Where to handle the accidental injury of medical insurance in Tianjin?

Go to the social security bureau for reimbursement, get invoices, bills, ID cards, medical insurance cards, hospital medical records and diagnosis certificates.

Provisions of Tianjin Municipality on Basic Medical Insurance

Chapter I General Provisions

first

In order to standardize the basic medical insurance relationship, protect the legitimate rights and interests of citizens to participate in the basic medical insurance and enjoy the basic medical insurance benefits, these Provisions are formulated in accordance with the Social Insurance Law of People's Republic of China (PRC) and the relevant provisions of the state, combined with the actual situation of this Municipality.

second

The basic medical insurance system adheres to the principles of wide coverage, basic insurance, multi-level and sustainability, determines the financing standard according to the financial situation and the economic affordability of employers and individuals, implements urban and rural overall planning, and gradually realizes the convergence and transformation of the basic medical insurance system for employees and residents.

essay

Employers and their employees and retirees as well as urban and rural residents within the administrative area of this Municipality shall participate in the basic medical insurance in accordance with these provisions. Basic medical insurance includes basic medical insurance for employees and basic medical insurance for residents. Organs, organizations, enterprises and institutions, private non-enterprise units, other organizations and individual industrial and commercial households with employees (collectively referred to as employers) and their employees and retirees shall participate in the basic medical insurance for employees. Urban and rural students, children and unemployed residents should participate in the basic medical insurance for residents. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees in the employer may choose to participate in the basic medical insurance for employees or residents.

Article 4

The municipal, district and county people's governments shall incorporate the basic medical insurance into the national economic and social development plan and give necessary financial support. The people's governments of all districts and counties shall organize employers and residents within their respective administrative areas to participate in the basic medical insurance according to law.

Article 5

The municipal administrative department of human resources and social security is responsible for the management of the city's basic medical insurance. Finance, health, education, price, food and drug supervision, auditing, civil affairs, industry and commerce, public security and other departments are responsible for the work related to essential drugs within their respective responsibilities.

Medical insurance work.

Article 6

City medical insurance agencies are responsible for the basic medical insurance registration, insurance premium collection, personal rights records, insurance benefits payment and other work. And provide business guidance to designated medical institutions, pharmacies and other medical insurance service institutions.

Article 7

The city has established a multi-level medical security system, encouraged the development of supplementary medical insurance, and the government supported enterprises to establish supplementary medical insurance.

Article 8

The municipal administrative department of human resources and social security employs representatives of employers, representatives of insured persons and relevant experts as social supervisors of medical insurance, and implements social supervision over the compliance of medical insurance management and handling services with laws, regulations and rules of basic medical insurance by relevant departments and personnel, designated medical institutions, designated pharmacies, doctor Yamatonokusushi and employers and insured persons. Any organization or individual has the right to report and complain about violations of laws, regulations and rules of basic medical insurance.

Article 9

The medical insurance agency shall regularly announce to the public the participation in medical insurance and the income, expenditure, balance and income of the medical insurance fund.

Chapter II Improvement of Basic Medical Insurance Expenses

Article 10

Employers, employees, retirees and residents shall pay the basic medical insurance premium in accordance with the prescribed standards.

Article 11

Employees shall pay the basic medical insurance premium at no less than 2% of their average monthly salary in the previous year, and the employer shall pay the basic medical insurance premium at no less than 00% of the sum of the individual payment bases of employees. The basic medical insurance premium paid by individual employees and the part allocated by the employer from the basic medical insurance premium according to the regulations are all included in the personal account. individual account

The principal and interest are owned by the individual, and the interest of the individual account is calculated with reference to the current savings deposit interest rate of the bank for the same period.

Article 12

The average monthly salary of employees in last year is higher than 300% of the average monthly salary of employees in this city in the previous year, and 300% of the average monthly salary of employees in this city in the previous year is the base for paying the basic medical insurance premium. The average monthly salary of employees last year was lower than last year.

The average monthly salary of employees in this Municipality is 60%, and 60% of the average monthly salary of employees in this Municipality in the previous year is the base for paying the basic medical insurance premium. If it is impossible to determine the average monthly salary of employees in the previous year, the average monthly salary of employees in this city in the previous year shall be the base for paying the basic medical insurance premium.

