Chapter I General Principles
Article 1 In accordance with the requirements of the spirit of the Decision of the State Council on the Establishment of a Basic Medical Insurance System for Urban Workers (Zhongguo
National Development [1998] No. 44) and the Circular of the People's Government of the Autonomous Region on the Issuance of the Overall Plan for the Establishment of a Basic Medical Insurance System for Urban Workers of the Guangxi Zhuang Autonomous Region (Gui Zheng Fa [1999] No. 61). The formulation of this approach.
Article 2 The principles of basic medical insurance are:
(1) "basic level", i.e., the level of basic medical insurance should be compatible with the level of socio-economic development of the city;
(2) "extensive coverage", i.e. All employers and their employees are required to participate in basic medical insurance, and local management is implemented. Flexibly employed people can also participate in basic medical insurance;
(3) "Both sides bear the burden", i.e., basic medical insurance premiums are borne by both employers and employees***;
(4) "Combination of unified accounts", i.e., the basic medical insurance fund is based on the implementation of social coordination and the implementation of social insurance. The medical insurance fund is mainly based on the combination of social integration and individual accounts, supplemented by the implementation of a single-building integration. The fund is raised, paid out and managed by the labor security administrative departments at all levels on the basis of the principles of determining expenditures on the basis of income and balancing revenues and expenditures.
Article 3 All urban employers within the jurisdiction of Wuzhou City, including enterprises (state-owned and state-controlled enterprises, collective enterprises, foreign-invested enterprises, joint-stock enterprises, private enterprises, private enterprises), organs, institutions, social organizations, private non-enterprise units and their employees, must participate in the basic medical insurance as a whole. Zhongzhi, zhongzhi, foreign units in wu and their employees are in accordance with the principle of territorial management, to participate in the basic medical insurance in wuzhou city. Flexible employment, individual businessmen can participate in basic medical insurance.
Wuzhou basic medical insurance is divided into the city-level coordination and county (city) level, and gradually transition to the city-level coordination. All employers and their employees are required to participate in the basic medical insurance of the coordinated area in accordance with the principle of territorial management, the implementation of a unified policy, a unified implementation plan, the implementation of the basic medical insurance fund of the unified fund-raising, use and management.
Article 4 Retirees, the Old Red Army and disabled soldiers of the revolution of the second grade B or above shall not participate in the basic medical insurance for employees, and their medical expenses shall be implemented in accordance with the relevant measures.
State civil servants, on the basis of participation in the basic medical insurance, enjoy the policy of medical subsidies, the specific measures in accordance with the "General Office of the State Council forwarded to the Ministry of Labor and Social Security Ministry of Finance on the implementation of the views of the State Civil Servants of the medical subsidies notice" (State Office of the State Council [2000] No. 37) is carried out.
Chapter II Basic Medical Insurance Management Organization and Responsibilities
Article 5 The labor security administrative department of Wuzhou City, Wuzhou City, the basic medical insurance administration, is responsible for the implementation of the city's basic medical insurance administration, unified organization and guidance of the city's basic medical insurance management. Its main responsibilities are:
(a) to implement the relevant policies of basic medical insurance, the development of specific provisions and systems of basic medical insurance;
(b) in conjunction with the health, finance, pricing and other departments to develop and improve the scope of basic medical insurance services, standards, and methods of settlement of medical expenses, according to the State Council ministries and commissions of the development of the basic medical insurance drug directory, diagnosis and treatment directory, standards for medical service facilities, as well as methods for qualifying designated medical institutions and retail pharmacies;
(3) validating the qualifications of designated medical institutions and retail pharmacies. (c) supervising and checking the implementation of basic medical insurance regulations by designated medical institutions and retail pharmacies, as well as by insured units and insured persons, and investigating and dealing with all kinds of violations of the basic medical insurance regulations;
(d) carrying out administrative management and supervision of the basic medical insurance agencies;
(e) coordinating the relationship between the various departments involved in the work of basic medical insurance, and mediating the related disputes.
