Full text of the 2018 Medical Insurance Regulations Full text of the new Work-related Injury Insurance Regulations
Chapter 1 General Provisions
Article 1 is to ensure basic medical care for urban employees, reasonable These regulations are formulated based on the relevant national regulations and the actual conditions of the province using medical resources.
Article 2 The following units in cities and towns in this province and their employees must participate in basic medical insurance in accordance with these regulations:
(1) Enterprises and their employees;
(2) Agencies, institutions, intermediaries, social groups, private non-enterprise units and their employees;
(3) Employing units affiliated with the military and their employees without military status.
This regulation shall apply to retirees of the above-mentioned units.
Article 3 establishes a basic medical insurance fund for urban employees and implements a system that combines payment from personal medical accounts (hereinafter referred to as individual accounts) and basic medical overall funds (hereinafter referred to as overall funds).
Ownership of personal accounts belongs to the individual. The ownership of the overall pool fund belongs to all persons participating in the basic medical insurance.
Article 4 Basic medical insurance premiums shall be borne jointly by both the employer and the employees.
Article 5 Basic medical insurance shall, in principle, take cities, counties, and autonomous counties as the coordinating units and implement localized management.
Article 6 Basic medical insurance premiums shall be collected and paid by the local tax authorities of the province (hereinafter referred to as the collection authorities).
Chapter 2 Collection and Payment of Basic Medical Insurance Premiums
Article 7 Basic medical insurance premiums shall be paid jointly by the employer and the employees***. Among them, the employer pays 5%-7% of the total monthly salary of the employees of the unit, and the basic medical insurance premium rate paid by the employees is not less than 2% of the total monthly salary of the employee.
Article 8 The monthly salary payment of employees shall be determined based on the actual total salary of the employee, but shall not be less than 60% of the average monthly salary of employees in the city, county or autonomous county in the previous year. The lower part shall be determined by The medical insurance premiums paid by myself will be paid by the employer instead.
Article 9 If the total monthly salary of an employee exceeds more than 300% of the average monthly salary of employees in the city, county, or autonomous county in the previous year, the basic medical insurance premium will not be paid, nor will it be used for the verification of personal accounts. The base of the quota.
Article 10 Within 30 days after obtaining a business license or being approved for establishment, the employer must go to the social insurance agency to register for basic medical insurance. When the registered items are changed or the payment obligation is terminated in accordance with the law, the registration change or deregistration must be processed in a timely manner. The social insurance agency shall promptly notify the collection authority of the registration status.
The employer shall, within 10 days after completing the registration procedures for basic medical insurance, go to the collection authority to register for payment of basic medical insurance premiums in accordance with relevant regulations.
Article 11 The amount of basic medical insurance premiums that employers and employees should pay shall be reported to the collection authority on a monthly basis by the employer, and shall be verified by the collection authority.
If the employer fails to declare the amount of basic medical insurance premiums it should pay according to regulations, the collection authority shall temporarily determine the amount payable based on 110% of the unit’s last month’s payment amount; if there is no last month’s payment amount, the amount shall be levied The agency determines the number of people and the amount that should be paid based on the unit's economic status, number of employees and other relevant circumstances. After the payment unit completes the declaration procedures and pays the basic medical insurance premium in the prescribed amount, the collection authority will settle the bill according to the facts.
Article 12 Basic medical insurance premiums are collected and paid on a monthly basis. Employers and employees shall pay basic medical insurance premiums to the collection authority within the prescribed period. The portion that employees should pay individually shall be withheld by the employer from their wages.
Basic medical insurance premiums cannot be reduced or reduced.
Article 13 The composition of the total salary required to pay basic medical insurance premiums shall be calculated in accordance with relevant national regulations.
The basic medical insurance premiums paid by the employer shall be disbursed in accordance with relevant national financial regulations.
Basic medical insurance premiums are not included in an individual’s current salary income and are exempt from personal income tax.
Employers shall not lower salary standards on the grounds that employees pay basic medical insurance premiums.
Article 14: Basic medical insurance premiums shall be subject to an annual inspection system. For any employer that has not gone through the annual inspection procedures for basic medical insurance premiums with the collection authority, the industrial and commercial administrative department will not handle the annual inspection procedures.
