Measures for the Administration of Settlement of Medical Insurance Expenses for Urban Employees in Yichun City and Detailed Rules for the Implementation of Basic Medical Insurance for Employees

Measures of Longnan Municipality (municipality directly under the Central Government) for the Administration of Settlement of Hospitalization Expenses of Basic Medical Insurance for Urban Employees

Article 1 In order to further strengthen the management of medical insurance services, improve the management level, effectively control medical expenses, safeguard the rights and interests of insured persons and medical institutions, ensure the healthy operation of medical insurance, and achieve a balance of payments, according to the spirit of the Notice on Printing and Distributing the Opinions on Strengthening the Management of Urban Workers' Basic Medical Insurance Expenses Settlement (Lao She Fa [1999] No.23) issued by the former Ministry of Labor and Social Security and other five ministries and commissions, Formulate these measures and the detailed rules for the implementation of the basic medical insurance for urban workers in Longnan City (No.21issued by Gansu Provincial Department), and combine the operation of the basic medical insurance for urban workers in the municipal organs.

Article 2 Application procedures for hospitalization. The insured person must go to the designated medical institution for medical treatment. If hospitalization is really necessary, the attending doctor shall issue a notice of hospitalization, and the insured patient or relative shall go through the hospitalization formalities with the approval of the Municipal Social Security Bureau with the unit letter of introduction and medical insurance certificate. If the employer and the insured fail to pay the basic medical insurance premium in full according to the regulations, they shall not apply for hospitalization declaration and shall not enjoy the basic medical insurance benefits.

Article 3 Settlement method of hospitalization expenses. The hospitalization expenses incurred by those who participate in the basic medical insurance for urban workers shall be settled by the insured, the Social Security Bureau and the designated medical institutions respectively. If the basic medical insurance policy stipulates that the Qifubiaozhun shall be borne by the individual and the proportion of the individual shall be borne by himself, the insured person shall directly settle with the designated medical institution in cash when he is discharged from the hospital; The remaining medical expenses shall be transferred and settled with designated medical institutions by the Municipal Social Security Bureau in the form of "grading quota, total amount control and regular verification". The Municipal Social Security Bureau signs service agreements with designated medical institutions through annual examination, introduces competition mechanism and implements dynamic management.

Article 4 Grading quota standard. Based on the average cost of discharged patients in the first three years (07, 08 and 09) of each designated medical institution, the Municipal Social Security Bureau reasonably determines the quota standard for the first year after the implementation of the settlement management measures after deducting the expenses beyond the scope of basic medical insurance payment. In the following years, the Municipal Social Security Bureau shall, according to the average cost of inpatients in hospitals at all levels in the previous year, exclude the expenses beyond the scope of payment of basic medical insurance, and approve the settlement quota standard of per capita hospitalization expenses with medical institutions at all levels.

Fifth overall fund settlement and payment scope.

1, all diseases in the catalogue of inpatient diseases of urban workers' basic medical insurance in Longnan area can be paid by the overall fund according to regulations when they are hospitalized.

2, included in the "basic medical insurance for urban workers in Gansu Province" and the "Interim Measures for the administration of basic medical insurance for urban workers in Gansu Province" in the scope of payment of medical expenses, can be paid by the overall fund.

Sixth, coordinate the allocation of funds. The Municipal Finance Bureau will allocate the basic medical insurance expenses approved at the beginning of the year to the Municipal Social Security Bureau on a monthly basis; The Municipal Social Security Bureau shall settle with the designated medical institutions according to the settlement procedures.

Seventh overall fund settlement procedures. Designated medical institutions should fill in the "Approval Form for Appropriation of Hospitalization Expenses" and the "Settlement Form for Hospitalization Expenses of Discharged Persons Last Month" before the 5th day of each month, and attach the medical insurance certificate and hospitalization expenses list of inpatients. After being audited by the Municipal Social Security Bureau, 90% of the quota standard will be paid to the designated medical institutions within 5 working days, and the rest 10% quota will be paid according to the semi-annual assessment of the designated medical institutions (the assessment methods will be formulated separately). At the end of the year, if the actual medical expenses are lower than 90% of the quota standard, they shall be settled according to the actual number, and appropriate rewards shall be given to the designated medical institutions; If the actual medical expenses are within 90%- 1 10% of the quota standard, they shall be settled according to the quota standard; If the actual medical expenses are 1 10%- 120%, 50% shall be paid to the social security bureau; Medical expenses exceeding the quota standard 120% shall be borne by medical institutions.

