Guangzhou residents' medical insurance enquiry telephone number

Notice on Issuing the Measures of Guangzhou Municipality on Basic Medical Insurance for Urban Residents

Notice of detailed rules for implementation

Sui Lao She Yi [2008] No.7

The labor and social security bureaus of all districts and county-level cities and relevant units:

According to the authorization of Article 22 of the Trial Measures for Basic Medical Insurance for Urban Residents in Guangzhou (Sui Fu Ban [2008] No.22), our bureau has formulated the Detailed Rules for the Implementation of Basic Medical Insurance for Urban Residents in Guangzhou. It is issued to you, please follow it.

Guangzhou Municipal Bureau of Labor and Social Security

July 2008 18

(Undertaking Office: Medical Insurance Office, Tel: 83330864)

Detailed rules for the implementation of basic medical insurance for urban residents in Guangzhou

According to the "Trial Measures for the Basic Medical Insurance for Urban Residents in Guangzhou" (Sui Fu Ban [2008] No.22, hereinafter referred to as the "Trial Measures"), these rules are formulated.

I insurance registration and payment

(1) Handling of insurance registration business

The departments of labor and social security, civil affairs, disabled persons' federations, education, etc. in all districts set up insurance registration points in labor and social security service centers, civil affairs offices, disabled persons' federations, kindergartens and schools in all streets (towns) within their respective jurisdictions according to the distribution of residents' residences. Urban residents (hereinafter referred to as "residents") in the medical insurance co-ordination areas of this Municipality (including Yuexiu District, Haizhu District, Liwan District, Tianhe District, Baiyun District, Huangpu District, Nansha District and Luogang District) shall go through the insurance registration procedures in the following ways:

Minors with urban household registration in this city (referring to residents who were under the age of 1 8 years ago in June of that year), non-employed residents and elderly residents choose to go to any street (town) labor security service center in this city to register for insurance;

Students who are officially registered in various schools in this city, and urban registered minors who are enrolled in kindergartens in this city, are uniformly registered by their schools and kindergartens;

Among the above-mentioned residents, the minimum living security objects, low-income families with difficulties and government dependents accommodated by social welfare institutions in this Municipality shall be registered by the social affairs (civil affairs) office of the street (town) where they are located.

The severely disabled people in this city shall go through the registration formalities with the disabled persons' Federation department in the street (town) where they are located.

(2) Insurance registration materials

1, the insured residents fill in the Application Form for Basic Medical Insurance for Urban Residents in Guangzhou, and register with the following information:

(1) Non-employed residents, elderly residents and full-time students of various institutions of higher learning, secondary vocational and technical schools and technical schools shall provide the original and photocopy of the household registration book and ID card (the photocopy of the household registration book includes the first page of household name and the insurance page, the same below);

(2) minors and full-time students in primary and secondary schools should provide the original and photocopy of the household registration book, and newborns within three months after birth should also provide the original and photocopy of the birth certificate;

(3) Foreign students should provide the original passport and a copy when applying for insurance;

2. If the insured chooses to pay the residents' medical insurance premium by bank transfer, he shall provide the passbook and photocopy of the designated bank, the original and photocopy of the passbook owner's ID card, and fill in and sign the authorization letter of entrusting the bank to pay the social insurance premium by automatic transfer. The insured registered personnel who have not gone through the formalities of bank automatic transfer payment shall pay the fees at the bank outlets entrusted by the municipal local tax department.

3, the following residents in addition to providing the above information, but also need to provide the corresponding information:

(1) Low-income families with difficulties need to provide the Certificate of Low-income Families in Guangzhou;

(2) The object of urban minimum living security personnel shall provide the "Guangzhou Urban Residents Minimum Living Security Jinling evidence";

(3) The rural minimum living security object personnel shall provide the Guangzhou Rural Residents Minimum Living Security Certificate;

(4) severely disabled people need to provide a disabled card.

(3) Collection and review of residents' personal information

Each street (town) labor and social security service center is responsible for minors, non-employed residents and elderly residents, child care institutions are responsible for their child care, schools are responsible for the collection and verification of their students' individual insurance information, and send the insurance registration data to the local social insurance fund management center for review every week; The District Social Insurance Fund Management Center shall, within 10 working days after receiving the information, review and print the Approval Form for Individual Collection and Payment of Basic Medical Insurance for Urban Residents in Guangzhou (hereinafter referred to as the Approval Form), which shall be issued to the insured by the above insurance registration agency.

