Interpretation of "Detailed Rules for the Implementation of Tianjin Maternity Insurance Regulations"

Interpretation of "Detailed Rules for the Implementation of Tianjin Maternity Insurance Regulations"

According to the recently published Detailed Rules for the Implementation of Maternity Insurance Regulations for Employees in Tianjin, we can learn more about the policy content of maternity insurance in Tianjin, and welcome your reference.

Interpretation of the Detailed Rules for the Implementation of Tianjin Maternity Insurance Regulations: According to the detailed rules, if an employer who has participated in pension, medical care, work-related injury and unemployment insurance should participate in maternity insurance according to Tianjin Maternity Insurance Regulations, the social security agency will directly register the maternity insurance, and the employer will not go through the registration formalities separately. If the employer suspends the payment of maternity insurance premiums for employees and pays them in full within three months, the maternity insurance benefits for employees shall be calculated from the month when the payment is suspended; If the payment is overdue for more than three months, the maternity insurance benefits for employees shall be calculated from the second month after the formalities for overdue payment and normal payment; Those who fail to pay maternity insurance premiums will stop enjoying maternity insurance benefits from the month when payment is interrupted. Those who have participated in maternity insurance can enjoy maternity insurance benefits according to regulations during the interruption of payment.

For the insured who participates in employee maternity insurance and resident maternity insurance at the same time, according to? Is it too high to repeat? Enjoy the principle of maternity insurance benefits, giving priority to maternity insurance for employees. During a pregnancy cycle, the expenses for prenatal examination incurred by the insured shall be calculated separately according to the limit payment standards corresponding to employee maternity insurance and resident maternity insurance, and shall not be reimbursed repeatedly.

According to the detailed rules, female workers can enjoy maternity allowance after registering their births in accordance with the city's birth registration system. If a female worker holds a birth registration certificate in a different place, she shall declare the birth allowance after being confirmed by the family planning administrative department or the employing unit at her current residence in this Municipality. Insured persons who give birth or terminate pregnancy abroad (including Hong Kong, Macao and Taiwan) shall enjoy maternity allowance in accordance with the relevant provisions of this Municipality's maternity insurance. If a female worker gives birth to a baby and issues a "Birth Medical Certificate" according to regulations, she will enjoy maternity allowance for 98 days during maternity leave and increase maternity allowance for 30 days.

The insured person shall, within 0/2 weeks after pregnancy, hold his/her resident ID card to the designated service institution at the grass-roots level where he/she lives or has his/her household registration. If it cannot be handled online for special reasons, it should be handled at the social security sub-center of the insured place in time; If you entrust others to handle it, you must also show your agent's resident identity card. Insured persons in the city to seek medical treatment in accordance with the provisions of the maternity medical expenses to implement instant online settlement. If the maternity medical expenses are paid in advance due to special circumstances, the employer shall uniformly report to the social security agency of the insured place within 12 months from the month after the female worker gives birth or terminates pregnancy. The medical expenses paid according to the project shall be settled by the social security agency with the designated medical institution according to the project payment method. Designated medical institutions to provide the insured with medical items other than the prescribed items and maternity insurance provisions, and charge corresponding fees, must obtain the consent of the insured in advance. If the insured needs medical treatment in different places due to childbirth, the medical expenses that meet the scope of maternity insurance payment shall be paid in accordance with the relevant provisions of this Municipality's maternity insurance after going through the formalities of medical treatment in different places with reference to the Notice of the Municipal Human Resources and Social Security Bureau on Printing and Distributing the Measures for the Medical Management of the Insured of Tianjin Basic Medical Insurance.

In the name of an individual who participates in the basic medical insurance for employees in this Municipality, the cost of family planning operation and the medical expenses for treating the complications of family planning operation shall be paid by the maternity insurance fund in accordance with the standards and procedures stipulated in the maternity insurance for employees in this Municipality. The maternity protection of those who receive unemployment insurance benefits is included in the employee maternity insurance system, and the maternity insurance premiums payable are paid from the unemployment insurance fund. Persons receiving unemployment insurance benefits enjoy the same maternity insurance benefits as employees. During the period of receiving unemployment insurance benefits, maternity insurance benefits shall be paid by the maternity insurance fund in accordance with the standards and procedures stipulated by the maternity insurance for employees in this Municipality.

