers to pay 1 year of basic medical insurance (conversion of 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 contributions, 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, enroll in the next year, from the start of the medical year six months before enjoying the basic medical insurance benefits in accordance with the provisions.
Article 29 of the following cases do not belong to the urban residents of the basic medical insurance fund to pay:
(a) work (public) injuries, occupational diseases, and women's childbirth medical expenses;
(b) the insured person to go abroad, or go to Hong Kong, Macao and Taiwan during the period of the medical expenses incurred;
(c) due to traffic accidents, and medical accidents, pharmaceutical accidents medical expenses incurred
(4) due to crime, alcoholism, fighting, suicide, self-inflicted injuries and other medical costs;
(5) national and provincial regulations do not belong to the urban residents of the basic medical insurance coverage of other medical costs.
Article 30 due to natural disasters and other factors caused by a wide range of emergency, critical, serious patients rescue medical expenses incurred, coordinated by the governments at all levels.
Chapter IV Management of medical services
Article 31 of the basic medical insurance for urban residents to implement the management of designated medical institutions, the insured should be the nearest choice of a designated hospital as their own inpatient and outpatient hospitals designated medical institutions for major illnesses, the service period of one year, the service period expired, the insured can change the designated medical institutions according to the service situation.
Except for the cases stipulated in Articles 24, 25 and 34 of these Measures, the basic medical insurance fund will not pay for the medical expenses incurred in non-designated medical institutions.
Article 32 of the hospitalization of insured persons should first be hospitalized in designated medical institutions. If the condition of the patient requires transfer to a hospital within the city, the designated medical institution shall, according to the patient's condition, handle the transfer procedures in a timely manner 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 institution.
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, according to 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 proof of emergency hospitalization 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 this approach.
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 in the basic medical insurance for urban residents 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 labor security, finance, audit and other departments.
Article 39 of the basic medical insurance fund for urban residents of income and expenditure management, should be regularly reported to the same level of social security supervisory committee, and regularly announced to the community to accept social supervision.
Chapter VI rewards and punishments
Article 40 of the urban residents of the basic medical insurance fee collection unit has one of the following acts, the Ministry of Labor and Social Security ordered to correct; refused to correct, by its competent departments of the main person in charge and directly responsible for the person to be given 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 medical 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 do not meet the conditions of the persons enrolled in the insurance or enjoy the government subsidies
(E) retention, misappropriation of medical insurance premiums;
(F) other violations of the basic medical insurance for urban residents laws and regulations.
Article 41 designated 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, suspended or canceled medical institutions designated qualification; constitutes a crime, be held criminally responsible.
(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 funds;
(c) will not meet the referral conditions of the insured referral;
(d) violation of the principle of treatment of diseases or relevant provisions, the emergence of (d) Violating the principle of treating patients according to their illnesses or the relevant regulations, such as indiscriminate examination, abuse of medicines, and charging arbitrary fees;
(e) Violating the basic medical insurance management regulations for urban residents.
Article 42 of the participants fraudulent medical insurance fund, the Ministry of Labor and Social Security shall order the return, and shall be punished in accordance with relevant laws and regulations; constitutes a crime, shall be investigated for criminal responsibility.
Article 43 of the parties to the Department of Labor and Social Security 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 according to law.
Article 44 of the Ministry of Labor and Social Security, social insurance agencies and their staff abuse of power, favoritism, dereliction of duty, damage to the legitimate rights and interests of insured persons or cause the loss of medical insurance fund, shall be given administrative sanctions; constitutes a crime, shall be investigated for criminal responsibility.
Article 45 to establish a reward system for reporting. Encourage all sectors of society on the designated medical institutions in violation of the basic medical insurance management regulations, infringement of the legitimate rights and interests of the participants in the 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, according to the provisions of the basic urban residents gradually into the scope of medical insurance services.
Article 47 has been carried out in urban residents of basic medical insurance ("new city") of the county (city, district), according to the provisions of this approach to integration.
Article 48 The municipal labor security department may formulate implementation rules in accordance with these measures.
The county (city) government should be based on the provisions of these measures, combined with the local reality, study and formulate specific comments, reported to the municipal government for approval and implementation. Article 49 of this approach since June 1, 2008 shall come into force.