Article 1 In order to ensure the basic medical needs of urban residents and establish and improve a multi-level medical security system, these Measures are formulated in accordance with the relevant provisions of the state and the province and combined with the actual situation of this Municipality.
Article 2 These Measures shall apply to the following non-employed urban residents with household registration in this Municipality who are not included in the basic medical insurance system for urban workers within the administrative area of this Municipality:
(1) Primary and secondary school students (including students from vocational high schools, technical secondary schools, technical schools and special education schools), children enrolled in kindergartens and other children under the age of 18 (hereinafter referred to as underage urban residents);
(two) urban residents who have reached the age of 60 for men and 55 for women (hereinafter referred to as elderly urban residents);
(3) Other qualified non-employed urban residents (hereinafter referred to as ordinary urban residents).
Those who participate in the new rural cooperative medical system cannot participate in the basic medical insurance for urban residents at the same time.
Article 3 The basic medical insurance system for urban residents shall adhere to the following principles:
(a) the level of medical security and financing standards are compatible with the level of economic development and affordability of this Municipality;
(two) low rates, wide coverage, serious illness as a whole;
(three) the government guidance, voluntary insurance, territorial management;
(four) individual contributions, appropriate government subsidies;
(five) the basic medical insurance fund is raised and used in accordance with the principle of fixed income and expenditure, balance of payments and slight balance;
(six) the basic medical insurance for urban residents and urban workers, the new rural cooperative medical system and social medical assistance are balanced, interconnected and coordinated.
Article 4 The basic medical insurance for urban residents in this Municipality shall implement a unified policy. At the initial stage, municipal overall planning was implemented in Kuiwen District, Weicheng District, Fangzi District, Hanting District, High-tech Development Zone, Economic Development Zone, Binhai Development Zone and Xiashan Development Zone (hereinafter referred to as urban areas), and each county (city) operated independently, and gradually transitioned to municipal overall planning when conditions were ripe.
Article 5 The labor and social security departments of city, county and municipal development zones are responsible for the management of basic medical insurance for urban residents within their respective administrative areas, and their social insurance agencies specifically undertake the basic medical insurance business for urban residents.
The basic medical insurance business for urban residents in urban areas is undertaken by the municipal social insurance agencies, and the social insurance agencies in various districts assist in the implementation.
Street offices and township governments are responsible for the registration of basic medical insurance for urban residents and other related work.
The development and reform department is responsible for bringing the basic medical insurance for urban residents into the national economic and social development plan and supervising its implementation; The financial department is responsible for budget arrangement, fund allocation and fund supervision; The health department is responsible for the construction and management of community medical institutions; The education department is responsible for organizing and coordinating urban primary and secondary school students to participate in the basic medical insurance for urban residents; The civil affairs department is responsible for the identification of urban residents, organizing and guiding residents to participate in insurance and supporting medical assistance; The Federation of Disabled Persons is responsible for the identification of severely disabled persons; The public security department is responsible for the household registration identification of insured residents and the provision of relevant information.
Food and drug supervision, price, auditing and other departments shall, according to their respective responsibilities, do a good job in the basic medical insurance for urban residents.
Article 6 The funds needed for the basic medical insurance for urban residents shall be borne by the finance at the same level.
Article 7 Governments at all levels shall strengthen the construction of social insurance agencies and labor security platforms in street communities, ensure the personnel, equipment and funds needed to carry out the work, and establish and improve the incentive, restraint, supervision and assessment mechanisms for expanding the basic medical insurance for urban residents.
Chapter II Fund Raising
Article 8 The basic medical insurance premium for urban residents shall be raised according to the following standards:
(a) minor urban residents per person per year in 80 yuan. Among them, individuals pay 20 yuan and the government subsidizes 60 yuan; Belonging to the minimum living allowance object or severely disabled person, the individual pays 10 yuan, and the government subsidizes 70 yuan.
(2) The average urban resident is in 280 yuan every year. Among them, individuals pay 200 yuan and the government subsidizes 80 yuan; Is a minimum target or severely disabled, individuals pay 20 yuan, government subsidies in 260 yuan.
(3) 280 yuan for urban elderly residents per person per year. Among them, individual contribution 140 yuan and government subsidy 140 yuan; Is a minimum target or severely disabled, individuals pay 20 yuan, government subsidies in 260 yuan.