The civil affairs departments of each street (town) are responsible for the collection, verification and preliminary examination of the personal information of the insured registered by them, and submit it to the District Civil Affairs Bureau for examination before the 20th of each month; The Civil Affairs Bureau of each district will send the audit results of the individual financing qualification of the insured to the local social insurance fund management center before the 23rd of each month; The district social insurance fund management center will review and print the approval form within 10 working days after receiving the information, and then the civil affairs departments of each street (town) will issue the approval form to the insured.

Each street (town) Disabled Persons' Federation department is responsible for collecting and checking the insurance information of severely disabled persons. After the preliminary examination of the individual contribution qualification of the insured, it shall be submitted to the district disabled persons' Federation department for review before 15 every month; District Disabled Persons' Federation Department shall review and summarize before the 20th of each month and submit it to the District Civil Affairs Bureau, and the District Civil Affairs Bureau shall send the review results of the insured person's individual funding qualification to the local social insurance fund management center before the 23rd of each month; The district social insurance fund management center will review and print the approval form within 10 working days after receiving the information, and then the disabled persons' Federation departments of each street (town) will issue the approval form to the insured.

For the insured who refuses to register and fails to pass the examination, the insurance registration department shall issue a notice of not participating in the residents' medical insurance.

Residents whose family members are managed by the provincial, municipal and district medical departments are not insured for the time being.

On the last 2 working days of each month, the insurance registration institution shall suspend the acceptance of insurance registration business.

(4) The starting and ending time of the insurance year.

Residents' basic medical insurance premium is levied annually. An insurance year is from July 1 day of the current year to June 30th of the following year.

The medical insurance relationship established after the registration of residents is valid within this insurance year.

(5) Collection of insurance premiums

The basic medical insurance premium for residents shall be collected by the local tax department entrusted by the bank. The specific business shall be defined by signing an agreement with the bank on behalf of the tax authorities.

(6) payment method and payment term

Residents who have registered for insurance should hold the "Approval Form" to pay the fee to the collection unit entrusted by the local tax department within the prescribed time limit. Among them, residents who are insured for the first time pay the fee from the 3rd to 23rd of the month after registration, and residents who are insured continuously in the new year pay the fee from the 3rd to 23rd of June each year.

The personnel funded by social medical assistance funds shall be paid as the insured after the Civil Affairs Bureau has examined and confirmed the funded objects and the amount of social medical assistance funds.

(seven) the collection of basic medical insurance for residents.

The residents' basic medical insurance premium levied by the local tax department should be remitted to the financial account of the residents' basic medical insurance fund in full in the current month, and be reconciled with the municipal social insurance fund management center (hereinafter referred to as the municipal fund center), the municipal medical insurance service management center (hereinafter referred to as the municipal medical insurance center) and the municipal finance bureau on a regular basis.

The municipal fund center will send the data report of social medical assistance fund to the Civil Affairs Bureau before 10 every month, and the Civil Affairs Bureau will send it to the municipal medical insurance center before the 20th of that month after examination and confirmation.

The municipal fund center will send the insured and social medical assistance funds approved by governments at all levels to the municipal medical insurance center. City medical center monthly summary of the amount of government funding at all levels and the amount of social medical assistance funds should be funded, apply to the Municipal Finance Bureau for funding, according to the annual liquidation.

City Finance Bureau will be funded by governments at all levels and social medical assistance funds unified allocation to the residents' basic medical insurance fund financial accounts. The Civil Affairs Bureau, the Municipal Medical Insurance Center and the Municipal Finance Bureau regularly reconcile.

Second, the insured changes, data changes.

(8) renewal procedures

Those who have participated in residents' medical insurance do not need to re-apply for insurance registration in the new year. After paying the basic medical insurance premium for urban residents in accordance with the regulations, their medical insurance benefits will automatically continue.

(9) Procedures for stopping insurance.

Need to stop the relationship between residents' medical insurance, the insured person (guardian) should fill in the "Registration Form for Stopping Insurance of Basic Medical Insurance for Urban Residents" and go through the formalities for stopping insurance at the affiliated insurance registration department before the end of May of that year.

If the insured fails to declare the termination of insurance before the end of May of that year, and fails to pay the fee in the new year, the insurance will be automatically terminated after the end of the new year.

(10) Handling of data changes

If the basic information such as the name, ID number, household registration and personal identity of the insured person needs to be changed, it is necessary to fill out the "Form for Change of Personal Information of Basic Medical Insurance for Urban Residents in Guangzhou" and go back to the original insurance registration department to handle the change procedures.