When an employer goes through the cancellation procedures for its business license, the industrial and commercial administration department shall first review the basic medical insurance relationship termination letter issued by the social insurance agency.
Article 15 After an employee retires, he or she will no longer pay basic medical insurance premiums, nor will his or her employer pay basic medical insurance premiums.
Article 16 If the employer is bankrupt, closed or terminated due to other reasons in accordance with the law, or if the employer is reorganized and the number of employees is reduced by more than 2/3, its retirees have actually paid basic medical insurance premiums for less than 10 years before retirement. , compensation from the basic medical insurance fund should be paid. The fund compensation is calculated based on each retiree's age from now to 75 years old multiplied by the average basic medical expenses of retirees in the same period. It is paid in one lump sum from the assets realized after liquidation. If there is indeed no ability to pay, the handling method shall be determined by the provincial people. The government shall stipulate otherwise. If the state has other regulations, such regulations shall prevail.
Article 17 If an employer terminates due to declaration of bankruptcy, cancellation, dissolution or other reasons, it shall pay off its unpaid basic medical insurance premiums, interest, late fees and fines in accordance with relevant national laws and regulations. .
When an employer merges, splits, or transfers, the unit that merges, splits, or transfers shall bear the unpaid basic medical insurance premiums and interest, late fees, and fines. If the state has other regulations, such regulations shall prevail.
Article 18 Medical expenses outstanding before the implementation of these Regulations will still be settled through the original channels.
Chapter 3 Basic Medical Insurance Fund Management
Article 19 All basic medical insurance premiums paid by employees will be credited to their personal accounts.
25-35% of the basic medical insurance premiums paid by the employer are used to establish personal accounts for retirees and employees. The specific allocation method is formulated by the provincial people's government in accordance with the principle of caring for the elderly; the remaining funds are used for To establish a co-ordination fund.
Article 20 The basic medical insurance fund shall be managed on two lines of revenue and expenditure, and shall be included in a special financial account of the social insurance fund. The funds shall be used exclusively for the basic medical care of employees and retirees and may not be diverted to other purposes. use.
Article 21 The interest calculation method of the basic medical insurance fund shall be implemented in accordance with relevant national regulations, and the interest due to individual accounts and overall funds shall be calculated and credited separately.
Article 22 No cash withdrawals or overdrafts are allowed from personal accounts. Overspending will not be compensated, and the balance will be rolled over for use. When employees or retirees die, the balance of their personal accounts can be inherited.
Article 23 An employer shall not increase the personal account funds of its employees or other personnel in violation of the provisions of these Regulations.
Article 24 Social insurance agencies shall establish basic medical insurance files for employees and retirees and issue basic medical insurance certificates.
Article 25 For those who move out of the province or move within the province, the balance of the funds in the personal account can be transferred; if it cannot be transferred, it shall be returned to the person.
The basic medical insurance premiums transferred to the overall planning fund belong to all the insured persons of the original overall planning unit and will not be transferred or refunded.
Article 26 The annual budget and final accounts of the basic medical insurance fund shall be prepared and approved in accordance with relevant national and provincial regulations.
Chapter 4 Basic Medical Insurance Benefits
Article 27 Employees of the employer who pay basic medical insurance premiums in accordance with these Regulations shall enjoy basic medical insurance benefits.
Article 28: Personal accounts are used to pay medical expenses beyond the scope of payment of the overall fund; if the personal account is insufficient to pay, it is the responsibility of the individual.
Article 29 Medical expenses for hospitalization for serious diseases shall be paid according to the following methods:
(1) The minimum payment standard shall, in principle, be controlled by employees in cities, counties and autonomous counties. 9%-11% of the average social salary in the previous year. [page]
(2) In principle, the maximum payment limit is controlled at 3-5 times the average annual social salary of employees in cities, counties, and autonomous counties in the previous year.
(3) Medical expenses above the minimum payment standard and below the maximum payment limit are mainly paid by the overall fund, and individuals bear a certain proportion.
Appropriate care will be given to the proportion of retirees paying medical expenses.
The scope of serious diseases, specific standards for deductibles and maximum payment limits, and the share of medical expenses above the deductible and below the maximum payment limit shall be determined by the Provincial People's Government.
Article 30 The overall fund will not pay for medical expenses below the minimum payment standard and above the maximum payment limit.