Article 6: The Wuzhou Employees' Basic Medical Insurance Management Office (hereinafter referred to as the Medical Insurance Management Office) under the labor security administrative department of Wuzhou City shall be the basic medical insurance agency of Wuzhou City, and its main duties shall be to:
(1) uniformly deal with the registration of employers and individuals in the integrated area in respect of basic medical insurance, the change of registration and the deregistration of such units and individuals;
(2) be responsible for (b) to raise, manage and pay for the basic medical insurance fund;
(c) to prepare the budget of the basic medical insurance fund, and to report all kinds of financial and statistical reports on basic medical insurance on time;
(d) to sign the basic medical insurance service agreement with designated medical institutions and retail pharmacies, to give guidance and management to the implementation of the basic medical insurance, and to make recommendations on the implementation of basic medical insurance for designated medical institutions and retail pharmacies in accordance with the agreement. (d) signing service agreements on basic medical insurance with designated medical institutions and retail pharmacies, providing guidance and management on the implementation of basic medical insurance, and inspecting and supervising the implementation of basic medical insurance regulations by designated medical institutions and retail pharmacies according to the agreements;
(e) coordinating disputes between insured persons and designated medical institutions and retail pharmacies on medical insurance business;
(f) accepting inquiries from insured units and their employees on basic medical insurance business;
(g) putting forward suggestions and opinions on improving and perfecting the basic medical insurance work;
(ix) raising, managing and paying large medical insurance premiums;
(x) handling the income and payment of premiums for civil servants' medical subsidies in the co-ordination area;
(xi) handling the medical expenses of retirees, the Old Red Army and the Second Class B or higher revolutionary disabled military personnel in the co-ordination area;
(xiii) handling the medical expenses for the co-ordination of medical expenses for the retired, the Old Red Army and the Second Class B or higher revolutionary disabled military personnel in the co-ordination area. (k) To handle the income and payment of insurance premiums for medical expenses of retired persons, old Red Army soldiers and second-class B-class disabled soldiers of the revolution in the coordinated area.
Article 7 The insured units shall set up a basic medical insurance management organization with full-time (part-time) staff. Its duties are:
(1) to publicize and implement the policies and regulations on basic medical insurance;
(2) to declare truthfully the basic medical insurance contribution base of the employees of the unit, to fill in the relevant reports on the basic medical insurance of the unit, and to pay the medical insurance premiums in full and in a timely manner;
(3) to regularly publicize to the employees of the unit the situation of the basic medical insurance premiums;
(4) to declare in a timely manner on a monthly basis the income from and payment of medical expenses for the disabled soldiers of the revolution. (d) Declare the changes of personnel increase or decrease in the unit on a monthly basis in a timely manner, and be responsible for the procedures related to the basic medical insurance;
(e) Manage the basic medical insurance affairs of the unit's employees, and convey and implement the relevant documents and spirits in a timely and accurate manner.
Article 8 The fixed-point medical institutions and retail pharmacies shall set up a basic medical insurance management office with full-time (part-time) staff. Their duties are:
(1) to publicize and implement the policies and regulations of basic medical insurance;
(2) to be responsible for the management of the specific work of the basic medical insurance of the unit, and to formulate and implement the management measures of the unit;
(3) to be entrusted by the medical insurance management office, and to approve the special examination, special treatment, special materials and medication items within the scope of authority;
(4) to supervise and inspect the management of the basic medical insurance of the unit; and ) Supervising and checking the implementation of basic medical insurance policies and regulations in the organization;
(e) Accepting the guidance, supervision and checking of the relevant operations of the Medical Insurance Administration Office;
(f) Reporting the relevant basic medical insurance reports to the Medical Insurance Administration Office as required, and doing a good job in transmitting the relevant data of the basic medical insurance.
Article 9 The administrative expenses of the labor security administrative department of Wuzhou City and the medical insurance management office under it shall be settled by the financial budget and shall not be drawn from the basic medical insurance fund.
Chapter III Basic Medical Insurance Fund Raising
Article 10 The basic medical insurance premiums shall be raised by the medical insurance administration office, and shall be paid by the employers and their employees*** together.