Recently, Tianjin Municipal Bureau of Human Resources and Social Security issued the "Detailed Rules for the Implementation of Maternity Insurance Regulations for Employees in Tianjin" to further refine and clarify the maternity insurance regulations for employees, which will be implemented on August 1 this year.

Detailed Rules for the Implementation of the Regulations of Tianjin Municipality on Maternity Insurance for Employees

Effectiveness level of labor employment policy in Tianjin

Promulgated by Tianjin Human Resources and Social Security Bureau/Tianjin Health and Family Planning Commission

DocumentNo. [20 17]54 of Tianjin Human Resources and Social Security Bureau

Implementation time: 20 17.8. 1

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Upper guide bearing

District Human Resources and Social Security Bureau, Health and Family Planning Commission and relevant units:

The detailed rules for the implementation of Tianjin maternity insurance regulations are hereby printed and distributed to you, please follow them.

Municipal Human Resources and Social Security Bureau

? Municipal Health and Family Planning Commission

20 17 may 18

Detailed Rules for the Implementation of the Provisions of Tianjin Municipality on Maternity Insurance for Employees Chapter I General Provisions

Article 1 In order to protect and safeguard the legitimate rights and interests of female workers in the process of childbirth and family planning, these Detailed Rules are formulated in accordance with the Provisions of Tianjin Municipality on Maternity Insurance for Workers (No.99 [2016], hereinafter referred to as the Provisions) and other relevant provisions.

Article 2 The Municipal Social Insurance Fund Management Center and its branches (hereinafter referred to as? Social security agency? ) responsible for the city's maternity insurance handling services.

Chapter II Insurance Payment

Article 3 If an employer who has participated in pension, medical care, work-related injury and unemployment insurance should participate in maternity insurance according to the regulations, the social security agency shall directly register the maternity insurance, and the employer shall not go through the registration formalities separately.

Item 4, Paragraph 3, Article 11 of the Regulations? The average monthly salary of employees in the previous year of the employer cannot be determined? , refers to the situation that when the payment base is approved, the employer is unable to provide the relevant information of the employee's salary to the agency or the information provided cannot confirm the amount of the employee's salary.

Article 5 If the employer suspends the payment of maternity insurance premiums for employees and pays them in full within three months, the maternity insurance benefits for employees shall be calculated from the month when the payment is suspended; If the payment is overdue for more than three months, the maternity insurance benefits for employees shall be calculated from the second month after the formalities for overdue payment and normal payment; Those who fail to pay maternity insurance premiums will stop enjoying maternity insurance benefits from the month when payment is interrupted. Those who have participated in maternity insurance can enjoy maternity insurance benefits according to regulations during the interruption of payment.

Article 6 For the insured persons who participate in maternity insurance for employees and maternity insurance for residents at the same time, according to? Is it too high to repeat? Enjoy the principle of maternity insurance benefits, giving priority to maternity insurance for employees. During a pregnancy cycle, the expenses for prenatal examination incurred by the insured shall be calculated separately according to the limit payment standards corresponding to employee maternity insurance and resident maternity insurance, and shall not be reimbursed repeatedly.

Item 7 of Article 13 of the Regulations? Reserve maternity insurance for pregnant female employees? The standards are published by the municipal human resources and social security departments year by year, and are handed over to the social security institutions of the places where the employers participate in the insurance for unified management.

Chapter III Scope of Payment

Item 8 of Article 21 of the Regulations? Except for the clause about overpayment? , refers to the maternity insurance with reference to "Tianjin basic medical insurance, industrial injury insurance and maternity insurance drug list" and "Tianjin basic medical insurance and maternity insurance diagnosis and treatment project list and service facilities standards" implementation, in which class B diagnosis and treatment projects and class B drugs do not have a personal increase payment ratio.

Article 9 Article 20 of the Regulations? Medical expenses that should be borne by employees according to regulations? , mainly including the following situations:

(a) the expenses incurred by the baby;

(2) the cost beyond the quota and quota standard;

(3) Medical expenses during pregnancy due to conservative treatment during pregnancy;

(four) medical expenses incurred in the implementation of human assisted reproductive technology;

(five) the expenses of prenatal examination, maternity medical care and family planning operation occurred overseas (including Hong Kong, Macao and Taiwan);

(six) the expenses incurred by the special needs project required by me.