Article 8 A minimum deductible line and a maximum payment limit shall be set for the overall fund to pay hospitalization expenses. The medical expenses below Qifubiaozhun shall be paid by the insured.

(a) the basic medical insurance for urban workers as a whole fund Qifubiaozhun, a hospital in 400 yuan, two hospitals in 500 yuan, three hospitals in 600 yuan; The maximum payment limit of employee medical insurance in that year is 40 thousand yuan;

(2) Expenses exceeding the maximum payment limit shall be subsidized by large medical insurance.

Article 9 Medical expenses above Qifubiaozhun and below the maximum payment limit are mainly paid by the overall fund, but individuals also have to bear a certain proportion (see the table below). Due to the need of illness, medical institutions must seek the opinions of patients or their families and sign off before using treatment items and drugs outside the three catalogues. The expenses of Class B drugs are borne by individuals, 15%, the expenses of special examination and treatment are borne by individuals, 20%, and the rest are included in the total medical expenses.

Grade of hospitalization medical expenses

Personal conceit of employees

Proportion (%)

Retirees are conceited.

Proportion (%)

Deductible-less than 20,000 yuan

15

13

Within 2000 1-40000 yuan

13

1 1

More than 40 thousand yuan

10

eight

Article 10 methods for auditing hospitalization expenses. Designated medical institutions should set up corresponding working institutions according to the needs of their work, and be equipped with specialized personnel familiar with the basic medical insurance policies to be responsible for accounting the hospitalization expenses of insured patients, and fill in various forms carefully and accurately as required. Medical institutions should be equipped with a microcomputer to calculate medical expenses (software developed by the Municipal Social Security Bureau). The Municipal Social Security Bureau shall regularly or irregularly check the cost audit of medical institutions, check the relevant medical records and ask the insured patients, and the designated medical institutions shall actively cooperate. If any problem is found, it shall be punished according to the relevant provisions of the service agreement.

Article 11 If the transfer ratio is determined according to the relevant provisions of the basic medical insurance and the service agreement, if it is really necessary to transfer the insured who is hospitalized in different places, and the medical expenses required for emergency hospitalization during the business trip and family leave in different places according to the regulations, I will pay them first, and after the treatment, I will go to the Social Security Bureau for reimbursement with the hospitalization expense statement and relevant medical records. If the medical expenses for the hospitalization of retirees in different places are confirmed by the Municipal Social Security Bureau, they shall be reimbursed according to the above methods.

Twelfth designated medical institutions should adhere to the principle of "treatment due to illness, reasonable examination, rational drug use and reasonable charges" to further standardize the medical service behavior of medical personnel. Formulate relevant supporting systems, clearly define the responsibilities of leaders, determine full-time personnel, strengthen internal management, and put an end to violations. The charging standards of designated medical institutions shall be subject to the supervision and inspection of the municipal price department. Designated medical institutions such as violations, once verified, by the Municipal Social Security Bureau to deduct the corresponding fees for violations.

Thirteenth of the natural disasters, sudden diseases, epidemics and other sudden factors caused by a wide range of dangerous, urgent and serious patients' medical expenses, coordinated by the municipal government to solve.

Fourteenth counties (districts) should refer to these measures to formulate the detailed rules for the implementation of the county (district).

Fifteenth these Measures shall be implemented as of the date of promulgation and shall be valid for five years.

Measures of Longnan Municipality (municipality directly under the Central Government) on the Administration of Individual Accounts of Basic Medical Insurance for Urban Employees

Article 1 In order to strengthen the standardized management of individual accounts of basic medical insurance in our city, these Measures are formulated with reference to the Detailed Rules for the Implementation of Basic Medical Insurance for Urban Employees in Longnan Region (No.212002).

Second directly under the basic medical insurance for urban workers insured personal accounts to implement credit card management. IC cards are issued by the Municipal Social Security Bureau. IC card production costs shall be borne by the insured.

Article 3 IC cards are used to record the basic information of insured persons and the income and expenditure of personal accounts.

Article 4 The composition of individual account funds:

(a) the basic medical insurance premiums paid by the insured individuals (2%) are all included in the personal account.

(two) the basic medical insurance premium paid by the unit, the on-the-job workers according to 1.6% included in the payment of wages; Retirees are calculated at 3.8% of paid wages.

(3) Interest income of the above two parts.

Article 5 The entry of personal account funds:

(1) The Municipal Social Security Bureau establishes individual payment accounts and individual account fund transfer record accounts for the insured.

(two) the Municipal Social Security Bureau monthly audit insured personal account transfer records, timely and full allocation of personal accounts.

(three) personal accounts are regularly checked by the employer and the Municipal Social Security Bureau.