(1) Employers participating in the basic medical insurance can participate in the integrated approach or the single-construction co-ordination approach:
1. In the case of participation in the integrated approach, the basic medical insurance premiums shall be paid by the employer and the individual active employees. The basic medical insurance premiums paid by the employer shall be based on the last year's gross salary of the working employee, and the contribution rate shall be 6.8%; the basic medical insurance premiums paid by the working employee shall be 2% of the last year's salary, which shall be withheld by the employer on behalf of the employee;
2. If you participate in the insurance under a single-construction integrated method, the basic medical insurance premiums shall be paid by the employer, and the basic medical insurance premiums shall be based on the last year's gross salary and the last year's pension of the retired person. The total amount of the retiree's last year's pension is the contribution base, the contribution rate is 4.8%, and the insured enjoys the basic medical insurance hospitalization treatment.
(2) in accordance with the integrated approach to insurance, the basic medical insurance premiums paid by the employer is divided into two parts, one for the establishment of the integrated fund, the other part of the individual account of the participants. The proportion to be credited to the individual account is about 30% of the employer's contribution; for those who are insured under the single-account system, all the basic medical insurance premiums paid are used to establish the integrated fund.
(3) The principle of basic medical insurance contribution is:
1. If the contribution base of the insured person exceeds 300% of the average social wage of the whole region in the previous year, 300% will be used as the contribution base; if it is lower than 60%, 60% will be used as the contribution base;
2. If there is no data on the wage income of the previous year, not less than 60% of the average social wage of the whole region in the previous year will be used as the contribution base for basic medical insurance. as the basic medical insurance contribution base.
Article 11 The setting and calculation method of the contribution period of the insured:
(1) For those who have not participated in the city's basic medical insurance before June 30, 2001, the years of their working life working in the employer's unit in accordance with the relevant provisions of the State and the autonomous region shall be regarded as the contribution period; for those who have participated in the city's basic medical insurance before June 30, 2001, the years of their working life before joining the insurance shall be regarded as the contribution period. The years of service before joining the insurance shall be regarded as contributory years. The portion of the deemed contribution period exceeding 25 years can be converted into actual contribution period: every over 1 year is counted as 1 year, less than 1 year is not counted, and the converted actual contribution period is up to 8 years;
(ii) the participants have reached the legal retirement age, and the cumulative total of 30 years of basic medical insurance premiums (the cumulative total of 30 years of basic medical insurance premiums includes both actual and deemed contribution period, of which the actual contribution period must reach 30 years). The actual contribution period must be 20 years), with the retirement certificate or identity proof for the change of the category of participants, no longer pay the basic medical insurance premiums, and enjoy the corresponding basic medical insurance treatment for retirees;
(c) the participants reach the statutory retirement age, with the following conditions, must be in accordance with the current year's contribution base and the proportion of the contribution, which is the responsibility of the unit of the unit contribution, is a personal Individuals are responsible for making full and one-time contributions to the basic medical insurance premiums that have not reached the stipulated contribution period before they can enjoy the corresponding basic medical insurance benefits for retirees in accordance with the regulations:
1. The actual contribution period has reached 20 years, but the cumulative total of years of payment of basic medical insurance premiums has not reached 30 years;
2. The cumulative total of years of payment has reached 30 years, but the actual total of years of payment has been less than 20 years. 20 years.
(4) The insured retirees who have gone through the retirement procedures before the implementation of these measures may make a one-time payment of the basic medical insurance premiums that have not yet reached the stipulated number of years of contributions, or continue to make monthly contributions until they reach the stipulated number of years of contributions. The principle of unchanged contribution base and contribution rate is applied to the lump sum or monthly payment, and will not be changed in the future, except for the unified adjustment policy. The contribution rate is 6.8% for those who participate in the integrated system and 4.8% for those who participate in the single-account system.
