Measures for the implementation of basic medical insurance for urban residents in Hainan Province as a whole

You don't need to participate in social endowment insurance to participate in medical insurance for urban residents, but you need to participate in endowment insurance first to participate in basic medical insurance for enterprise employees.

Notice of the General Office of the People's Government of Hainan Province on Printing and Distributing the Implementation Measures of Basic Medical Insurance for Urban Residents in Regional Coordinating Areas of Hainan Province [2008] No.31

The people's governments of cities, counties and autonomous counties and the units directly under the provincial government:

The measures for the implementation of the basic medical insurance for urban residents in Hainan Province as a whole have been approved by the provincial government and are hereby issued to you, please implement them carefully.

March 2008 18

Regional master planning area of Hainan Province

Measures for the implementation of basic medical insurance for urban residents

Chapter I General Provisions

Article 1 According to the Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No.20), Notice of Hainan Provincial People's Government on Printing and Distributing Opinions on Doing a Good Job in the Pilot Work of Basic Medical Insurance for Urban Residents (Fu Qiong [2007] No.35), Supplementary Notice of Hainan Provincial People's Government on Doing a Good Job in the Pilot Work of Basic Medical Insurance for Urban Residents (Fu Qiong [2007] No.50) and Notice of the Ministry of Labor and Social Security on Determining the List of Expanded Pilot Cities for Basic Medical Insurance for Urban Residents in 2008 (Letter from the Ministry of Labor and Social Security [2008]

Article 2 In accordance with the principle of "starting at a low level, focusing on ensuring the medical needs of urban residents for serious diseases and gradually improving the level of protection", in the regional overall planning areas (including Wenchang City, qionghai city City, Danzhou City, Wanning City, Wuzhishan City, Dongfang City, Ding 'an County, Tunchang City, Chengmai County, Lingao County, Changjiang County, Ledong County, Lingshui County, Baisha County, etc.

Not included in the coverage of the basic medical insurance system for urban workers, non-agricultural residents of agricultural reclamation (hereinafter referred to as agricultural reclamation residents) shall participate in the basic medical insurance for urban residents in the districts, cities and counties where their household registration is located according to the principle of territorial management.

Article 3 As the overall planning unit of the basic medical insurance for urban residents, the overall planning area shall adopt the mode of regional fund planning, city and county handling and surplus and deficiency adjustment. Unified fund-raising standards, unified treatment and payment standards, unified fund management, unified collection agencies and unified handling agencies.

Article 4 The provincial department of personnel, labor and social security shall be responsible for studying and formulating the rules and regulations of basic medical insurance for urban residents in the regional overall planning area jointly with relevant departments. The personnel, labor and social security departments of cities and counties (including Yangpu, the same below) in the regional overall planning area are responsible for the implementation, management and supervision of the basic medical insurance system for urban residents in this city and county.

The provincial finance department is responsible for the management of the basic medical insurance fund for urban residents in the overall planning area of this region. The financial departments of the cities and counties in the regional overall planning area are responsible for the management of the basic medical insurance funds for urban residents in the cities and counties.

Provincial local tax authorities are responsible for the collection and supervision of basic medical insurance premiums for urban residents in regional overall planning areas. The local tax and social insurance fee collection departments of cities and counties in the regional overall planning area are responsible for the collection of basic medical insurance premiums for urban residents in this city and county with the assistance of community labor and social security service institutions.

Provincial social insurance agencies are responsible for the supervision of the payment of basic medical insurance benefits for urban residents in the overall planning area of this region. The social security agencies of cities and counties in the regional overall planning area are responsible for the payment of basic medical insurance benefits for urban residents in cities and counties of this city.

Provincial Land Reclamation Bureau and its affiliated farms and enterprises are responsible for the publicity, registration and payment of basic medical insurance for urban residents. The Provincial Land Reclamation Bureau is also responsible for the implementation of some subsidy funds undertaken by the bureau.

Health, publicity, development and reform, education, civil affairs, public security, food and drug supervision, auditing, disabled persons' federations and other departments at all levels carry out their duties and actively cooperate with the basic medical insurance for urban residents.