Article 13

If it is difficult for an employer to pay fees in accordance with the provisions of Article 11 of these Provisions, it may, with the consent of the workers' congress or the workers' congress, reduce the proportion of payment in accordance with the relevant provisions without establishing a personal account. Individual industrial and commercial households without employees, part-time employees and other flexible employees who are not insured by the employing unit may pay the basic medical insurance premium in accordance with relevant regulations without establishing individual accounts.

Article 14

Residents to participate in the basic medical insurance to implement the differential payment system. Students, children and adult residents pay the basic medical insurance premium according to the prescribed standards. The payment standard for adult residents is set in grades, and I voluntarily choose to pay. The government gives appropriate subsidies to individual contributions in accordance with the prescribed standards. Family members with severe disabilities, subsistence allowances and special difficulties shall be implemented in accordance with the provisions of the archives.

For the second time, the individual does not pay, and the government fully subsidizes it. Residents should pay the basic medical insurance premium for the next year in one lump sum from September to the end of February.

Article 15

The subsidy funds for residents to participate in the basic medical insurance shall be jointly borne by the municipal and district/county people's governments.

Article 16

According to the level of economic and social development, the Municipal People's Government shall adjust the basic medical insurance payment standard and government subsidy standard accordingly. The municipal administrative department of human resources and social security shall, jointly with the municipal finance and other relevant departments, formulate an adjustment plan and report it to the Municipal People's Government for approval before implementation.

Chapter III Basic Medical Insurance Benefits

Article 17

Employees enjoy basic medical insurance benefits from the month of payment. When employees reach the statutory retirement age, they have paid the basic medical insurance premium for 25 years for men and 20 years for women, and the actual payment period has reached 5 years. After retirement, they will no longer pay the basic medical insurance premium and continue to enjoy the basic medical insurance benefits; Those who are less than the above-mentioned years can enjoy basic medical insurance benefits after making up the basic medical insurance premiums that employers and individuals should pay according to the payment standards of the year when they retire. Individual industrial and commercial households without employees, part-time employees and other flexible employees who are not insured by the employer shall enjoy the basic medical insurance benefits from the payment of 6 months. The period for students and children in the park to enjoy basic medical insurance benefits is from September of the payment year to August of the following year, and the period for other residents to enjoy basic medical insurance benefits is from 65438+ 10 to 65438+February of the payment year.

Article 18

Medical expenses incurred by the insured, such as hospitalization, outpatient (emergency) consultation, etc. , who meet the national and municipal basic medical insurance drug list, diagnosis and treatment project directory and medical service facilities directory (collectively referred to as the scope of reimbursement), according to the provisions of payment from the basic medical insurance fund.

Article 19

The medical expenses within the scope of hospitalization reimbursement of the insured shall be determined according to the hospital level and the number of hospitalizations. /kloc-If the insured is hospitalized for more than 2 times within 0/year, starting from the second hospitalization, the Qifubiaozhun for employees and retirees will be implemented at 30%, and residents will not set the Qifubiaozhun.

Article 20

The proportion of hospitalization reimbursement for employees' basic medical insurance should take proper care of retirees and other groups, and the proportion of hospitalization reimbursement for residents' basic medical insurance should be set according to the hospital level and payment level.

Article 21

The highest payment standard for hospitalization of basic medical insurance shall be implemented in accordance with state regulations. The highest payment standard for employees and retirees in hospitals at all levels is the same, and the highest payment standard for residents in hospitals is set according to the hospital level and payment level.

Article 22

The reimbursement ratio of outpatient (emergency) medical expenses for common diseases within the scope of reimbursement for employees and retirees is determined according to the hospital level. The proportion of reimbursement for medical treatment by residents in outpatient (emergency) departments of first-class hospitals (including community health service centers) is determined according to the payment level.

Article 23

Insured persons suffering from diseases within the prescribed scope may apply for family bed treatment because of their older age and mobility difficulties, and the medical expenses incurred shall be reimbursed for hospitalization expenses. The insured suffers from outpatient specific diseases within the prescribed scope, and the basic medical insurance treatment standard is determined according to the standard higher than that of outpatient (emergency) common diseases.

Article 24

The medical expenses of the insured suffering from Class A infectious diseases shall be paid in full by the basic medical insurance fund. Give appropriate care to patients with other infectious diseases.

Article 25

The Municipal People's Government shall, according to the level of economic and social development and the ability to pay the basic medical insurance fund, make corresponding adjustments to the level of basic medical insurance benefits. The municipal administrative department of human resources and social security shall, jointly with the municipal finance and other relevant departments, formulate an adjustment plan and report it to the Municipal People's Government for approval before implementation.