Article 31 The proportion of individual out-of-pocket payments for diagnostic and treatment items for which the basic medical insurance fund pays part of the cost and drugs in the Category B catalog shall be determined by the Provincial People's Government.
Article 32 The medical expenses for Class A infectious diseases such as cholera and plague shall be fully paid from the overall fund. The medical expenses for fulminant and epidemic infectious diseases confirmed by the health administrative department shall be settled by special funds allocated by the people's government.
Article 33: State civil servants and other qualified personnel shall receive medical subsidies on the basis of participating in basic medical insurance.
In order to solve the problem of medical expenses above the maximum payment limit for persons other than those specified in the preceding paragraph, the provincial people's government may organize the implementation of supplementary medical insurance.
Article 34 Anyone who is over 50 years old when participating in the basic medical insurance and has continuous service or less than 5 years of service according to national regulations can only be eligible for the basic medical insurance after participating in the basic medical insurance for one year. Enjoy the benefits of medical expenses paid by the unified fund.
Article 35 The payment period specified in these regulations includes the actual payment period and the deemed payment period.
The term deemed payment period as mentioned in the preceding paragraph refers to the continuous service years or working years that comply with national regulations before the implementation of these Regulations.
Article 36 For employees who retire after the amendment and implementation of these Regulations, the number of years for which they have paid basic medical insurance premiums is 30 years for men and 25 years for women. After retirement, their basic medical insurance benefits shall be based on The provisions of this Regulation shall be implemented.
When an employee retires, if the number of years he or she has paid basic medical insurance premiums has not reached the provisions of the preceding paragraph, for every one year less than the period of payment, the basic medical insurance benefits he or she will enjoy after retirement will be based on the prescribed treatment standards. Reduced by 5%.
Article 37 If a retiree has actually paid basic medical insurance premiums for 10 years before retirement, the employer’s failure to pay basic medical insurance premiums after retirement will not affect his enjoyment of the basic medical insurance premiums for retirees stipulated in these regulations. Medical insurance benefits.
Retirees who have actually paid basic medical insurance premiums for less than 10 years before retirement and whose original employer does not pay basic medical insurance premiums after retirement will not enjoy the basic medical insurance benefits for retirees stipulated in these regulations.
Article 38 The overall fund will not pay for medical expenses incurred by employees and retirees due to alcoholism, suicide, self-mutilation, illegal crimes, etc.
Medical expenses incurred due to traffic accidents and medical accidents shall be handled in accordance with relevant national regulations.
Article 39 If a retiree is treated in a medical institution in another place with the approval of the social insurance agency and has lived in another place for more than one year, his basic medical insurance benefits shall be implemented in accordance with these regulations.
Article 40 Medical expenses incurred by employees and retirees while abroad or in Hong Kong, Macao and Taiwan shall be governed by these Regulations.
Chapter 5 Medical Service Management of Basic Medical Insurance
Article 41 The provincial labor and social security administrative department shall, in accordance with relevant national regulations, work with the planning, economic and trade, finance, health administration, pharmaceutical The supervision and management department determines the basic medical insurance drug list.
In accordance with relevant national regulations, the provincial labor and social security administrative department shall determine the catalog of basic medical insurance diagnosis and treatment items, the scope of medical service facilities and payment standards in conjunction with the planning, finance, health administration, and drug supervision and management departments.
The cost pooling fund shall not pay for the use of drugs, diagnosis and treatment items, and medical service facilities that are not covered by basic medical insurance.
Article 42 The provincial labor and social security administrative department shall, in accordance with relevant national regulations, work with the health administration and drug supervision and management departments to formulate management measures for designated medical institutions of basic medical insurance.
The provincial labor and social security administrative department shall, in accordance with relevant national regulations, work with the drug regulatory department to formulate management measures for designated pharmacies under basic medical insurance.
The labor and social security, health administration and drug supervision and management departments implement dynamic management of the qualifications of designated medical institutions and designated pharmacies.
Article 43 Labor and social security, health administration, drug supervision and management departments and social insurance agencies shall, in accordance with the management regulations of designated medical institutions and designated pharmacies, and in accordance with the simultaneous emphasis on traditional Chinese and Western medicine, community, specialist and comprehensive medical institutions. Taking into account the principle of facilitating medical treatment for insured persons, designated medical institutions and designated pharmacies are determined and announced to insured persons.