Chapter II Insurance Scope and Payment Method

Article 5 Non-agricultural household registration in cities and counties within the regional overall planning area, students (including students from vocational high schools, technical secondary schools and technical schools) who are not covered by the basic medical insurance system for urban workers, children and other non-employed urban residents may voluntarily participate in the basic medical insurance for urban residents. Students are insured at their place of registration.

Article 6 The basic medical insurance for urban residents in the overall planning area shall be subject to the annual regular payment system.

In the second quarter of 2008, Dongfang and Tunchang paid the insurance premiums from September 2008 to February 2009, and residents enjoyed the basic medical insurance benefits for urban residents from September 2008 to February 3, 2009. Other cities and counties (including Yangpu) paid insurance premiums from July 2008 to February 2009, and residents enjoyed basic medical insurance benefits for urban residents from July 2008 to February 3, 2009.

From 2009, the fourth quarter of each year is the time for the collection of the basic medical insurance premium for urban residents in the next year. Residents enjoy the basic medical insurance for urban residents from June 65438+1 October1to February 65438+February 3 1 the following year.

The specific measures for the collection of the basic medical insurance premium for urban residents in regional overall planning areas shall be formulated separately by the provincial finance department in conjunction with the provincial local taxation department and the provincial personnel and labor security department.

Chapter III Fund Raising

Seventh urban residents basic medical insurance financing standards as a whole:

(1) The annual fund-raising standard for each adult is 140 yuan, in which the individual pays 60 yuan and the financial subsidy is 80 yuan. Among the financial subsidies, 40 yuan is subsidized by the central government, 32 yuan is subsidized by the provincial government, and 8 yuan is subsidized by the cities and counties.

(two) the annual subsidy standard for minors is 90 yuan, in which the individual pays 20 yuan and the financial subsidy is 70 yuan. Among the financial subsidies, 40 yuan is subsidized by the central government, 24 yuan is subsidized by the provincial government, and 6 yuan is subsidized by the cities and counties.

(three) the individual contributions required by students and children with minimal assurance or severe disabilities shall be subsidized by the central government according to the 5 yuan per person per year; For other low-income recipients, severely disabled people who have lost their ability to work, and elderly people over 60 years old from low-income families, the central government will give subsidies according to 30 yuan per person per year. In addition to the central financial subsidies, the insufficient part is all subsidized by cities and counties, and is charged from the medical assistance funds of cities and counties.

Not included in the coverage of the basic medical insurance system for urban workers, the individual contributions of urban entitled groups are all subsidized by cities and counties, and charged from the medical assistance funds of cities and counties.

The part of individual contributions required by the insured persons with non-severe disabilities is 50% of the financial subsidy, 80% of the required funds are borne by the provincial finance and 20% by the city and county finance.

(4) The financial subsidy funds required for farmers to participate in the basic medical insurance for urban residents in their districts, cities and counties, in addition to the central financial subsidy, shall be borne by the provincial finance 80% and the State Administration of Land Reclamation 20%.

The individual contributions of subsistence allowances, entitled groups, severely disabled people and low-income families over 60 years of age in agricultural reclamation residents are all subsidized by local finance except the central financial subsidies, and the required funds are charged from the medical assistance funds in the cities and counties where they are located; Individuals with disabilities pay 50% of the financial subsidies, and the required funds are borne by the provincial finance 80% and the State Administration of Land Reclamation 20%.

Article 8 Severe disability refers to the disability of Grade 2 according to the Practical Assessment Standard for Disabled Persons in China (Trial) issued by China Disabled Persons' Federation/kloc-0.

Low-income families refer to families whose per capita income was less than twice the minimum living standard as recognized by the civil affairs department in the previous year.

Article 9 Conditional employers may subsidize employees' families to pay insurance premiums. Encourage all kinds of economic organizations, social organizations and individuals to donate funds to support the basic medical insurance for urban residents, but not forcibly apportion.

Chapter IV Basic Medical Insurance Benefits

Tenth in accordance with the provisions of these measures to pay the basic medical insurance for urban residents (hereinafter referred to as the insured), enjoy the benefits of pooling funds. If the insured person interrupts the payment, he will stop enjoying the treatment.