Kindergarten children, students and other insured persons leave the park, graduate, transfer, new students enter the school, etc. And continue to participate in residents' medical insurance in the new year. If the basic information needs to be changed, the child care institution or school shall go through the formalities of change at the social insurance fund center in the district.

Third, the insurance certificate management

(eleven) the management of social medical insurance card.

Guangzhou urban residents' medical insurance card (hereinafter referred to as "residents' medical insurance card"), as a certificate for the insured to seek medical treatment and handle medical insurance-related business, is managed by the municipal medical insurance center. Residents' medical insurance cards shall be handled with reference to the measures for the issuance of medical insurance cards for urban workers in Guangzhou.

Residents' medical insurance card has the financial function of ordinary savings card.

Street (town) labor and social security service institutions, child care institutions, schools, district civil affairs departments, and district disabled persons' federations will receive residents' medical insurance cards from the medical insurance agency in the bidding area after the first registration of the insured person in the next month 19, and issue the medical insurance cards to the insured person who has paid the fee in the current month before the end of the month.

(twelve) the use of social medical insurance card

The resident medical insurance card is only for the insured person's own use and may not be lent to others. Medical expenses arising from illegal use shall be borne by the insured after verification.

During the period when the resident medical insurance card is lost or copied, the resident medical insurance card shall be reissued with the report of loss or the re-printed receipt.

(13) Effectiveness of insurance certificate

The insured to the designated medical institutions for medical treatment, must produce a valid medical insurance certificate and valid identity documents; Before presenting a valid medical insurance certificate, all medical expenses incurred in seeking medical treatment shall be borne by the insured.

If the insured can't show the medical insurance certificate on the spot because of emergency admission or coma, their relatives should go through the formalities of showing the certificate within three working days of admission.

When the insured person goes through the hospitalization registration due to the birth and termination of pregnancy in line with the family planning policy, he must also produce the original valid certificate approved by the family planning department.

Fourth, medical management.

(fourteen) the management and use of "medical insurance outpatient medical records" and "medical records in different places".

The municipal medical insurance center uniformly printed the medical records of Guangzhou social medical insurance outpatient service (referred to as the medical records of residents' medical insurance outpatient service) and the medical record book of Guangzhou in different places (referred to as the medical record book in different places). When the insured person goes to the designated medical institutions in this Municipality for medical treatment, he shall purchase it at the price stipulated by the price department and keep it by himself. The specific measures for use shall be formulated separately by the Municipal Medical Insurance Center.

(fifteen) inpatient and outpatient specific projects and designated chronic disease outpatient medical management.

The medical management of residents' medical insurance insured persons in the designated medical institutions in this Municipality for specific items of hospitalization and outpatient service and the treatment of chronic diseases at designated places shall be implemented in accordance with the relevant provisions of the medical insurance system for employees in our city.

(sixteen) general outpatient (emergency) medical management.

General outpatient (emergency) diagnosis refers to outpatient specific items and outpatient (emergency) diagnosis other than designated chronic disease clinics.

In the designated social insurance medical institutions for outpatient (emergency) medical expenses that can be accounted by the city's medical insurance information system, students and minors in school choose a community health service institution (except for the community medical institutions with secondary and tertiary medical institutions in this department, the same below) or the medical institution of their school and another medical institution, and the elderly residents choose a community health service institution as the designated medical institution for outpatient (emergency) medical treatment.

Students and minors in school can enjoy the prescribed treatment when they go to the designated hospital for outpatient (emergency) diagnosis of corresponding specialized diseases. Specific designated hospitals and specialties shall be announced separately by the Municipal Medical Insurance Center.

In each social security year, when the insured chooses a general outpatient (emergency) consultation medical institution for the first time, he shall go through the formalities to determine the choice of medical institution. The insured or his guardian shall fill in the Registration Form of Selected Medical Institutions for General Outpatient (Emergency) Diagnosis in the medical records of residents' medical insurance clinics, and paste the recent one-inch bareheaded color photos; After checking the information of the insured person, the medical institution shall affix a special label at the corner of the photo; The insured person shall confirm that the medical institution is the selected medical institution in the current year after the settlement of medical treatment.

After the selected medical institutions are determined, they will not be changed during the year. However, if the insured has permanent residence or the qualification of designated medical institutions changes, minors and students transfer to other specific circumstances, they can go through the formalities for the change of designated medical institutions in the offices of the Municipal Medical Insurance Center.

(seventeen) the management of medical treatment in different places.