Article 44 When using a personal account, patients can seek medical treatment and purchase medicines at any designated medical institution or designated pharmacy.
If medical expenses are paid by the unified fund as required, patients should go to designated designated medical institutions for medical treatment.
Article 45: When paying medical expenses from the overall planning fund, according to the principle of total volume control, a total prepayment settlement system may be implemented.
Social insurance agencies can regulate the amount of prepaid overall funds based on the quantity and quality of medical services provided by designated medical institutions and the protection of legitimate medical rights and interests of insured persons.
Article 46 Designated medical institutions and designated pharmacies shall abide by national and provincial medical and health and basic medical insurance regulations, and shall not damage the legitimate medical rights and interests of insured persons in any way.
Designated medical institutions must inform patients of relevant medical services and fee details.
Article 47 The charging standards for basic medical services shall be formulated and revised by the provincial labor and security and price management department in conjunction with the health administration, finance and other departments, and shall be submitted to the provincial government for approval.
Basic medical insurance drug prices should comply with national regulations on drug pricing.
In case of violation of charging standards for basic medical services and drug price regulations, each account of the basic medical insurance fund will not pay medical expenses that exceed the standard.
Chapter 6 Organization, Management and Supervision of Basic Medical Insurance
Article 48 The provincial labor and social security administrative department is the administrative authority responsible for the basic medical insurance for urban employees in this province. Its responsibilities It is:
(1) Prepare the development plan for basic medical insurance for employees;
(2) Work with relevant departments to formulate the financial management system, statistical system and internal audit of the basic medical insurance fund system;
(3) Supervise and manage the province’s basic medical insurance work and exercise the power of administrative penalties in accordance with the law;
(4) Announce the basic medical insurance work status to the public every year; < /p>
(5) Other duties that should be performed by the administrative authorities.
The labor and social security administrative departments of cities, counties, and autonomous counties shall, in accordance with regulations, manage and supervise the basic medical insurance work for urban employees within their respective administrative regions.
Article 49 The social insurance agency is responsible for managing the basic medical insurance business for urban employees. Its responsibilities are:
(1) Responsible for basic medical insurance registration;
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(2) Manage the basic medical insurance fund;
(3) Supervise the medical services provided by the basic medical insurance;
(4) Responsible for the payment of basic medical insurance benefits ;
(5) Propose budget and final account preparation suggestions for basic medical insurance fund expenditures;
(6) Entrusted by the labor and social security administrative department, conduct inspections and inspections related to basic medical insurance Investigation work;
(7) Responsible for maintaining and increasing the value of basic medical insurance funds in accordance with national regulations;
(8) Providing consultation and other services on basic medical insurance policies;
(9) Responsible for handling other basic medical insurance matters stipulated by the state and the province. [page]
Article 50 The collection authority is responsible for handling basic medical insurance payment registration; proposing budget and final account preparation suggestions for basic medical insurance fund income; collecting and paying basic medical insurance premiums in accordance with the law; and monitoring payment units and individuals. Basic medical insurance premiums paid shall be subject to supervision and inspection and violations shall be dealt with.
Article 51 The health administrative department and the drug regulatory department shall strengthen the management and supervision of designated medical institutions and designated pharmacies, and assist social insurance agencies in carrying out basic medical insurance work.
The health administrative department shall deal with any behavior by medical institutions that violates relevant regulations on medical care and basic medical insurance and harms the legitimate medical rights and interests of insured persons.
The drug regulatory authorities should intensify drug supervision and management to ensure that medical institutions and designated pharmacies provide patients with quality, safe and effective drugs; and investigate drug accidents that occur in designated medical institutions and designated pharmacies in accordance with the law. deal with.
The price management department shall inspect and supervise the charging items and charging standards of basic medical insurance, strengthen management, and deal with unauthorized increases in charging items and charging standards in accordance with the law.
Article 52 Social insurance agencies shall send a list of personal account records to paying individuals at least once a year.
The employer shall announce the payment of basic medical insurance premiums to its employees and retirees every year and accept their supervision.
