Can Mianyang urban workers' medical insurance reimburse those expenses?

Insurance Xiaobian helps you to answer, and more questions can be answered online.

Notice of Mianyang Municipal People's Government on Printing and Distributing the Implementation Measures of Mianyang City's Basic Medical Insurance System for Urban Employees

(Mian Fu Fa [1998] No.172)

In order to implement the State Council's Decision on Establishing the Basic Medical Insurance System for Urban Employees, the implementation measures of Mianyang City's Basic Medical Insurance System for Urban Employees are formulated in accordance with the Notice.

1. tasks and principles

1. the main tasks of the basic medical insurance system for urban employees are:

to establish a basic medical insurance system for urban employees, that is, a social medical insurance system that adapts to the socialist market economic system and guarantees the basic medical needs of employees according to the affordability of finance, enterprises and individuals.

2. The principles of establishing the basic medical insurance system for urban workers are as follows:

The level of basic medical insurance should adapt to the development level of productive forces in the primary stage of socialism; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The basic medical insurance premium shall be borne by both the employer and the employee, and the basic medical insurance shall be combined with social pooling and individual accounts.

II. Coverage and payment methods

1. All employers at Mianyang City level, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises), government agencies, institutions, social organizations, private non-enterprise units and their employees, must participate in the basic medical insurance (the municipal level and above in Fucheng District and Youxian District will participate in the basic medical insurance at the city level). Within the scope of the Ministry, provincial units, railways, electric power and other enterprises with large production mobility and their employees can participate in Mianyang's basic medical insurance at the corresponding level in a relatively centralized way in accordance with the principle of territorial management, implement unified policies, and raise, use and manage insurance funds in a unified manner.

2. The basic medical insurance premium shall be paid by both the employer and the employee.

the employer pays 7% of the total wages of employees in the previous year, and the individual employee pays 2% of his salary income in the previous year. With the economic development, the employer and employee pay rates can be adjusted accordingly.

3. The total wages of employees in the previous year are based on the statistical caliber of labor wages of the Municipal Bureau of Statistics. Where the payment wage is lower than the municipal average wage, it shall be paid according to the municipal average wage.

4. The collection of employees' basic medical insurance premiums can be entrusted to the bank or paid directly by the unit, and paid monthly or quarterly (the first 1 days of the first month of each month and quarter). Those who fail to pay or pay within the time limit will be fined 2‰ for late payment, which will be incorporated into the overall fund; If the payment is overdue for 3 months, the medical insurance relationship will be suspended.

5. Retirees participate in the basic medical insurance, and individuals do not pay the basic medical insurance premium.

6. When the insured unit is divided, merged or terminated, the unpaid medical insurance premium must be paid off first; When an enterprise goes bankrupt and liquidates, it must pay off the unpaid and payable medical insurance premiums in full.

III. Establishing social insurance pooling and individual accounts for basic medical care

1. The basic medical insurance combines social pooling and individual accounts, and the basic medical insurance fund consists of pooling funds and individual accounts. Individual accounts and pooling funds are accounted for separately, and cannot be squeezed out of each other.

① personal account: all the basic medical insurance premiums paid by employees are included in the personal account. The basic insurance premium paid by the employer is divided into two parts, one part is used to establish the overall fund and the other part is included in the personal account.

the proportion transferred to individual account is calculated according to the employee's salary (annual retirement fee for retirees), 3% for those under 45 years old (including 2% paid by individuals) and 4% for those over 45 years old (including 2% paid by individuals); Retirees are included in personal accounts at 4% of their annual retirement fees from social pooling funds.

individual medical accounts are transferred quarterly according to the unit payment.

② pooling fund: the balance of medical insurance premium paid by the unit after deducting it into personal account is used as pooling fund, which is managed by the Municipal Social Security Bureau.

2. Payment scope of personal account and overall fund:

① Personal account is mainly used to pay outpatient medical expenses, and can also pay the self-paid part of hospitalization medical expenses, and all the expenses will be paid by themselves when they are insufficient.

② The overall fund is mainly used to pay for hospitalization expenses. The hospitalization expenses of the insured (in line with the scope of basic medical reimbursement) shall be settled in a single hospitalization. The qifubiaozhun paid by the overall fund for each hospitalization is: tertiary hospital 7 yuan, secondary hospital 6 yuan, first-class and ungraded hospital 5 yuan, and the qifubiaozhun for retirees is lower than that for on-the-job personnel by 1 yuan. Medical expenses below Qifubiaozhun can be paid by personal accounts or by individuals themselves. The basic medical insurance expenses above Qifubiaozhun and below the maximum payment limit are mainly paid by the overall fund, accounting for 8% of employees (2% paid by individuals) and 9% of retirees (1% paid by individuals). The accumulative maximum payment limit for the annual basic medical expenses of the insured is 25, yuan.