1, the insured person to seek medical treatment in different places, according to the provisions of the "Trial Measures" to enjoy the corresponding basic medical insurance benefits for residents:

(1) The insured who has lived in the same different place in China for more than half a year and has gone through the long-term medical treatment procedures in different places chooses the specific items of hospitalization and outpatient service in medical institutions and specifies the treatment of chronic diseases in different places;

(2) Approved referral to public medical institutions outside the city for hospitalization;

(3) Being hospitalized or observed in an emergency in a different place;

(4) During the winter and summer vacations, during the period of suspension from school due to illness, students return to their registered residence, or are hospitalized in local public medical institutions, outpatient specific projects and designated chronic disease treatment or emergency treatment.

The residents' medical insurance fund will not pay the medical expenses incurred by medical treatment in different places that do not fall within the above scope.

2, residents' medical insurance management in different places, with reference to the relevant provisions of the basic medical insurance for urban workers in this city.

For the insured who have lived in the same place in China for more than half a year, according to the management of long-term medical treatment in different places, go through the procedures of long-term medical treatment in different places, use the medical treatment record book in different places, and standardize the medical treatment information records in different places.

Other circumstances of medical treatment in different places shall be managed according to temporary medical treatment in different places.

Five, residents' medical insurance benefits

(eighteen) the scope and standard of treatment.

The scope and standard of residents' medical insurance benefits shall be implemented in accordance with the relevant provisions of the Trial Measures.

The basic medical expenses (emergency) incurred by the insured elderly residents in their selected medical institutions shall be reimbursed by 50%;

Students and minors in school will be reimbursed 70% for basic medical expenses in the selected community medical institutions or the general outpatient (emergency) of their school medical institutions, and 40% for basic medical expenses in other selected medical institutions, designated hospitals and specialist general outpatient (emergency);

The insured person meets the requirements of the general outpatient (emergency) medical expenses, which should be paid by individuals, and the insured patients directly go to the designated medical institutions for settlement; Belonging to the residents' medical insurance fund, the designated medical institutions shall first keep accounts and then report to the municipal medical insurance center for settlement on a monthly basis.

The residents' medical insurance fund will not pay the general outpatient (emergency) medical expenses incurred by the insured in non-designated medical institutions or hospitals or specialties. However, during the winter and summer vacations of students in school, or during the period of suspension from school due to illness and field practice. The basic outpatient medical expenses incurred in the emergency department of public medical institutions in different places shall be reimbursed by the residents' medical insurance fund at a rate of 40%.

(nineteen) the treatment of cross insurance convergence.

During the period of participating in residents' medical insurance, urban residents who change to participate in urban flexible employment medical insurance can continue to enjoy residents' medical insurance benefits during the paid residents' medical insurance year and the waiting period of flexible employment medical insurance.

(twenty) the cumulative annual maximum payment limit.

In a social security year, if a resident changes the scope of social medical insurance with the change of identity, the medical expenses incurred during the period of participating in different coverage shall be accumulated separately, and the annual maximum payment limit shall be calculated separately.

(XXI) Term of payment

The insured payment period for urban residents to participate in residents' medical insurance is not accumulated as the insured payment period for participating in the basic medical insurance for employees in this Municipality.

Intransitive verb fund payment

(twenty-two) the scope and standard of fund payment.

The scope of the residents' medical insurance fund to pay the medical expenses of the insured shall be implemented in accordance with the relevant provisions of the drug list, diagnosis and treatment items, medical service facilities and payment standards of the basic medical insurance for urban workers in this Municipality.

In accordance with the provisions of the family planning policy, the hospitalization expenses incurred in the birth or termination of pregnancy shall be implemented in accordance with the standards stipulated in the scope and catalogue of the medical expenses paid by maternity insurance for enterprise employees in this Municipality and the trial measures.

(23) the fund does not pay.

In any of the following circumstances, the residents' medical insurance fund shall not pay the relevant medical expenses:

1, seeking medical treatment in a medical institution other than the designated medical institution for social insurance in Guangzhou without approval;

2. Suicide or self-mutilation (except mental illness);

3, fighting, alcoholism, drug abuse and other criminal acts that cause injuries or violate the "Public Security Administration Punishment Law";

4. Identify the medical expenses paid by the other party for traffic accidents, accidents, medical accidents or industrial injury insurance;

5. Abroad or in Hongkong, Macao Special Administrative Region and Taiwan Province Province;

6. Other non-payment circumstances stipulated by the state, province and city.

Seven, designated medical institutions management and medical expenses settlement

(twenty-four) management of designated medical institutions

The management of resident medical insurance designated medical institutions shall be implemented in accordance with the relevant provisions of the basic medical insurance system for urban workers in this Municipality, and a supplementary agreement shall be signed between the municipal medical insurance center and the designated medical institutions.