The basic medical insurance premium for urban residents in counties (cities) shall be raised according to the standard that minor urban residents shall not be lower than that of 80 yuan, ordinary and elderly urban residents shall not be lower than that of 240 yuan. Among them, the government gives subsidies according to the standard of not less than 40 yuan, 60 yuan and 100 yuan per person per year; Is a minimum living standard or severely disabled, respectively, according to the standard of not less than 60 yuan, 180 yuan, 180 yuan per person per year.
Ninth urban residents basic medical insurance financing standards and government subsidies can be adjusted according to the level of economic development, by the labor and social security department in conjunction with the financial sector to put forward opinions, reported to the government at the same level for approval before implementation.
Tenth government subsidies, in addition to financial subsidies at or above the provincial level, municipal finance subsidies to some counties and cities according to a certain proportion. Among them, urban subsidy is 50%, Anqiu City, Changle County and Linqu County are subsidized by 15%, Qingzhou City, gaomi city City and Changyi City are subsidized by 10%, and the rest is borne by counties and cities. Government subsidy funds are included in the fiscal budget on an annual basis, and are directly incorporated into the financial accounts of the basic medical insurance fund for urban residents by the financial department.
Eleventh to encourage qualified employers to give subsidies to urban residents in their families. Individual contributions and unit subsidy funds enjoy preferential tax policies stipulated by the state.
Twelfth basic medical insurance for urban residents to pay once a year. The payment period for the next medical year is 1 1 in October to 65438+3 1 in February. Where the payment is not made within the payment period, the insurance payment procedures will not be handled during the year. Every year from 65438+1 October1to 65438+February 3 1 is a medical year.
Thirteenth basic medical insurance for urban residents shall be collected by the following units:
(a) primary and secondary school students, the education department is responsible for organizing the collection and distribution;
(two) other personnel in the family as a unit by the domicile of the streets, township labor and social security service agencies responsible for withholding.
Article 14 All collection units shall do a good job in the collection of basic medical insurance premiums, registration and change of insurance information, assist social insurance agencies in the confirmation of insurance information and other related work, and hand over the basic medical insurance premiums for urban residents to social insurance agencies in a timely manner, and shall not intercept or misappropriate them.
Social insurance agencies should establish payment and payment records for insured urban residents, and be responsible for providing information inquiry for the insured.
Chapter III Basic Medical Insurance Benefits
Fifteenth basic medical insurance for urban residents focuses on ensuring the insured's hospitalization and outpatient medical treatment for serious illness due to illness, and gives due consideration to the medical treatment for accidental injuries of primary and secondary school students.
Sixteenth basic medical insurance for urban residents, medical service facilities and payment standards, as well as the management measures of designated medical institutions with reference to the relevant provisions of the basic medical insurance for urban workers in our city. Children's drug list needs to be increased, in accordance with the relevant provisions of the state and province.
Seventeenth urban residents basic medical insurance fund payment to implement the annual maximum payment system. The maximum payment limit for urban insured persons in each medical year is 48,000 yuan for minor urban residents and 30,000 yuan for other urban residents. The maximum payment limit of each county (city) is not less than 30 thousand yuan.
Eighteenth insured in designated medical institutions in accordance with the provisions of the hospitalization expenses, included in the basic medical insurance fund for urban residents to pay. According to different levels of hospitals, the corresponding minimum payment standard and payment ratio are determined. First-,second-and third-class hospitals, the urban Qifubiaozhun are 300 yuan, 500 yuan and 700 yuan respectively; From the minimum payment standard to the maximum payment limit, the payment ratio is 60%, 55% and 50% respectively. Counties (cities) can determine their own Qifubiaozhun and payment ratio.
Nineteenth the establishment of outpatient serious illness medical system. Urban insured persons suffering from malignant tumor radiotherapy and chemotherapy, uremia dialysis treatment, organ transplantation anti-rejection treatment and chronic aplastic anemia treatment, and underage insured persons suffering from hepatitis B, type I diabetes, systemic lupus erythematosus, active tuberculosis, epilepsy, rheumatic fever and bronchial asthma need outpatient treatment. Approved by the municipal social insurance agency, you can go to the designated outpatient medical institutions for treatment, and the outpatient medical expenses for serious illness can be included in the payment scope of the basic medical insurance fund. The qifubiaozhun for medical expenses of serious illness in urban outpatient department is 600 yuan; Qifubiaozhun to the highest payment limit, the payment ratio is 50%. Counties (cities) can determine their own outpatient diseases, Qifubiaozhun and payment ratio. Twentieth primary and secondary school students emergency medical expenses due to accidental injuries, 80% paid by the basic medical insurance fund, the annual maximum payment limit of 1 000 yuan.