Article 11 The urban residents' basic medical insurance pooling fund in the overall planning area is mainly used for the medical expenses that the insured person meets the Hainan Province basic medical insurance drug list, disease list and outpatient treatment special disease list, diagnosis and treatment items and service facilities. There is no personal account for the basic medical insurance for urban residents in regional overall planning areas.

Article 12 The medical expenses of the insured who meet the requirements shall be paid by individuals below the Qifubiaozhun within a settlement year, and the medical expenses above the Qifubiaozhun and below the maximum payment limit of the overall fund shall be borne by the overall fund and the insured according to the proportion of payment.

Residents with insurance difficulties who meet the conditions of urban medical assistance shall apply to the local civil affairs department for subsidies according to relevant regulations.

(1) Qifubiaozhun

Level I Hospital 150 yuan, Level II Hospital 400 yuan, Level III Hospital 600 yuan. If the patient is hospitalized within a settlement year, the deductible line shall be calculated cumulatively, and the accumulative deductible amount shall not exceed 600 yuan.

(2) Payment proportion

First-class hospitals: 65% of overall funds and 35% of individuals; Secondary hospitals: 55% of the overall fund and 45% of individuals; Tertiary hospitals: 45% for overall funds and 55% for individuals.

The use of the "Class B Catalogue" in the Catalogue of Drugs for Basic Medical Insurance for Urban Residents in Hainan Province and the Regulations on the Management of Medical Treatment Projects for Urban Residents in Hainan Province belongs to the medical treatment projects for which the basic medical insurance for urban residents pays part of the expenses. After the insured pays 20%, he shall pay compensation in accordance with the provisions of these Measures.

(three) the maximum payment limit of the overall fund

In a settlement year, the maximum payment limit of the overall fund is 20000 yuan; For those who have been insured for more than 3 years in a row, the maximum payment limit of the overall fund is 23,000 yuan; For those who have been insured for more than 6 years in a row, the maximum payment limit of the overall fund is 26,000 yuan; For those who have been insured for more than 8 years, the maximum payment limit of the overall fund is 30,000 yuan.

The settlement year of Dongfang and Tunchang is from September 2008 1 to February 3, 20091. The insured only needs to pay at least once, and the maximum compensation limit of the overall fund is 27,000 yuan. In other cities and counties (including Yangpu), July 1 day, 2008 to February 3 1 day, 2009 is a settlement year, and the insured only needs to pay the minimum threshold once, and the maximum payment limit of the overall fund is 30,000 yuan.

Thirteenth urban residents basic medical insurance outpatient treatment of special diseases of medical expenses payment measures shall be formulated separately.

Fourteenth medical expenses of class A infectious diseases such as cholera and plague shall be paid in full by the overall fund. The medical expenses of explosive and epidemic infectious diseases confirmed by the administrative department of health shall be solved by the people's government.

Fifteenth basic medical insurance fund for urban residents shall not pay the following fees:

(1) Medical expenses incurred in non-designated medical institutions without approval;

(2) Expenses incurred during the period when the insured interrupts payment;

(three) the cost of committing crimes or violating the law of public security administration punishment caused by suicide, self-mutilation (except mental illness), fighting, fighting, alcoholism, drug abuse and other injuries;

(4) Expenses incurred during going abroad or leaving the country;

(five) expenses incurred in beauty, orthopedics (except functional orthopedics) and physical defect treatment.

Chapter V Management of Medical Services

Sixteenth basic medical insurance for urban residents to implement the service management of designated medical institutions. Medical and health institutions (including agricultural reclamation medical and health institutions) that have obtained the Practice License of Medical Institutions have obtained the qualification of designated medical institutions after being examined and confirmed by the administrative department of personnel, labor and social security of the city and county jointly with the administrative department of health, and the social insurance agencies of the city and county have signed a service agreement with them. Designated medical institutions shall hang unified signs.