Article 53 The collection agencies, labor and social security administrative departments and social insurance agencies have the right to verify the employer’s employee roster, salary payment forms, financial accounting books and other relevant information, and when necessary The audit department should cooperate. The departments or institutions involved in the verification shall keep the employer's business secrets.
Employers shall truthfully provide employee rosters, salary payment forms, financial accounting books and other relevant information, and shall not forge, alter, lie, conceal or conceal.
Article 54 The labor and social security administrative departments and social insurance agencies have the right to inspect the implementation of basic medical insurance regulations by designated medical institutions and designated pharmacies in the process of diagnosis, examination, treatment, drug supply and charging. situation; the right to review medical prescriptions (doctor's orders), diagnosis and treatment reports, medical records, expense receipts and other relevant materials before paying medical expenses. Health administration, drug supervision and management, price management and other departments should provide assistance when necessary.
Designated medical institutions and designated pharmacies or other parties shall truthfully provide medical prescriptions (doctor's orders), diagnosis and treatment reports, medical records, expense receipts and other relevant information, and shall not forge, alter, lie, conceal or conceal.
Article 55 If designated medical institutions or designated pharmacies violate the relevant provisions of basic medical insurance, the labor and social security administrative department may order them to make corrections within a time limit according to different circumstances. If they still fail to make corrections within the time limit, their designation may be cancelled. qualifications.
Article 56: Finance, auditing, supervision and other departments and the social insurance fund supervisory board shall supervise the collection and management of basic medical insurance funds in accordance with the law, and strengthen the payment of basic medical insurance by employers and employees in accordance with the law. Supervision of expenses.
The annual income and expenditure of the basic medical insurance fund shall be audited by the auditing agency and announced to the public before June 30 of the following year to accept social supervision.
Article 57 Employers and individuals have the right to inquire about the payment of basic medical insurance premiums, personal account payment records and the enjoyment of basic medical insurance benefits. The collection agency, social insurance agency or other relevant institutions shall Provide services.
Employers and individuals have the right to supervise the collection of basic medical insurance premiums by collection agencies and the basic medical insurance work of social insurance agencies; they have the right to apply for legal applications for basic medical insurance disputes related to themselves Administrative reconsideration or filing a lawsuit.
Article 58 Employers and individuals have the right to report illegal activities in the collection of basic medical insurance premiums and the payment of basic medical insurance benefits. After receiving a report, the labor and social security administration, supervision and other departments shall promptly investigate the report, handle it in accordance with relevant regulations, and keep the whistleblower confidential.
Article 59 The funds required by social insurance agencies to manage basic medical insurance shall be included in the fiscal budget at the same level.
Chapter 7 Legal Responsibilities
Article 60 If an employer fails to register, change registration or cancel registration for basic medical insurance in accordance with the provisions of these Regulations, the labor and social security administrative department shall order Correction within a time limit; if the circumstances are serious, the directly responsible person in charge and other directly responsible personnel may be fined not less than 1,000 yuan but not more than 5,000 yuan; if the circumstances are particularly serious, the directly responsible person in charge and other directly responsible personnel may be fined not less than 5,000 yuan A fine of less than 10,000 yuan.
Article 61 If the employer fails to declare the amount of basic medical insurance premiums payable in accordance with the provisions of these Regulations, the collection authority shall order it to make corrections within a time limit; if the case is serious, the directly responsible person in charge and other The person directly responsible may be fined not less than 1,000 yuan but not more than 5,000 yuan; if the circumstances are particularly serious, the directly responsible person in charge and other directly responsible persons may be fined not less than 5,000 yuan but not more than 10,000 yuan.
Article 62 If an employer fails to pay or withhold basic medical insurance premiums in accordance with the amount and time limit stipulated in these regulations, the collection authority shall order the employer to pay the overdue amount and interest within a time limit; If payment is not made, in addition to making up the overdue amount, a late payment penalty of 2‰ of the overdue amount will be charged on a daily basis from the date of overdue payment, but interest will not be calculated at the same time. Late payment fees are incorporated into the basic medical insurance pooling fund.