Twenty-first in a medical year, the insured eligible inpatient medical expenses and outpatient medical expenses are calculated together, and the basic medical insurance fund payment does not exceed the annual maximum payment limit.
Article 22 The annual maximum payment limit, Qifubiaozhun, outpatient serious illness and payment ratio of the basic medical insurance fund for urban residents shall be adjusted in a timely manner by the labor and social security department in conjunction with the finance department at the same level according to the balance of the basic medical insurance fund.
Twenty-third ordinary and elderly urban residents who have not incurred serious medical expenses for hospitalization and outpatient service in one medical year and continue to pay insurance premiums in the next medical year can enjoy the general outpatient medical subsidy of 10% of the individual contributions in the previous medical year. When conditions are ripe, gradually co-ordinate the general outpatient medical expenses.
Article 24 If the insured person needs to be transferred to a foreign hospital for hospitalization due to illness, the third-level hospital in our city or the municipal specialized hospital shall issue the transfer procedures and report them to the social insurance agency for approval. After the transfer is approved, the hospitalization expenses incurred shall be borne by the individual at first 10%, and the rest shall be implemented according to the treatment standards of tertiary hospitals in this way; The basic medical insurance fund will not pay the hospitalization expenses incurred by unauthorized transfer.
Twenty-fifth insured medical expenses for emergency hospitalization in different places due to visiting relatives, traveling and other reasons, the individual shall bear 20% first, and the rest shall be implemented according to the treatment standard of tertiary hospitals.
Twenty-sixth the establishment of payment period and enjoy medical treatment linked mechanism. After urban residents pay the basic medical insurance premiums continuously, the proportion of hospitalization expenses paid by the basic medical insurance fund will increase by 1 percentage point every five years.
Twenty-seventh ordinary urban residents who participate in the basic medical insurance for urban residents and participate in the basic medical insurance for urban employees after employment shall be included in the payment period of the basic medical insurance for urban employees 1 year every three years (if the conversion is insufficient 1 year, it shall be calculated according to the actual conversion time).
Twenty-eighth insured persons shall pay the basic medical insurance premium in full and on time. If payment is interrupted, the basic medical insurance fund for medical expenses incurred during the interruption will not be paid. Urban residents who meet the conditions and fail to pay insurance premiums in time will be insured in the following year and enjoy basic medical insurance benefits in accordance with the regulations after 6 months from the beginning of the medical year.
Twenty-ninth the following circumstances do not belong to the basic medical insurance fund for urban residents:
(1) Medical expenses incurred due to work-related injuries, occupational diseases and female childbirth;
(2) Medical expenses incurred by the insured during going abroad or going to Hongkong, Macao and Taiwan Province Province;
(3) Medical expenses incurred due to traffic accidents, medical accidents and drug accidents;
(four) medical expenses due to illegal crimes, alcoholism, fighting, suicide, self-mutilation, etc. ;
(five) other medical expenses stipulated by the state and the province that do not belong to the basic medical insurance coverage of urban residents.
Thirtieth due to natural disasters and other factors caused by large-scale emergency, dangerous, serious patient rescue medical expenses, by the governments at all levels to coordinate and solve.
Chapter IV Management of Medical Services
Article 31 The basic medical insurance for urban residents shall be managed by designated medical institutions, and the insured person shall choose the nearest designated hospital as his designated medical institution for inpatient and outpatient serious illness, with the service life of 1 year. After the expiration of the service period, the insured may change the designated medical institution according to the service situation.
In addition to the provisions of article twenty-fourth, article twenty-fifth and article thirty-fourth, the basic medical insurance fund will not pay the medical expenses incurred in non-designated medical institutions.
Thirty-second insured persons should be hospitalized in designated medical institutions. Because of illness need to be transferred in the city, by the designated medical institutions according to the patient's condition, timely transfer procedures, reported to the social insurance agencies for the record.
The basic medical insurance fund will not pay the hospitalization expenses incurred in the transfer procedures of designated medical institutions.
Article 33 When seeking medical treatment in a designated medical institution, the insured shall go through the hospitalization formalities with relevant certificates. After the end of medical treatment, according to the standards stipulated in these measures, the insured and the hospital only settle the part that should be borne by the individual, and the rest of the expenses are settled regularly by social insurance agencies and medical institutions.
The basic medical insurance fund will not pay the medical expenses incurred by not going through the hospitalization procedures as required.
Thirty-fourth insured persons in the event of acute and critical diseases, can be hospitalized nearby. Hospitalization in non-designated medical institutions, with emergency hospitalization certificate and related materials within 3 working days to designated medical institutions and social insurance agencies for the record, the hospitalization expenses incurred by the individual shall be borne by 5%, and then according to the relevant provisions of these measures.