Seventeenth the implementation of designated medical service institutions access and exit mechanism. The administrative department of personnel, labor and social security of the city and county shall, jointly with the administrative department of health, organize regular inspections of designated medical institutions. Meet the conditions, confirm to retain its designated qualification, city and county social insurance agencies continue to sign service agreements with them. Those who do not meet the requirements will be disqualified and the service agreement will be terminated.

Eighteenth designated medical institutions shall strictly implement the price policy, and publish the basic medical insurance for urban residents and the basic medical service price.

Article 19 Medical staff of designated medical institutions shall treat diseases, adhere to the principles of reasonable examination, reasonable treatment and reasonable referral, make diagnosis and treatment in strict accordance with the prescribed technical specifications for medical diagnosis and treatment, and provide good medical services for the insured.

Twentieth insured persons with the "medical insurance certificate of basic medical insurance for urban residents in Hainan Province" (hereinafter referred to as medical insurance) to the designated medical institutions for medical treatment, enjoy the basic medical insurance for urban residents.

Article 21 If the medical expenses incurred by the insured in the designated medical institutions meet the relevant provisions of the basic medical insurance for urban residents, the designated medical institutions shall directly keep accounts in accordance with the provisions, and then the municipal and county social insurance agencies and designated medical institutions shall examine and settle the accounts in accordance with the provisions. Designated medical institutions shall provide a list of expenses to the hospitalized insured, which shall be signed and confirmed by the patient himself or relevant agents and witnesses. Where there is no signature to confirm the medical expenses, the overall fund will not pay.

Twenty-second insured persons should first go to the designated medical institutions in the city and county. If the illness needs to be transferred to a designated medical institution at the next higher level for further treatment, I shall apply for it, and the designated medical institutions at the city and county shall put forward their opinions. After the approval of the social insurance agencies at the city and county, they can be transferred to a designated medical institution at the next higher level for treatment. There is no referral certificate, and the overall fund will not pay.

Article 23 In case of emergency, critically ill patients who are directly sent to the first-class designated medical institutions for emergency treatment shall report to the municipal and county social insurance agencies within 10 working days (including 10 working days) after admission, and go through the referral procedures at the same time.

Twenty-fourth approved medical expenses incurred in non-designated medical institutions shall be paid by the insured first, and then reviewed and reimbursed by the municipal and county social insurance agencies after discharge. Medical insurance, referral application form, discharge certificate (with official seal), expense list, invoice and other relevant certification materials should be issued when handling the expense reimbursement procedures.

Article 25 If the insured person lives outside the insured city or county (including Yangpu Economic Development Zone), he may, upon his own application, choose two designated hospitals in his place of residence, which shall be examined and approved by the social insurance agency of the city or county and go through the relevant formalities. The medical expenses incurred shall be handled in accordance with the provisions of these measures. Failing to go through the relevant formalities as required, the overall fund will not pay.

Twenty-sixth temporary out in different places for emergency treatment, in 10 working days (including 10 working days) should be reported to the city and county social insurance agencies, and handle the relevant procedures. The medical expenses incurred shall be handled in accordance with the provisions of these measures. Failing to go through the relevant formalities as required, the overall fund will not pay.

Twenty-seventh in the following circumstances, the designated medical institutions shall refer the insured:

(1) Difficult diseases that cannot be diagnosed by examination and consultation;

(two) do not have the conditions for diagnosis, treatment and rescue of critical diseases;

(3) Lack of necessary inspection, diagnosis and treatment items and facilities;

(four) the diagnosis is clear, and the insured person requests to be transferred to a low-level designated medical institution for further treatment.

Chapter VI Fund Management and Supervision

Article 28 The financial management and accounting of the basic medical insurance fund for urban residents in cities and counties in the regional overall planning area shall be implemented with reference to the current social insurance system and regulations, and the adjustment system of the basic medical insurance fund for urban residents in the regional overall planning area shall be established.

Article 29 The basic medical insurance fund for urban residents in cities and counties within the regional overall planning area consists of the overall planning fund for cities and counties and the adjustment fund:

(a) the city and county co-ordination fund is the remaining funds paid by governments at all levels to the insured urban residents in cities and counties after deducting the adjustment fund. City and county pooling funds are mainly used for the payment of medical expenses for urban residents insured in cities and counties.