Article 12 Before the implementation of these measures, the municipal government has approved the bankruptcy or restructuring of the enterprise's retirees, has been reserved and paid the basic medical insurance premiums in accordance with the provisions of the basic medical insurance will continue to be implemented in accordance with the original provisions of the basic medical insurance.
Article XIII has reached the legal retirement age, after the implementation of these measures to participate in the insurance, shall be in accordance with the provisions of these measures, the number of years of contributions to pay a one-time payment of basic medical insurance premiums. If you participate in the insurance in the employing organization, the contribution base shall be the pension or retirement pension of the previous year (if the contribution base is lower than 60% of the average social wage of the whole region in the previous year, the contribution base shall be 60%), and the contribution rate of the unit shall be 6.8%. For those who participate in the insurance as individuals, the contribution base is not less than 60% of the average social wage of the whole region in the previous year, and the contribution rate is 8.8%. Only after the above persons have made contributions for the required number of years can they enjoy the basic medical insurance benefits for retirees.
Article 14 The flexibly employed persons and individual businessmen may participate in the basic medical insurance according to the method of combining the accounts or the method of building a single integrated system, with no less than 60% of the average social wage of the whole region in the previous year as the contribution base, and the individuals shall pay the basic medical insurance premiums, and the specific measures shall be decided separately.
Article 15 The insured units or individuals can not pay the basic medical insurance premiums in full and on time, from the next month onwards to stop enjoying the basic medical insurance benefits. After clearing the arrears of fees and late payment, they will continue to enjoy the basic medical insurance benefits.
Article 16 When an insured unit merges, splits, transfers, terminates or goes bankrupt, it must first settle the outstanding basic medical insurance premiums, and at the same time, it must also make a one-time payment of the basic medical insurance premiums of the retired and retired personnel who have not reached the required contribution period.
Article 17 In order to meet the medical needs of different levels, an enterprise may establish supplementary medical insurance for its employees. The part of the supplementary medical insurance premiums within 4% of the total wages may be directly charged to the cost of the enterprise.
Article 18 The basic medical insurance premiums paid by the insured units shall be paid through the following channels: organs and institutions mainly financed by the financial supply shall be arranged by the financial budget to the units and shall be charged to the budget of the units; other institutions shall be charged to the funds of the institutions; enterprises shall be charged to the welfare fees of the employees; social organizations shall be charged to the funds of the associations; and privately-run non-enterprises shall be charged to the funds of the privately-run non-enterprises. The following is a summary of the expenses incurred by the private non-enterprise units.
Article 19 The total wages of serving employees are determined strictly in accordance with the statistical caliber stipulated by the state.
Article 20 of the insured units must be reported to the annual wage statement by April each year to the medical insurance management office to approve the contribution base and other circumstances, approved by the medical insurance management office, on July 1 each year to adjust the contribution base. Article 21 The procedures for enrollment shall be handled in accordance with the following procedures:
(1) The employer shall fill in the "Wuzhou Employee Basic Medical Insurance Enrollment Unit Registration Form" and the "Wuzhou Employee Basic Medical Insurance Enrollment Personnel Registration Form" and attach a copy of the "Industrial and Commercial Business License" or the "Certificate of Legal Personality of the Unit" to the Medical Insurance Administration Office.
(2) Upon approval by the Medical Insurance Management Office, the "Wuzhou Employees' Basic Medical Insurance Card" (referred to as "Medical Card"), "Wuzhou Employees' Basic Medical Insurance Settlement Card" (referred to as "Settlement Card"), and "Patient Record Book" will be uniformly issued to the insured persons for their safekeeping and purchasing of medicines by virtue of them. The production costs of the Medical Card, Settlement Card and Medical Record Book are charged at cost and borne by the insured units or individuals.
Article 22 The collection of basic medical insurance premiums is entrusted to banks. The insured units shall withhold and pay the part payable by the unit and the part payable by the insured individuals before the 20th day of each month.
Chapter 4: Configuration and Management of the Basic Medical Insurance Fund
Article 23: The basic medical insurance fund is a combination of social integration and individual account. That is, the basic medical insurance fund consists of a social fund and individual account. Individual accounts shall not be set up for participants in the single-construction co-ordination.