Item 10 of Article 15 of the Regulations? Medical expenses for childbirth? , refers to the prenatal examination fee, delivery fee, operation fee, treatment fee, hospitalization fee, medicine fee, etc.

Article 15 and Article 11 of the Regulations? Medical expenses for family planning? Refers to the medical expenses incurred by the insured in placing (taking out) IUD, abortion, induced labor, sterilization and recanalization.

Article 15 and Article 12 of the Regulations? Maternity allowance? , refers to the insured female workers during maternity leave in accordance with state regulations should be paid. Female workers can enjoy maternity allowance after registering in accordance with the birth registration system of this Municipality. If a female worker holds a birth registration certificate in a different place, she shall declare the birth allowance after being confirmed by the family planning administrative department or the employing unit at her current residence in this Municipality.

Insured persons who give birth or terminate pregnancy abroad (including Hong Kong, Macao and Taiwan) shall enjoy maternity allowance in accordance with the relevant provisions of this Municipality's maternity insurance (see Annex 1 for specific payment standards).

If a female worker gives birth to a baby and issues a "Birth Medical Certificate" according to regulations, she will enjoy maternity allowance for 98 days during maternity leave and increase maternity allowance for 30 days.

Article 17 and Article 13 of the Regulations? Difficult labor? , refers to the use of forceps for midwifery, fetal head suction, breech midwifery and cesarean section (without medical indications, except when employees require cesarean section).

Chapter IV Payment Methods and Standards

Fourteenth maternity medical expenses shall be paid in the form of quota, quota and project payment (see Annex 2 for specific treatment standards).

(1) Restrict payment. Including prenatal examination fees and medical expenses for spontaneous abortion or drug abortion.

(2) Fixed payment. Including natural delivery, artificial intervention delivery, cesarean section, induced labor, high-risk induced abortion, abortion, intrauterine device placement (removal), female worker sterilization and male worker sterilization.

Manual intervention in delivery includes: single-child forceps, single-child breech traction (midwifery), fetal head suction, inversion, taking placenta by hand and abortion.

Induced labor includes: amniotic cavity (external) injection induced labor, water bag induced labor and drug induced labor.

High-risk induced abortion refers to the following situations that require hospitalization for induced abortion: 1. Abortion under 20 years old or over 50 years old; 2. Have a history of termination of pregnancy within half a year or two induced abortions within 1 year; 3. 1 year-old has a history of cesarean section; 4. Still breastfeeding within 1 year after delivery; 5. Genital malformation or pelvic tumor; 6. Have a history of uterine or cervical perforation; 7. pregnant with a device; 8. The uterine position is highly inclined or it is difficult to expose the cervix; 9. Previous pregnancy with placental adhesion and massive bleeding; 10. The lesions of spine, lower limbs and pelvic cavity cannot be located at the lithotomy position of bladder; 1 1. Have a history of hemorrhagic diseases; 12. Complicated with serious organic diseases in internal surgery.

(3) Pay by project. Including recanalization after sterilization, intrauterine device removal with incarceration, fracture, deformation, ectopic or menopausal period exceeding 1 year, complications of family planning operation, delivery complications, serious internal and surgical diseases during delivery, and medical expenses related to delivery that occurred in the transfer-out hospital due to special circumstances during delivery hospitalization.

The municipal or district health and family planning commission is responsible for the identification of complications of family planning operation, and issues the identification conclusion and relevant certificates. The employer shall uniformly report to the social security institution of the insured place within 12 months after issuing the identification conclusion.

Birth complications during delivery refer to the following situations from the beginning of delivery to the end of this delivery: 1. Rupture of uterus; 2. Amniotic fluid embolism; 3. Placenta previa, placenta adhesion or implantation need urgent hemostasis treatment; 4. postpartum hemorrhage; 5. Suture of third degree perineum and complicated laceration; 6. Severe preeclampsia and eclampsia in hypertensive disorder complicating pregnancy.

Serious medical diseases during delivery refer to the following situations: 1. Heart disease with cardiac insufficiency; 2. Combined with acute hepatitis or active chronic hepatitis and acute fatty liver; 3. Severe anemia (hemoglobin below 6g/dl); 4. Severe thrombocytopenia (platelet count below 50,000/mm3); 5. Combined with hyperthyroidism (hyperthyroidism crisis); 6. Nephropathy with renal insufficiency.