Article 6 The scope of use of the insured's personal account:

(a) medical expenses for outpatient treatment in designated medical institutions;

(two) the cost of purchasing drugs in designated retail pharmacies;

(three) other medical expenses that should be borne by individuals.

Article 7 If the employing unit and the insured fail to pay the basic medical insurance premium in full according to the regulations, the transfer of personal accounts shall be suspended until the expenses of the current year are fully paid.

Article 8 The Municipal Social Security Bureau shall set up personal accounts for the insured, issue IC cards and establish a personal account microcomputer management system. The employer is responsible for the collection and distribution of IC cards of the insured persons of the unit. Designated medical institutions and retail pharmacies are equipped with credit card machines, and are responsible for the settlement and entry of personal accounts.

Ninth insured to designated medical institutions and designated retail pharmacies to buy drugs, with IC card for settlement.

Article 10 The Municipal Social Security Bureau shall implement unified management of individual accounts and check the relevant information of individual accounts regularly or irregularly. Employers, insured persons, designated medical institutions and designated retail pharmacies shall cooperate.

Eleventh insured personal account funds, according to the same period of urban and rural residents deposit interest rates, after approval into personal accounts. The principal and interest of an individual account are owned by the individual, and the remaining funds can be carried forward for use. Cash withdrawal or overdraft is not allowed.

Article 12 The insured persons stationed outside Wudu City and retirees resettled in different places do not issue IC cards, and the funds in their personal accounts are distributed to the insured units quarterly or annually, which will be transferred by the insured units.

Thirteenth insured workers in the city within the scope of job transfer, if the transferred units have been insured, the relevant procedures, IC cards and personal accounts continue to use; If the transfer-out unit is uninsured and the personal account is used until there is no balance, the IC card will be stopped and kept by myself, and will continue to be used after re-insurance. If the insured person is transferred out of the city, the balance of funds in his personal account will be paid to him in one lump sum, and the IC card will be recovered by the Municipal Social Security Bureau.

Article 14 If the insured and the insured unit suspend the payment of basic medical insurance premiums due to the dissolution or termination of labor relations, their personal accounts will be used until there is no balance, and the ic card will be suspended and kept by themselves, and will continue to be used after re-insurance.

Fifteenth after the death of the insured, the balance of personal account funds according to the provisions of the "People's Republic of China (PRC) * * * and Inheritance Law", the beneficiary or legal heir designated by him before his death shall inherit according to law. If the designated beneficiary or legal heir has participated in the basic medical insurance, the balance of personal account funds will be transferred to the designated beneficiary or legal heir's personal account, and the ic card of the deceased will be recovered by the Municipal Social Security Bureau; If the designated beneficiary or legal heir does not participate in the basic medical insurance, the balance of personal account funds will be sent to the designated beneficiary or legal heir at one time, and the ic card of the deceased will be recovered by the Municipal Social Security Bureau.

Article 16 The IC card of the insured shall be properly kept. If it is lost, it should be reported to the unit in time, and the employer should apply to the Municipal Social Security Bureau for reporting the loss and go through the replacement procedures. The loss of personal account funds caused during the loss period shall be borne by the insured himself.

Seventeenth insured persons have the right to inquire about personal account funds and supervise the collection, use and management of personal account funds. The Municipal Social Security Bureau and the employing unit shall check the fund balance of the personal account of the insured once a year, and the employing unit shall announce it to the insured.

Eighteenth IC card records belong to the Municipal Social Security Bureau. If the employer or the insured alters, forges or embezzles the IC card, it shall be confiscated immediately upon discovery. If serious losses are caused to the basic medical insurance fund, it shall be handed over to judicial organs for handling.

Nineteenth insured personal accounts, one-time approval at the beginning of the year. The proportion of personal accounts in that year remains unchanged, and will be uniformly adjusted when approved next year.

Twentieth designated medical institutions and retail pharmacies use the IC card of the insured as a voucher for medical treatment and drug purchase, which is used to settle expenses and reduce personal account funds. Before 5 days of each quarter, submit the medical expenses and drug purchase expenses vouchers of the previous quarter, and go through the disbursement procedures after being audited by the Municipal Social Security Bureau.

Twenty-first designated medical institutions and retail pharmacies shall provide a summary of the use of personal account funds to the employer and the Municipal Social Security Bureau every year, as well as the personal account funds they usually have.

Twenty-second counties (districts) shall formulate detailed rules for the implementation of the county (district) with reference to these measures.

Article 23 These Measures shall be implemented as of the date of promulgation and shall be valid for five years.

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