③ Medical expenses that are approved to be transferred to a foreign hospital or admitted to a foreign public hospital for emergency on business trip and meet the basic medical reimbursement. The minimum payment standard is 7 yuan for employees and 6 yuan for retirees. Those above the minimum payment standard and below the maximum payment limit are mainly paid by the overall fund, accounting for 7% of employees (3% paid by individuals) and 8% of retirees (2% paid by individuals).

④ On-the-job and retirees who are resident in other places do not use medical magnetic cards, and the outpatient medical expenses are used in lump sum according to the above-mentioned Article ①, and the hospitalization medical expenses are handled according to the above-mentioned Article ③.

3. The medical expenses incurred by the insured who need to rely on drugs for a long time in outpatient medical treatment and who need outpatient medical treatment after being discharged from the hospital with serious illness, which are in line with the scope of basic medical reimbursement, have been certified by hospitals and units above the second level and audited by the Municipal Social Security Bureau, and are paid by the overall fund at a rate of 3% for individuals and 3% for units, which will be summarized by the unit every six months and reimbursed by the Municipal Social Security Bureau.

iv. management and supervision of the basic medical insurance fund

1. the basic medical insurance fund shall be included in the financial special account management, and shall be used for special purposes and shall not be misappropriated.

2. The Municipal Social Security Bureau is responsible for raising, managing and paying the basic medical insurance fund.

3. The business funds of the Municipal Social Security Bureau shall not be drawn from the insurance fund, and shall be solved by the municipal budget.

4. Calculation method of the bank interest rate of the basic medical insurance fund: the part raised in that year will bear interest according to deposit interest rate; The fund principal and interest carried forward from the previous year shall bear interest at the bank deposit rate of lump-sum deposit for 3 months; The deposited funds deposited in the financial special account of social security shall bear interest according to the three-year zero deposit and lump-sum savings deposit interest rate, which is not lower than the interest rate of this grade.

5. The principal and interest of individual accounts are owned by the employees themselves, and can only be used for medical expenses, and cash cannot be withdrawn or used for other purposes, but can be carried forward and inherited. When employees are transferred from this city, the balance of personal account funds will be transferred or returned to me at one time.

6. Settlement of basic medical expenses.

① Settlement of medical expenses of insured persons

Outpatient medical treatment: All medical treatment in designated medical institutions and drug purchases in designated pharmacies with microcomputer networking will be settled by magnetic card, and all personal accounts will be paid by themselves when they are used up; Where the designated medical institutions and pharmacies that have not implemented computer networking purchase drugs, they will all be settled in cash, and then they can be settled by the unit on a monthly or quarterly basis by the Municipal Social Security Bureau.

Hospitalization: If the insured employee really needs hospitalization due to illness, he/she shall go through the hospitalization formalities at the Municipal Social Security Bureau or the agency of the Municipal Social Security Bureau with the admission certificate of the designated hospital and the introduction of the unit. Where the designated medical institutions that have implemented computer networking are hospitalized, the hospitalization medical expenses shall be settled by magnetic card. The expenses below the Qifubiaozhun, the individual's own expenses and the self-paid part shall be directly charged to the patients by the medical institution according to the regulations. Part of the overall fund payment shall be settled by the medical institution and the Municipal Social Security Bureau. All patients who are hospitalized in designated medical institutions without computer networking will be settled with medical institutions in cash, and will be settled by the unit to the Municipal Social Security Bureau after discharge.

② The designated medical institutions and designated pharmacies will co-ordinate the fund settlement

The 25th of each month is the settlement date. The designated medical institutions that implement microcomputer networking should report the outpatient medical expenses and the expenses of discharged patients in hospitalization to the Municipal Social Security Bureau for settlement in accordance with the regulations, and the designated pharmacies that implement microcomputer networking should report the expenses of insured persons for drug purchase in the current month to the Municipal Social Security Bureau for settlement in accordance with the regulations.

the time for submitting the fee settlement of designated medical institutions and pharmacies is within 1 days after each settlement date.

7. If the designated medical institutions and pharmacies violate the relevant provisions of the basic medical insurance, the Municipal Social Security Bureau will notify them according to the seriousness of the case, and impose an economic penalty of 3-5 times the illegal expenses. If the circumstances are serious, they will be disqualified.

8. If the insured units and insured personnel violate the relevant provisions of the basic medical insurance, the Municipal Social Security Bureau will notify them according to the seriousness of the case, and impose an economic penalty of 3-5 times of the illegal expenses. If the circumstances are serious, the unit account and the insured personnel's magnetic card will be frozen.

9. The Municipal Social Security Bureau shall, according to the basic medical service scope, standards, medical expense settlement methods, drug list, diagnosis and treatment items, medical service facilities standards and corresponding management methods formulated by the labor and social security departments at higher levels, and in combination with the actual situation of our city, formulate corresponding measures in conjunction with relevant departments, and organize their implementation. Before the introduction of the above management measures, the drug list, the scope and standards of medical services shall be temporarily implemented according to the original measures.