Surgical diseases during childbirth refer to the following situations: 1. Abdominal wound infection and dehiscence; 2. Combined with acute pancreatitis, acute cholecystitis and acute appendicitis; 3. Complicated with intestinal obstruction; 4. Combined with venous thrombosis and phlebitis of lower limbs.

Patients with complications and complications should stay in hospital for no more than 45 days.

Article 15 If the insured is pregnant for more than 28 weeks (inclusive) and takes or fails to take measures to terminate the pregnancy in time, the corresponding payment standard shall be determined according to the actual induced labor, natural delivery, artificial intervention delivery, simple cesarean section and other corresponding payment items.

Article 16 If the insured terminates pregnancy or carries out family planning operation, and complications occur, the medical expenses incurred shall be implemented with reference to the relevant treatment payment standards for delivery complications or serious medical and surgical diseases during delivery.

Chapter V Settlement Management

Seventeenth insured persons should be in pregnancy 12 weeks, with my ID card to the current residence or domicile of the grassroots designated service institutions online for medical registration. If it cannot be handled online for special reasons, it should be handled at the social security sub-center of the insured place in time; If you entrust others to handle it, you must also show your agent's resident identity card.

Eighteenth insured medical treatment in this city in line with the provisions of the maternity medical expenses to implement real-time online settlement. If the maternity medical expenses are paid in advance due to special circumstances, the employer shall uniformly report to the social security agency of the insured place within 12 months from the month after the female worker gives birth or terminates pregnancy.

Nineteenth for the medical expenses paid by the limit, if the actual expenses are higher than the limit standard, they shall be paid according to the limit standard; If it is lower than the limit standard, it shall be paid according to the actual expenditure.

Twentieth for the fixed payment of medical expenses, social security agencies shall settle accounts with designated medical institutions in accordance with the fixed standards. The expenses incurred by the insured beyond the prescribed items and not paid by the maternity insurance fund shall be borne by the insured individual.

Twenty-first for the medical expenses paid according to the project, the social security agency shall settle accounts with the designated medical institutions according to the project payment method. The expenses incurred by the insured beyond the prescribed items and not paid by the maternity insurance fund shall be borne by the insured individual. The maternity allowance shall be implemented in accordance with the Notice of the Municipal Human Resources and Social Security Bureau on Improving the Methods of Applying for and Issuing Maternity Allowance for Female Employees (No.63 issued by the Tianjin Human Resources and Social Security Bureau [2015]) and the notice of the implementation time of the Notice of the Municipal Human Resources and Social Security Bureau on Adjusting the Methods of Applying for Maternity Allowance for Female Employees (No.7 issued by the Tianjin Human Resources and Social Security Bureau [2016]).

Twenty-second designated medical institutions provide the insured with medical items other than the prescribed items and maternity insurance provisions, and charge corresponding fees. The consent of the insured must be obtained in advance.

Article 23 If an insured person needs medical treatment in a different place due to childbirth, he shall refer to the Notice of the Municipal Bureau of Human Resources and Social Security on Printing and Distributing the Administrative Measures for Medical Treatment in Different Places for the Insured of Tianjin Basic Medical Insurance (No.206543816), and pay the medical expenses that meet the scope of maternity insurance payment after going through the formalities of medical treatment in different places.

Twenty-fourth insured workers because both husband and wife have no immediate family members in this city, they can apply for delivery in different places, and medical institutions seeking medical treatment in different places can be relaxed to grassroots designated medical institutions with midwifery technical qualifications.

Article 25 The expenses of prenatal examination, maternity medical care and family planning operation of the insured in different places shall be paid by the individual in advance, and the employer shall uniformly report to the social security agency of the insured place within 12 months after the female worker gives birth or terminates pregnancy. The audit and payment standards of expenses shall be implemented in accordance with the provisions of this Municipality's maternity insurance. Areas with off-site medical network settlement conditions can implement off-site medical network settlement.

Chapter VI Medical Management

Article 26 The social security agency shall complete the examination within 15 working days after receiving the details of medical expenses declared by the insured or their employers and designated medical institutions, and allocate the expenses that meet the requirements to the insured's personal social security card account or designated medical institutions.

Article 27 If the employer fails to pay the maternity insurance premium in full and on time, the social security agency shall order it to pay it back according to law. If the employer fails to pay back the maternity insurance benefits in accordance with the regulations, the employer shall compensate according to law.