Article 63: An employer violates laws, regulations and relevant national regulations on finance, accounting, statistics and relevant national provisions by forging, altering, lying, concealing, concealing, or deliberately destroying the roster of employees, payment of wages, etc. If there are no records, financial accounting books and other information, or there are no account books, resulting in the basic medical insurance premium payment base cannot be determined, in addition to administrative penalties, disciplinary sanctions, criminal penalties in accordance with the provisions of relevant laws and regulations, in accordance with Article 10 of these Regulations If payment is delayed, the collection authority shall decide to impose additional late fees in accordance with the provisions of the preceding article, and impose a fine of not less than RMB 5,000 but not more than RMB 20,000 on the person in charge and other persons directly responsible.
Article 64 If a social insurance agency fails to pay basic medical insurance benefits as required, the labor and social security administrative department shall order it to pay; if it refuses to pay, the relevant responsible personnel shall be given administrative sanctions.
If a designated medical institution fails to pay basic medical insurance benefits as required, the labor and social security administrative department or social insurance agency shall order it to pay; if it refuses to pay, the labor and social security administrative department or social insurance agency shall handle the matter. The institution will handle it accordingly in accordance with relevant regulations.
If the parties concerned are dissatisfied with the handling decision, they may apply for administrative review or report or accuse in accordance with the law.
Article 65 If the labor and social security administrative department, financial department, collection agency or social insurance agency violates the provisions of these Regulations and commits any of the following acts, the administrative agency at the next higher level shall order it to make corrections within a time limit , recover the basic medical insurance funds that have been misappropriated or lost; if there are illegal gains, the illegal gains will be confiscated and merged into the basic medical insurance overall fund; the main person in charge and the person directly responsible for the unit will be held administratively responsible respectively; if a crime is constituted, the illegal gains will be investigated in accordance with the law. Pursuing criminal liability:
(1) Failure to credit basic medical insurance premiums into personal accounts and pooled funds as required;
(2) Failure to transfer basic medical insurance funds to personal accounts as required into the special financial account of the basic medical insurance fund;
(3) Embezzling or misappropriating the basic medical insurance fund;
(4) Violating the provisions on maintaining and increasing the value of the basic medical insurance fund, causing the fund to Loss;
(5) Unauthorized reduction, exemption or increase of the basic medical insurance premiums that employers and employees must pay;
(6) Unauthorized changes to basic medical insurance benefits .
Article 66 If the labor and social security administrative departments, audit departments, collection agencies or social insurance agencies and their staff leak the employer’s business secrets, they shall be held legally responsible in accordance with the relevant national laws and regulations. . [page]
Article 67 If a designated medical institution, designated pharmacy or other party adopts any of the following behaviors to defraud basic medical insurance fees, the social insurance agency shall refuse to pay the basic medical insurance fees or The basic medical insurance premiums and interest paid shall be recovered in full; if the case is serious, the labor and social security administrative department or other administrative departments shall impose a fine of twice the amount incurred on the relevant medical institutions and pharmacies or other parties; if it constitutes a crime, the administrative department of labor and social security or other administrative departments shall impose a fine of twice the amount incurred; if it constitutes a crime, the administrative department of labor and social security or other administrative departments shall impose a fine of twice the amount incurred. Pursuing criminal liability:
(1) Forging or altering medical insurance documents, medical orders, and medical fee vouchers;
(2) Falsifying or falsely listing lists of medical personnel, diagnosis and treatment items, treatment time, medical materials, and drugs;
(3) Violating government price regulations and falsely reporting the prices of diagnosis and treatment items, medical materials, and drugs.
Article 68 If the employer or other parties are dissatisfied with the decision of the collection authority or labor and social security administrative department to collect basic medical insurance premiums, interest, late fees, penalties, etc., they may apply for reconsideration or initiate administrative proceedings in accordance with the law. litigation. If you fail to apply for reconsideration, file a lawsuit, or implement the decision within the time limit, the expropriation agency or labor and social security administrative department may apply to the People's Court for compulsory execution.
Chapter 8 Supplementary Provisions
Article 69 The medical treatment of retired personnel, old Red Army soldiers, and second-class Class B disabled retired revolutionary servicemen shall be handled in accordance with relevant national regulations.
Article 70 Whether employees of urban individual economic organizations and township enterprises participate in basic medical insurance shall be decided by the provincial people's government.
Article 71 The Provincial People's Government may formulate implementation rules in accordance with these regulations.
Article 72 These Regulations shall come into effect on the date of promulgation.