(I) the configuration of the individual account.
1. All the basic medical insurance premiums paid by individual employees are credited to the individual account;
2. The basic medical insurance premiums paid by the employer for the insured person are credited to the individual account, and are credited to the individual account according to the age of the insured person based on the actual contribution base of the person himself/herself. Active employees under the age of 35 are allocated 1.8%, from 36 to 50 years of age 2%, from 51 years of age to the statutory retirement age 2.5%; retirees are allocated 6.5%. Retirees who have made a one-time contribution to reach the required number of years of contribution are allocated 6.5% according to the actual contribution base of the one-time contribution at that time, and the base to be allocated in the future will no longer be adjusted with the increase of the retirement fee or pension;
3. The determination of the actual age of the active employees is subject to the calculated value of their age as of December 31st of the previous year, which is approved in a lump sum at the beginning of the year. The proportion of their individual accounts allocated within the year will not change, and will be adjusted uniformly in the next year's approval;
4. Those who have been approved to retire by the labor, organization and personnel departments within the year will be entitled to the basic medical insurance benefits of retirees accordingly from the month following the month in which they go to the medical insurance administration office to formally handle the formalities of transferring the active to retired status to reach the stipulated number of years of contributions, and the unit and the individual will no longer contribute to the basic medical insurance premiums;
5. The individual account fund of those who are insured according to the method of integrating the accounts is transferred to the fund by the medical insurance management office on a monthly basis according to the contribution status;
6. The principal and interest of the individual account of the insured are owned by the insured person, which can be carried forward and inherited according to the law, and can only be used for the basic medical treatment, and cannot be withdrawn in cash. When a participant's job is transferred, the balance of his or her personal account can be transferred with him or her.
(2) The composition of the integrated fund.
The basic medical insurance premiums paid by the employer, in addition to the above provisions into the individual account of the insured person, the remaining part of all into the basic medical insurance fund. Five percent of the total amount goes into the basic medical insurance fund and is set aside as a risk fund.
Article 24 The basic medical insurance fund shall be managed by a special financial account, and the fund shall be used exclusively for the purpose, and shall not be squeezed or misappropriated, nor used to balance the financial budget. Medical insurance management office to establish and improve the fund budgeting system, financial accounting system and internal audit system.
Article 25 of the basic medical insurance fund interest accrued in accordance with relevant state regulations.
Article 26: Establishment of the basic medical insurance fund supervision mechanism. The income and expenditure of the basic medical insurance fund to accept the supervision of the financial and audit departments at the same level. Set up by the relevant departments of the municipal government, representatives of medical institutions, trade unions and relevant experts to participate in the basic medical insurance fund supervision organization, regularly listen to the basic medical insurance fund income and expenditure operation and management reports, to strengthen the supervision and management of the basic medical insurance fund.
Chapter V: Basic Medical Insurance Treatment
Article 27: The unified fund and individual accounts are operated in a way that they are separately accounted for and managed and do not crowd each other out. The scope of payment shall be as follows: the individual account shall be used to pay for the outpatient expenses and the out-of-pocket part of the hospitalization medical expenses in accordance with the provisions of the basic medical insurance; and the integrated fund shall be used to pay for the hospitalization medical expenses in accordance with the provisions of the basic medical insurance.
Article 28 Outpatient Expenses Payment. Outpatient medical fees and medication expenses incurred by insured persons in designated medical institutions and retail pharmacies in accordance with the provisions of the basic medical insurance shall be paid from their individual accounts, and they shall be responsible for any over-expenditures. If a participant is recognized by the Municipal Basic Medical Insurance Expert Committee as suffering from a special chronic disease that requires long-term outpatient treatment, the medical fees required will be paid from his/her individual account first, and the overspent portion of the medical fees will be paid from his/her own contribution base, and he/she will pay 10% out-of-pocket first, and then settle the fees according to the standards set out in Article 29(2) and (3) of the Measures after approval from the medical insurance management office. For those who are insured under the single-construction integrated approach, if they suffer from special chronic diseases, they can refer to the implementation.