(two) from cities and counties to adjust according to a certain proportion of the total annual financing of the basic medical insurance for urban residents. Measures for the administration of the adjustment fund shall be formulated separately by the provincial finance department in conjunction with the provincial personnel and labor security department.

Thirtieth cities and counties should set up a supervision committee on the basic medical insurance for urban residents, which is composed of supervision and auditing departments, deputies to the National People's Congress, CPPCC members and representatives of the insured, and the representatives of the insured shall not be less than 20% of the total number. The board of supervisors is responsible for supervising the income and expenditure and management of the fund.

Chapter VII rewards and punishments

Thirty-first departments, designated medical institutions and related staff who have made outstanding achievements in the basic medical insurance for urban residents shall be commended by the municipal and county people's governments. The specific measures for commendation shall be formulated by the municipal and county people's governments themselves.

Thirty-second social insurance agencies and their staff have one of the following acts, which shall be handled by the relevant departments in accordance with the relevant provisions; Suspected of a crime, transferred to judicial organs:

(a) dereliction of duty or violation of financial discipline, resulting in the loss of the basic medical insurance fund for urban residents;

(two) corruption, misappropriation of the basic medical insurance fund for urban residents or bribery, dereliction of duty, abuse of power, corruption;

(three) unauthorized approval does not belong to the basic medical insurance for urban residents;

(4) changing the treatment of the insured person without authorization;

(five) interception, misappropriation of the basic medical insurance fund for urban residents;

(six) other violations of the relevant provisions of the basic medical insurance for urban residents.

Thirty-third designated medical institutions and their staff have one of the following acts, depending on the seriousness of the case, according to the relevant provisions; Suspected of a crime, transferred to judicial organs:

(a) the basic medical insurance for urban residents management measures are not in place, violations occur from time to time, affecting the normal work of the basic medical insurance for urban residents;

(2) Failing to strictly implement the basic medical insurance drug list, disease list and outpatient treatment special disease list, diagnosis and treatment items and service facilities for urban residents in Hainan Province, and not strictly implementing the national price policy;

(three) do not strictly implement the provisions of diagnosis and treatment, buck passing, random referral, random relaxation of admission indications, random inspection;

(four) to intercept patients who need to be transferred to the designated medical institutions at the next higher level for treatment due to illness;

(five) do not strictly implement the relevant policies and regulations of the basic medical insurance for urban residents, and make false invoices, resulting in the loss of the basic medical insurance fund for urban residents;

(six) medical personnel do not verify or register for diagnosis and treatment, or provide convenience for imposters;

(seven) in violation of the provisions of the basic medical insurance for urban residents, a large prescription or a fake prescription;

(eight) taking advantage of work, taking a ride to prescribe drugs, or forging prescriptions with patients, and exchanging drugs, health care products and daily necessities at their own expense for drugs in the basic catalogue;

(nine) other acts that violate the provisions of the basic medical insurance for urban residents.

Thirty-fourth the insured person has one of the following acts, in addition to recover the medical expenses paid by the overall fund, depending on the seriousness of the case, give criticism and education; Suspected of a crime, transferred to judicial organs:

(1) Falsely issuing invoices and prescriptions for medical expenses to defraud the basic medical insurance fund for urban residents;

(2) Lending residents' medical insurance to others for medical treatment;

(three) unauthorized alteration of medical expenses invoices, medical records, prescriptions, inspection reports or illegal inspections, prompting medical personnel to practice fraud;

(four) illegal reselling of drugs issued by designated medical institutions;

(five) other violations of the provisions on the administration of basic medical insurance for urban residents.

Chapter VIII Supplementary Provisions

Thirty-fifth urban residents' basic medical insurance financing standards and treatment payment standards as a whole, according to the level of economic and social development and the actual operation of the fund, the provincial personnel and labor security department in conjunction with the provincial finance department to be adjusted.

Thirty-sixth approach by the Provincial Department of personnel and labor security is responsible for the interpretation of.

Article 37 These Measures shall be implemented as of the date of promulgation.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.