Chapter iv collection and settlement of basic medical insurance premiums

Article 26

The basic medical insurance premium is uniformly collected by the whole city. Medical insurance agencies are responsible for the specific work of the basic medical insurance premium collection.

Article 27

Residents to participate in the basic medical insurance to implement classified registration, registration in medical insurance agencies in accordance with the following provisions:

(a) all kinds of schools and kindergartens at all levels of students and children, by the school and kindergarten is responsible for the medical insurance agencies for insurance registration;

(II) personnel enjoying subsistence allowances, family members with special difficulties, and entitled groups shall be identified by the civil affairs department, and the personnel details shall be transferred to the medical insurance agency for insurance registration;

(three) the severely disabled are confirmed by the Disabled Persons' Federation, and the details of the personnel are transferred to the medical insurance agency, which will handle the insurance registration;

(4) The spouses and widows of retired cadres shall be identified by the management department of retired cadres, and the personnel details shall be transferred to the medical insurance agency, which shall handle the insurance registration;

(five) rural residents in the village as a unit, other residents in the family as a unit to the township, street labor and social security service institutions for insurance registration.

Article 28

The basic medical insurance premiums paid by students and children in the park are collected and remitted by schools and kindergartens. Rural residents are collected and remitted by villagers' committees.

Article 29

Medical insurance agencies shall, in accordance with the way of total prepayment, disease payment, project payment, capitation payment or negotiation payment, pay the medical expenses that meet the requirements of basic medical insurance to designated medical institutions, designated pharmacies or insured persons in full and on time.

Article 30

The insured person's medical treatment and drug purchase are settled immediately through the medical insurance information payment system, and only the part that the individual should bear is paid to the designated medical institutions or pharmacies, and other expenses are settled by the medical insurance agency and the designated medical institutions and pharmacies on a monthly basis. Where the state and this Municipality have special provisions on advance payment, those provisions shall prevail.

Chapter V Management of Basic Medical Insurance Services

Article 31

The medical insurance agency shall establish and improve the business, finance, safety and risk management system. Medical insurance agencies collect and summarize relevant data through business handling and statistical investigation, and relevant units and individuals shall provide them in a timely and truthful manner. Street, township labor and social security service agencies and their community and village labor and social security agencies are responsible for organizing residents' insurance resources investigation, insurance registration approval and the collection of medical expenses paid in advance.

Article 32

According to the needs of management services, medical insurance agencies can sign service agreements with designated medical institutions and pharmacies to standardize medical service behavior.

Article 33

Designated medical institutions and pharmacies shall designate medical insurance institutions, determine the full-time (part-time) staff of the basic medical insurance, and be responsible for the management and service of the basic medical insurance of their own units.

Article 34

Designated medical institutions shall give priority to providing medical services within the scope of the drug list, diagnosis and treatment project list and medical service facilities list stipulated by the basic medical insurance for the insured. When providing self-funded drugs, medical consumables and diagnosis and treatment items to insured patients, the consent of the insured patients should be obtained in advance, and the details of medical expenses should be provided.

Article 35

Designated pharmacies should establish a management system that is compatible with basic medical insurance; Ensure the quality and variety of basic medical insurance drugs, and provide rational drug use consulting services for the insured.

Article 36

The municipal administrative department of human resources and social security shall, jointly with the municipal health, food and drug supervision departments, establish and improve the directory management system of Yamatonokusushi, an in-service physician of basic medical insurance, and supervise and inspect the implementation of the basic medical insurance policy by Yamatonokusushi, an in-service physician.

The specific measures for the management of the list of Yamatonokusushi, an on-the-job physician in the basic medical insurance, shall be formulated separately by the municipal administrative department of human resources and social security in conjunction with the municipal health, food and drug supervision departments.

Article 37

Medical insurance agencies and designated medical institutions and pharmacies may apply to the medical insurance settlement dispute mediation institution for mediation or bring a lawsuit to the people's court if there is a dispute over the performance or change of the service agreement.

Article 38

The municipal administrative department of human resources and social security shall establish and improve the basic medical insurance information system, and realize the functions of online registration and payment, online payment of benefits and online real-time monitoring. Medical insurance agencies use the basic medical insurance information system to pay insurance benefits, and should ensure all-weather and holiday free online settlement with designated medical institutions and pharmacies. Designated medical institutions shall establish and improve the information management system of their own units, and realize online settlement and real-time information sharing of outpatient (emergency) consultation, hospitalization and medical insurance agencies. Designated pharmacies should establish and improve the information management system of their own units to realize online settlement and real-time information sharing with medical insurance agencies.