Thirty-fifth designated medical institutions shall establish and improve the internal management system of basic medical insurance for urban residents, strictly implement relevant policies and regulations and medical service agreements, and equip full-time (part-time) management personnel to do a good job in the internal management of basic medical insurance for urban residents.
Chapter V Fund Management and Supervision
Thirty-sixth urban residents' basic medical insurance fund shall be divided into two lines, which shall be included in the management of financial accounts and accounted for separately. No unit or individual may occupy or misappropriate it.
Article 37 The basic medical insurance fund for urban residents shall implement a unified social insurance fund budget and final accounts system, financial accounting system and internal audit system.
Thirty-eighth social insurance agencies should establish and improve the internal management system, strengthen the management of the income and expenditure of the basic medical insurance fund for urban residents, and accept the supervision and inspection of labor security, finance, auditing and other departments.
Thirty-ninth urban residents' basic medical insurance fund revenue and expenditure management, should be regularly reported to the social security supervision committee at the same level, and regularly announced to the public, accept social supervision.
Chapter VI rewards and punishments
Fortieth urban residents basic medical insurance premium collection unit has one of the following acts, the labor and social security department shall order it to make corrections; Refuses to correct, by the competent department of the main person in charge and the person directly responsible to give criticism and education or administrative sanctions; If a crime is constituted, criminal responsibility shall be investigated according to law.
(1) Failing to register or change the insured information for the insured according to regulations;
(2) Failing to collect medical insurance premiums as required;
(three) failing to provide relevant medical management services for the insured;
(four) do not carefully examine the relevant documents or resort to deceit, so that people who do not meet the conditions are insured or enjoy government subsidies;
(5) withholding or misappropriating medical insurance premiums;
(six) other acts in violation of the laws and regulations of the basic medical insurance for urban residents.
Forty-first designated medical institutions and their staff, one of the following acts, by the labor and social security departments in accordance with the relevant provisions; If the circumstances are serious, suspend or cancel the qualification of designated medical institutions; If a crime is constituted, criminal responsibility shall be investigated according to law.
(a) the medical service for the insured is not in place or the referral is not handled in time;
(two) forged medical documents to defraud the medical insurance fund, or did not seriously confirm the identity of the insured, resulting in the loss of the fund;
(3) Referral of insured patients who do not meet the referral conditions;
(four) in violation of the principle of treatment due to illness or the relevant provisions, there are acts of random inspection, random medication, arbitrary charges, etc.;
(five) other violations of the provisions on the administration of basic medical insurance for urban residents.
Forty-second insured persons who defraud the medical insurance fund shall be ordered by the labor and social security department to return it and be punished according to relevant laws and regulations; If a crime is constituted, criminal responsibility shall be investigated according to law.
Article 43 If a party refuses to accept the administrative punishment decision of the labor and social security department, it may apply for administrative reconsideration or bring an administrative lawsuit according to law. If a party fails to perform the decision on administrative punishment within the time limit, the administrative organ that made the decision on administrative punishment shall apply to the people's court for compulsory execution according to law.
Article 44 Labor and social security departments, social insurance agencies and their staff who abuse their powers, engage in malpractices for selfish ends, neglect their duties, damage the legitimate rights and interests of the insured or cause losses to the medical insurance fund shall be given administrative sanctions according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
Forty-fifth to establish a reward system for reporting. Encourage all sectors of society to report acts of designated medical institutions that violate the regulations on the management of basic medical insurance and infringe upon the legitimate rights and interests of insured persons. For reported cases involving the basic medical insurance fund, once verified, the whistleblower will be rewarded according to the standard of recovering the illegal amount 10% according to law, with a maximum of 20,000 yuan; Does not involve the basic medical insurance fund, in accordance with the standards of not more than 500 yuan reward informants.
Chapter VII Supplementary Provisions
Forty-sixth after the conditions are ripe, the community health service institutions and retail pharmacies will be gradually included in the basic medical insurance for urban residents.
Forty-seventh counties (cities, districts) that have carried out the basic medical insurance for urban residents (hereinafter referred to as "new towns") shall be merged in accordance with the provisions of these measures.
Forty-eighth municipal labor and social security departments can formulate detailed rules for implementation according to these measures.
County (city) government should study and formulate specific opinions according to the provisions of these measures and local conditions, and implement them after being approved by the municipal government. Article 49 These Measures shall come into force as of June 6, 2008.