1. The basic medical insurance shall be managed by designated medical institutions and pharmacies. The Municipal Social Security Bureau shall, jointly with relevant departments, be responsible for determining the designated medical institutions and pharmacies according to the qualification examination methods for designated medical institutions and pharmacies formulated by the superior labor and social security departments, and sign medical service contracts with the designated medical institutions and pharmacies to clarify their respective responsibilities, rights and obligations.

11. The Municipal Finance Bureau should strengthen the supervision and management of the basic medical insurance fund.

12. The Municipal Audit Bureau shall regularly audit the income and expenditure and management of the medical insurance fund of the Municipal Social Security Bureau.

13. The Municipal Health Bureau should conscientiously implement the Decision on Health Reform and Development (Zhongfa [1997] No.3) issued by the Central Committee and the State Council, actively promote the structural adjustment of medical and health service system, accelerate the reform of health institutions, standardize medical behaviors, reduce staff and increase efficiency, and improve the utilization efficiency of health resources. It is necessary to invest less money to enable the people to get basic medical services and promote the healthy development of medical and health undertakings. It is necessary to gradually implement separate accounting and management of medicines in municipal medical institutions, form a competitive mechanism between medical services and drug circulation, and reasonably control the level of medical expenses. We should actively develop community services and incorporate basic medical services in community services into basic medical insurance coverage.

14. Set up a supervision group of Mianyang employees' basic medical insurance fund, which is attended by representatives of relevant government departments, employers, medical institutions, trade unions and relevant experts (the participating units and personnel will be issued separately). Its main responsibilities are:

① to supervise and check the implementation of basic medical insurance policies and systems;

② To supervise and inspect the collection and use of medical insurance funds;

③ To supervise and inspect the implementation of basic medical policies, charging standards and service quality by designated medical institutions;

④ to supervise and inspect the implementation of basic medical policies, drug quality, price and service quality in designated pharmacies.

5. Properly solve the medical treatment of relevant personnel

1. The medical treatment of retired personnel and the old Red Army will remain unchanged, and the medical expenses will be solved according to the original funding channels. If it is really difficult to pay, the people's government will help solve it.

2. The medical treatment of disabled revolutionary servicemen above Grade B and Grade B remains unchanged, and the medical expenses will be solved according to the original funding channels, which will be managed by the Municipal Social Security Bureau separately, and the insufficient medical expenses will be solved by the Municipal People's Government.

3. Civil servants enjoy the Medicaid policy on the basis of participating in the basic medical insurance, which will be implemented after the specific measures are formulated by the state.

4. In order not to reduce the existing medical consumption level of employees in certain industries, enterprises are allowed to establish supplementary medical insurance as a transitional measure on the basis of participating in basic medical insurance. The part of enterprise supplementary medical insurance premiums within 4% of the total wages shall be paid from the employee welfare funds, and the part of the welfare funds that is insufficient shall be included in the cost after being approved by the Municipal Finance Bureau. Enterprise supplementary medical insurance is not included in social pooling. The delineation of specific industries will be determined after the state formulates relevant documents.

5. The basic medical insurance for laid-off workers from state-owned enterprises is still implemented in accordance with the Notice on Medical Insurance for Employees of Bankrupt State-owned Enterprises during Custody (Mianfu Office Letter [1998] No.41).

6. The medical expenses incurred by employees of municipal administrative institutions due to work-related injuries and maternity are not included in the basic medical care category, and the municipal social security bureau will implement the work-related injuries and maternity insurance system among employees of municipal administrative institutions.

7. The medical expenses above the maximum payment amount shall still be implemented according to the special medical expenses solution for seriously ill workers with more than 25, yuan in the document No.5 issued by Mianwei Office, and shall be implemented according to the new regulations after the country has new regulations.

VI. Strengthening organizational leadership

The reform of the medical system is policy-oriented and involves a wide range, which is related to the vital interests of the broad masses of workers, economic development and social stability. All insured units should earnestly strengthen their leadership, unify their thinking, raise their awareness, do a good job in propaganda and ideological work for employees, so that the broad masses of employees and all sectors of society actively support and participate in the basic medical insurance for urban employees at the city level, and carefully organize and implement the new and old schemes in accordance with the tasks, principles and requirements of establishing the basic medical insurance system for urban employees, combined with the actual situation of their own units, so as to ensure the smooth transition of the old and new schemes.

VII. Others

1. These Measures shall be implemented as of January 1, 1999. The original "Mianyang medical security system reform implementation measures" and "Mianyang workers' social medical insurance implementation rules" are inconsistent with these measures.

2. Mianyang Social Security Bureau is responsible for the interpretation of these Measures.