Article 39

The insured person must hold a social security card for medical treatment and medicine purchase. If the insured is unable to purchase medicines at designated medical institutions or pharmacies due to special circumstances, he may entrust others to purchase with the social security card of the insured, and the client shall show his identity certificate.

Article 40

Insured persons can choose to go to designated medical institutions for medical treatment and purchase medicines within the prescribed scope, or they can buy medicines at designated pharmacies with prescriptions. Medical institutions shall provide prescriptions for the insured who choose to buy medicines in designated pharmacies.

Article 41

The municipal administrative department of human resources and social security shall, jointly with the relevant administrative departments, establish a credit system for basic medical insurance.

Chapter VI Basic Medical Insurance Fund

Article 42

The basic medical insurance fund consists of the following funds:

(a) the basic medical insurance premium paid by the employer and the insured;

(2) government subsidy funds;

(3) Social donation funds;

(4) late fees;

(5) interest;

(6) Other funds.

Article 43

The part raised by the basic medical insurance fund in that year shall bear interest according to the bank deposit 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 three months; The deposit funds deposited in the social security financial special account shall bear interest according to the three-year zero deposit and lump-sum savings deposit interest rate.

Article 44

The basic medical insurance shall be coordinated by the whole city, and the basic medical insurance fund shall be included in the financial special account management and deposited in the bank that undertakes the medical insurance handling business. The basic medical insurance fund includes the basic medical insurance fund for employees and the basic medical insurance fund for residents, and accounts are established separately, and the unified national accounting system is implemented.

Article 45

The draft budget and final accounts of the basic medical insurance fund shall be compiled by the municipal medical insurance agency, audited by the municipal human resources and social security administrative department, audited by the municipal finance department, and implemented after being approved by the Municipal People's government.

Article 46

The competent units of district and county people's governments, designated medical institutions and designated pharmacies shall strengthen the management and supervision of medical expenses of designated medical institutions and designated pharmacies, ensure legitimate medical needs, and maintain the safe operation of the basic medical insurance fund. Designated medical institutions and pharmacies should strengthen the education and management of their doctors, pharmacists and staff, standardize the diagnosis and treatment behavior, and provide reasonable and necessary medical services for insured patients.

Article 47

The administrative department of human resources and social security shall strengthen supervision over the income and expenditure of medical insurance agencies and basic medical insurance funds, and establish and improve the budget and final accounts system, financial accounting system and internal audit system of basic medical insurance funds; The financial department is responsible for the management of the financial accounts of the basic medical insurance fund; The auditing department shall supervise the basic medical insurance fund through auditing according to law.

Chapter VII Legal Liability

Article 48

The administrative department of human resources and social security shall strengthen the supervision of compliance with the laws, regulations and rules of basic medical insurance. The municipal administrative department of human resources and social security may entrust the medical insurance supervision and inspection institutions to implement the supervision and inspection of basic medical insurance and other administrative law enforcement work. Human resources and social security, health, food and drug supervision and other administrative departments shall establish communication and coordination mechanisms and information sharing mechanisms for the discovery, investigation and identification of violations of basic medical insurance.

Article 49

Designated medical institutions have one of the following acts, defrauding the basic medical insurance fund expenditure, and the administrative department of human resources and social security shall order them to return the defrauded medical insurance money, and impose a fine of more than 2 times and less than 5 times the defrauded amount; The medical insurance agency terminates the service agreement; If the directly responsible person in charge and other directly responsible personnel have the qualification to practice, the health, food and drug supervision departments shall revoke their qualification to practice according to law:

(1) Forging or altering the medical records of the insured;

(two) the income of the insured who does not meet the hospitalization conditions is hospitalized or the hospitalization time is intentionally extended, and the fake hospitalization and fake hospitalization are made;

(3) Insured persons who do not meet the registration conditions for outpatient specific diseases are registered as outpatient specific diseases and given treatment by forging or altering relevant certificates;

(4) Forging, altering, falsely making out, buying, selling, transferring or failing to keep special bills for basic medical insurance within the prescribed time limit;

(5) Lending a credit card machine for basic medical insurance expenses, renting out a medical treatment department to carry out medical treatment activities, or falsely claiming medical expenses in the name of a registered doctor or pharmacist;

(six) fraudulent use or fraudulent use of other people's social security cards to defraud the basic medical insurance fund;

(7) Repeated charges. The administrative department of human resources and social security shall implement the provisions of the preceding paragraph for designated medical institutions.