Article 29 Payment of hospitalization medical expenses. The hospitalization medical expenses incurred by the insured in the designated medical institutions in accordance with the provisions of the basic medical insurance, such as the use of Class B drugs and special examinations, special treatments and special materials, shall be paid by the insured person by 10% to 50%, and the rest shall be borne by the insured person by a certain amount of hospitalization starting payment standard. The part that exceeds the starting standard shall be paid by the integrated fund and the insured person according to the method of "calculating in sections and paying cumulatively":
(1) Setting the starting standard of hospitalization for the insured person: for the first time of hospitalization in one year, it is RMB 600 Yuan for the tertiary hospitals, and RMB 500 Yuan for hospitals of less than secondary level; for the second time of hospitalization, it is RMB 480 Yuan for the tertiary hospitals, and RMB 380 Yuan for hospitals of less than secondary level. For the second hospitalization, it is RMB 480 for the third hospitalization and RMB 380 for the hospitals below the second level; for the third hospitalization and the hospitalizations above the third hospitalization, it is RMB 360 for the hospitals below the third level and RMB 260 for the hospitals below the second level; (2) The part of the hospitalization medical expenses of the insured persons that exceeds the starting standard shall be paid by the coordinated fund and the individuals of the insured persons in accordance with the method of "calculating in sections and making payment by adding up the total amount". The participants' out-of-pocket expenses are as follows:
1. Starting standard to 10,000 yuan (including 10,000 yuan), the individual out-of-pocket expenses of active employees are 20%, and the individual out-of-pocket expenses of retirees are 16%;
2. 10,000 to 20,000 yuan (including 20,000 yuan), the individual out-of-pocket expenses of active employees are 15%, and the individual out-of-pocket expenses of retirees are 12%;
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3. 20000 to 24000 yuan, the individual self-payment rate for active employees is 10%, and the individual self-payment rate for retirees is 8%.
(3) The annual cumulative maximum payment limit of the integrated fund is 24,000 yuan. Medical expenses above the maximum payment limit shall not be paid by the Basic Medical Insurance Coordination Fund and can be settled through large medical insurance, supplementary medical insurance, commercial insurance and social assistance.
Article 30 The retired participants who are resettled in other places shall apply by themselves, and their units or individuals shall go to the medical insurance management office in January every year to register for resettlement. The outpatient medical expenses in accordance with the provisions of the basic medical insurance shall be paid from the personal account of the participant; when hospitalization is required, the participant shall seek medical treatment at the local designated medical institution for basic medical insurance and report to the medical insurance administration office in a timely manner. After being discharged from the hospital, the medical insurance administration office will reimburse the medical expenses in accordance with the regulations with the relevant information. The specific measures are determined separately. The medical expenses incurred by retirees in emergency cases in other places are handled in accordance with the above provisions.
Article 31 If a participant needs to be transferred to a hospital for treatment due to his/her condition, he/she shall be transferred according to the principle of transferring to a hospital on a step-by-step basis. The conditions for transferring to a hospital for treatment outside the city are: critical and difficult diseases that cannot be treated in the city due to limited technical and equipment conditions; and difficult diseases that have not been determined by the city's medical institutions or specialized medical institutions or expert consultations.
(1) Any request for transfer procedures, the patient or family members to apply, the original treatment of the designated medical institutions to make recommendations, reported to the medical insurance management office for approval before the transfer;
(2) due to the critical condition can not be timely and in accordance with the provisions of the procedures for the transfer of hospitals, shall be transferred to hospitals for medical treatment within five working days to make up for the formalities;
(3) the transfer of the incurred medical expenses first by the (c) The medical fees incurred in the transfer of hospitalization shall be paid by the individual first, and then reimbursed to the medical insurance administration office in accordance with the regulations after discharge from the hospital with the discharge summary issued by the medical institution, the certificate of disease, the relevant examination report, the detailed list of medical fees and invoices. The proportion of individual out-of-pocket payment for medical expenses above the starting line and below the maximum payment limit shall be increased by 10% for those who are transferred within the region and 15% for those who are transferred out of the region on the basis of the provisions of Article 29 of these Measures.