Twenty-eighth social security agencies should sign a service agreement with designated medical institutions with midwifery and family planning technical service qualifications and willing to provide medical reproductive services for the insured, and announce it to the public. The agreement shall be filed with the municipal administrative department of human resources and social security.

Article 29 The birth and prenatal examination of the insured shall be in accordance with the Measures of Tianjin Municipality for Implementing the Law of the People's Republic of China on Maternal and Infant Health Care, the Notice of the Municipal Health and Family Planning Commission on Printing and Distributing the Implementation Plan for Preventing Mother-to-Child Transmission of AIDS, syphilis and hepatitis B in Tianjin (No.38/KLOC-0 [2065438]) and the Notice of the Municipal Health and Family Planning Commission on Printing and Distributing the Tianjin Maternal and Infant Health Care Standard (Jinwei Maternal and Child).

Thirtieth new participants in maternity insurance, from the month of insurance payment, enjoy prenatal examination fees, maternity medical expenses and family planning surgery fees. Maternity allowance shall be implemented in accordance with Article 21 of these Rules.

Thirty-first maternity insurance benefits arising from the flow of employees are connected in the following ways:

(a) workers from uninsured units to insured units, in the original unit of prenatal examination fees, maternity or termination of pregnancy medical expenses, family planning surgery fees, solved by the original funding channels. From the date of transferring to a new employer, the prenatal examination fee, medical expenses for childbirth or termination of pregnancy, and family planning operation fee shall be paid by the maternity insurance fund, and the maternity allowance for the remaining maternity leave days shall be calculated and paid by the maternity insurance fund according to the prescribed standards.

(II) Workers flow from the insured units to the uninsured units, and the prenatal examination fees, medical expenses for delivery or final pregnancy, and family planning operation fees incurred before they are transferred to the new units are paid by the maternity insurance fund, and the maternity allowance for maternity leave days is calculated and paid by the maternity insurance fund according to the prescribed standards. The maternity insurance fund will not pay the expenses incurred after transferring to a new unit.

Thirty-second people who are employed for the first time and re-employed after unemployment, the maternity insurance related expenses incurred by the employer from the month of enrollment shall be paid by the maternity insurance fund. The maternity allowance for the remaining days of maternity leave is calculated and paid by the maternity insurance fund according to the prescribed standards.

Thirty-third in accordance with the provisions of the maternity insurance premium has been reserved, the maternity insurance benefits of female workers in accordance with the reserved maternity insurance premium standards to pay. Maternity insurance benefits for female employees who terminate pregnancy shall be paid according to the actual expenses.

Chapter VII Supplementary Provisions

Thirty-fourth in the name of urban individuals who participate in the basic medical insurance for employees in this Municipality, the expenses of family planning operation and the medical expenses for treating the complications of family planning operation shall be paid by the maternity insurance fund in accordance with the standards and procedures stipulated by the maternity insurance for employees in this Municipality.

Thirty-fifth employees who enter and leave the enterprise staff trusteeship center shall be reimbursed for their prenatal examination fees, maternity medical expenses and medical expenses incurred in the implementation of family planning operations in accordance with the relevant provisions of maternity insurance for employees, and shall not enjoy maternity allowance.

Thirty-sixth all kinds of retirees who participate in the basic medical insurance for employees in this Municipality shall be paid by the maternity insurance fund in accordance with the standards and procedures stipulated by the maternity insurance for employees in this Municipality.

Article 37 The maternity protection of persons receiving unemployment insurance benefits shall be incorporated into the employee maternity insurance system, and the maternity insurance premiums payable shall be paid from the unemployment insurance fund. Persons receiving unemployment insurance benefits enjoy the same maternity insurance benefits as employees. During the period of receiving unemployment insurance benefits, maternity insurance benefits shall be paid by the maternity insurance fund in accordance with the standards and procedures stipulated by the maternity insurance for employees in this Municipality.

Thirty-eighth unemployed spouses who participate in maternity insurance in this Municipality shall participate in residents' medical insurance and be included in residents' maternity insurance.

Article 39 These Detailed Rules shall come into force on August 20 17 1 day, and shall be valid for five years. The original Notice on Implementing Relevant Issues (No.238 [2005] of the Bureau of Labor and Social Security) shall be abolished at the same time. Where the previous provisions are inconsistent with these rules, these rules shall prevail.

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