Punishment, it shall inform the health administrative department at the same level. Medical insurance agencies and designated medical institutions to terminate the service agreement, it shall inform the health administrative department at the same level, and timely announce the designated medical institutions to terminate the service agreement.

Article 50

Designated pharmacies have one of the following acts, defrauding the basic medical insurance fund, and the administrative department of human resources and social security shall order them to return the defrauded medical insurance money, and impose a fine of more than 2 times and less than 5 times the defrauded amount; The medical insurance agency terminates the service agreement; If the directly responsible person in charge and other directly responsible personnel have obtained the practicing qualification, the food and drug supervision department shall revoke their practicing qualification according to law:

(1) Failing to sell drugs according to the varieties, specifications, dosage forms and dosages indicated in the purchased prescriptions, or forging or altering the purchased prescriptions;

(2) Selling basic medical insurance drugs instead of non-basic medical insurance drugs or other articles, or forging or altering medical insurance-related materials such as bills and drug expense details;

(three) fraudulent use or fraudulent use of other people's social security cards to defraud the basic medical insurance fund;

(4) Forging, altering, falsely making out, buying, selling, transferring or failing to keep special bills for basic medical insurance within the prescribed time limit;

(five) the actual number of drugs is inconsistent with the number of bills and declarations;

(6) falsely reporting medical expenses in the name of registered pharmacists, or leasing or contracting designated pharmacies to non-designated pharmacies.

Article 51

Yamatonokusushi, a medical practitioner in designated medical institutions and pharmacies, has one of the following acts, and shall be given a warning and ordered to make corrections by the municipal administrative department of human resources and social security; If the circumstances are serious, the municipal administrative department of human resources and social security shall, jointly with the municipal health, food and drug supervision and other departments, delete it from the list of doctors and pharmacists serving the basic medical insurance, and give informed criticism to the doctors, pharmacists and directly responsible persons in charge who violate the provisions of this article:

(1) Forging or altering medical documents or medical certificates, or issuing false prescriptions or falsely reporting the expenses of basic medical insurance;

(two) tampering with non-basic medical insurance drugs or other items as basic medical insurance drugs, or tampering with non-basic medical insurance diagnosis and treatment items and service facilities standards as basic medical insurance payment items;

(3) prescribing drugs or purchasing vouchers in the name of the insured's treatment, and colluding with the insured to exchange cash or securities without taking drugs;

(four) do not use expensive drugs and large-scale inspection and other medical measures according to the needs of the disease;

(5) Deliberately disassembling the prescription, and prescribing drugs in excess or repeatedly.

Article 52

The insured has one of the following acts, defrauding the basic medical insurance fund expenditure, the administrative department of human resources and social security shall order it to return the defrauded medical insurance money, and impose a fine of more than 2 times and less than 5 times the defrauded amount:

(1) Using another person's social security card for medical treatment or medicine purchase, or giving my social security card to another person for use;

(two) my social security card to the designated medical institutions or designated pharmacies;

(3) Forging or altering reimbursement documents and prescriptions;

(four) reselling basic medical insurance drugs.

Article 53

The insured person has the acts specified in Article 52 of these Provisions, and if it exceeds 1 month and is less than 1 year, the municipal administrative department of human resources and social security may adjust the settlement method of medical expenses. During the period of adjusting the settlement method of medical expenses, we will continue to enjoy the basic medical insurance benefits, and the medical expenses incurred will be fully reimbursed.

Article 54

Human resources and social security administrative departments, medical insurance agencies and their staff abuse their powers, neglect their duties, engage in malpractices for selfish ends, and the directly responsible person in charge and other directly responsible personnel shall be punished according to law; If losses are caused to the employing unit or individual, it shall be liable for compensation.

Chapter VIII Supplementary Provisions

Article 55

The city takes measures to realize the trans-regional transfer and connection of the basic medical insurance for the insured.

Article 56

Establish a large medical expenses relief system for employees. On-the-job employees and retirees pay assistance fees according to the prescribed standards and enjoy corresponding treatment.

Article 57

Establish an additional insurance system for accidental injury of basic medical insurance. If the insured suffers medical treatment, disability or death due to accidental injury, the supplementary insurance fund for accidental injury of the basic medical insurance shall pay corresponding treatment according to the prescribed standards.

Article 58

These Provisions shall come into force on March 5, 20 12.

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