Article 32 Where the conditions for transfer are not met, and the patient or his family requests to be transferred to an out-of-town hospital for treatment, the reimbursement of the medical expenses that fall within the scope of payment of the basic medical insurance shall be calculated in accordance with the proportion of out-of-pocket expenses of the individual as stipulated in Item (3) of Article 31 of the present Measures, subject to the maximum payment limit of the amount of per capita hospitalization coordinated medical expenses of the insured in the previous year.
Article 33 of the fixed-point medical institutions, retail pharmacies and insured persons shall strictly abide by the relevant departments of the State Council and the autonomous region formulated the "Basic Medical Insurance Diagnosis and Treatment Catalog", "Basic Medical Insurance Drug Catalog", "Basic Medical Insurance Medical Service Facilities Standards" and the corresponding management regulations. The basic medical insurance fund will not pay for the costs of diagnosis and treatment, services and medicines that are beyond the prescribed limits.
Article 34 Principles of payment of medical expenses for special cases of insured persons:
(1) The basic medical insurance fund shall not pay for the medical expenses incurred by individuals who bear the responsibility for crimes, drunkenness, drug addiction, self-injury, suicide (except for psychiatric attacks), etc.
(2) Medical expenses incurred in medical accidents, work-related injuries and births shall be implemented in accordance with the relevant provisions; (c) The medical expenses incurred in traffic accidents, other injuries and other killings for which other people are responsible, if the case cannot be closed within one year from the date when the judicial department opens the case for investigation, it can be advanced by the basic medical insurance fund in accordance with the regulations first. If the judicial department concludes the case and determines that another person is responsible, the responsible person shall return the medical expenses advanced by the Basic Medical Insurance Coordination Fund. If the judicial department determines that the responsible person does not have the financial ability to pay the victim's medical expenses, the basic medical insurance fund may reimburse the medical expenses in accordance with the provisions of the Basic Medical Insurance Pool Fund.
Article 35 The medical expenses incurred by insured persons who are hospitalized in a foreign place in case of emergency during the period of going out on official business or statutory family visit leave shall be reimbursed in accordance with the provisions of Article 29 of the present Measures on the basis of the valid bills of medical expenses from the medical institutions at or above the township level, the hospitalization summary and the certificate of the employing unit (with a copy of the travel reimbursement voucher). If you need to be stationed abroad for a long period of time for official business, the employing unit shall submit the list of the staff stationed abroad to the medical insurance administration office for filing procedures, and if you have not filed the procedures, the medical expenses incurred in the other place shall not be paid.
Chapter 6: Settlement of Basic Medical Insurance Expenses and Management of Medical Services
Article 36: When a person insured under the integrated account method goes to a designated medical institution for outpatient consultation or to a designated retail pharmacy for purchase of medicines, he/she must hold a Medical Card and a Settlement Card. The receiving doctor (pharmacist) will first verify and then dispose of them. The medical expenses in compliance with the regulations are settled from the balance of the personal account of the Settlement Card.
Article 37 If a participant is sick and needs to be hospitalized, he or she must present the diagnostic opinion of the designated medical institution and the Medical Certificate and Settlement Card, and pay a certain amount of hospitalization advance payment to the designated medical institution. The fixed-point medical institution is required to file a record with the Health Insurance Administration Office within three days after accepting the hospitalization of the insured person.
Article 38 The settlement of outpatient and inpatient medical expenses in accordance with the provisions of the basic medical insurance shall be jointly formulated by the administrative department of labor security together with the departments of health and finance in accordance with the relevant provisions of the State.
Article 39 The basic medical insurance implements fixed-point medical treatment and establishes an annual inspection system for fixed-point qualifications. Each year by the administrative department of labor security has been designated medical institutions, retail pharmacies for assessment and validation. Qualified designated medical institutions and retail pharmacies sign service agreements with the medical insurance administration office to provide medical and pharmaceutical services to insured persons. Article 40 The administrative department of labor security, together with the health department, establishes a basic medical insurance expert committee (composed of experts from the administrative department of labor security, the health department and the designated medical institutions), which is specifically responsible for the appraisal of disputes relating to basic medical insurance matters.
Chapter VII Penalties and Rewards
Article 41 For employers who refuse to participate in basic medical insurance, as well as for those who refuse to pay, default on payment, concealment, underpayment of basic medical insurance premiums, and those who falsify facts that result in untruthfulness of their participation files, the administrative department of labor and security shall deal with the employers and the persons responsible for the employers in accordance with the Provisional Regulations on the Collection and Payment of Social Insurance Premiums.
Article 42 Anyone who fraudulently obtains basic medical insurance benefits or fraudulently obtains the basic medical insurance fund shall, in accordance with the provisions of the Regulations on Supervision of Labor Security, be ordered by the administrative department of labor security to make restitution and shall be fined not less than one and not more than three times the amount of money fraudulently obtained; in case of seriousness of the case, the employing unit concerned shall be recommended to give administrative sanctions; in case of constituting a crime, the employer concerned shall be held criminally liable in accordance with the law.
Article 43 In addition to recovering or refusing to pay the incurred medical expenses, the designated medical institutions and retail pharmacies that violate the provisions of the basic medical insurance administration shall be subject to rectification within a certain period of time; in serious cases, the qualification of the basic medical insurance service shall be suspended; in case of fraudulent use of the basic medical insurance fund, the designated medical institution or retail pharmacy shall be subject to a fine not less than one and not more than three times of the amount of the fraudulent use in accordance with the "Regulations on the Supervision of Labor Protection"; if the institution or retail pharmacy fails to rectify or the rectification is ineffective, the designated medical institution shall be canceled. or rectification is ineffective, cancel the qualification of fixed-point.
Article 44 Any staff member of a medical insurance administration office who does any of the following shall be given an administrative sanction by the unit in which he or she is employed; if a crime is constituted, he or she shall be held criminally liable in accordance with the law:
(a) in the course of collecting basic medical insurance premiums and examining medical expenses, he or she acts in favor of his or her own interests or in detriment to the public interest;
(b) he or she solicits and accepts bribes for personal gain by using the power of his or her position and work
(3) dereliction of duty resulting in losses to the basic medical insurance fund.
Article 45 Employers or individuals have the right to report violations of basic medical insurance policy to the labor security administrative department. Upon verification, the whistleblower will be rewarded and the source of funds will be expended from the income from fines. If there is no income from fines, it will be included in the budget.
Chapter VIII Supplementary Provisions
Article 46 The medical expenses for the rescue of a wide range of emergency, critical and serious patients caused by sudden disease epidemics and natural disaster factors shall be separately resolved by the municipal people's government.
Article 47 In the event of disputes concerning basic medical insurance between insured units, insured persons, designated medical institutions, designated retail pharmacies, and medical insurance administration offices, the disputing parties shall settle the disputes through consultations; in the event that the consultations fail, the disputes shall be dealt with in accordance with the relevant laws and regulations.
Article 48 In accordance with these Measures, the administrative department of labor security, in conjunction with the departments of finance and health to formulate other supporting documents and implement them simultaneously.
Article 49 These Measures shall be interpreted by the municipal labor security administrative department.
Article 50 These measures shall be implemented from March 1, 2006 onwards. Previously issued by the city of Wuzhou Municipal People's Government on the issuance of "Wuzhou urban workers basic medical insurance system implementation measures (for trial implementation)" notice (Wu Zheng Fa [2000] No. 92), "Wuzhou Municipal People's Government on the issuance of municipal urban workers basic medical insurance supporting documents notice" (Wu Zheng Fa [2000] No. 94) ceased to be implemented. If these measures are in conflict with the new relevant documents issued by the higher level, please follow the relevant documents issued by the higher level. The counties (cities) under the jurisdiction of the city may refer to the implementation of these measures.