(twenty-five) medical expenses settlement

The basic medical expenses incurred by the insured for the specific items of hospitalization and outpatient service and the treatment of chronic diseases at designated points shall be settled according to the corresponding settlement methods of the basic medical insurance for urban workers in this Municipality.

The basic medical expenses incurred by students, minors and other insured persons in the designated medical institutions in this Municipality according to the regulations shall be settled according to the service items.

Students, minors and elderly residents in line with the provisions of the general outpatient (emergency) medical expenses, which are paid by the medical insurance fund, are first accounted for by the hospital, and settled by the municipal medical insurance center and designated medical institutions according to the service items, "annual per capita limit" or "monthly average limit". The specific way is determined in the medical service agreement.

(twenty-six) retrospective treatment of residents' medical insurance.

The scope of retrospective treatment of residents' medical insurance:

The basic medical expenses incurred from birth to the month of payment if the newborn is insured within 3 months (including 3 months) and pays the annual residents' medical insurance premium;

The basic medical expenses incurred by the students in the month from July of that year 1 to June of that year 1;

Basic medical expenses within three months after the implementation of the Trial Measures (before August 23, 2008), from July 1 day of that year to the payment month.

Settlement method for retrospective treatment of residents' medical insurance:

1. The retrospective operation of in-patient medical treatment adopts the mode of "patients pay the deposit first and the hospital delays the settlement".

From July 1 2008, designated medical institutions can collect a deposit equivalent to the hospitalization expenses after consultation with the insured patients when handling the discharge check-out for the hospitalized patients who have participated in or are ready to participate in the residents' medical insurance but have not enjoyed the treatment.

After the discharged patients enjoy the treatment of residents' medical insurance, they will apply to the original inpatient medical institution for medical expenses accounting and settlement with the residents' medical insurance card, valid identity documents, deposit receipt and discharge certificate from August 1 2008.

Designated medical institutions shall, after inquiring and confirming the identity and treatment of the insured on the medical insurance information system, go through the formalities of admission registration and discharge settlement, and immediately refund the deposit equal to the medical expenses to be recorded.

2, emergency observation and other outpatient specific projects within the validity period of examination and approval, medical treatment for the designated chronic diseases, according to the retrospective hospitalization treatment.

3, general outpatient (emergency) medical treatment according to the "sporadic reimbursement by the selected medical institutions" way.

From June 365438+1October 3 1 day, 2008, the selected medical institutions began to accept sporadic applications for reimbursement of basic medical expenses for outpatients (emergency) in their own medical institutions during the treatment review period.

The procedures for reimbursement of medical expenses for sporadic outpatient (emergency) in designated medical institutions are as follows:

(1) The insured person goes to the selected medical institution where the original medical expenses occurred, fills in the Application Form for Retroactive Treatment of Medical Expenses of Medical Insurance for Urban Residents in Guangzhou (hereinafter referred to as the application form), presents the residents' medical insurance card, valid identity documents and medical insurance outpatient medical records, and submits the copies of the front and back of the residents' medical insurance card, the receipt (invoice) of the original medical expenses and the details of medical expenses.

The selected medical institution shall immediately review and confirm the information, affix a seal on the application form, and give the receipt to the insured.

(II) Designated medical institutions shall summarize the retrospective application materials for outpatient (emergency) treatment of residents on a monthly basis, and fill in the Summary of Retrospective Application for Outpatient (emergency) treatment medical expenses of designated medical institutions for urban residents' medical insurance in Guangzhou (hereinafter referred to as the "application form").

The selected medical institutions will send the zero application materials and the application form submitted by the insured to the office of the municipal medical insurance center every month to centrally handle sporadic reimbursement of outpatient (emergency) medical expenses.

(3) After accepting and reviewing the application materials for outpatient (emergency) treatment, the municipal medical insurance center will directly transfer the expenses paid by the residents' medical insurance fund to the personal bank settlement account of the insured residents' medical insurance card.

(twenty-seven) cross social security annual settlement.

Cross-social security year continuous hospitalization and outpatient treatment of specific projects shall be settled by stages according to the social security year, and the medical expenses incurred shall be accumulated separately according to the social security year, and only one hospitalization Qifubiaozhun shall be paid.

(28) Cross insurance settlement

If the insured changes the medical insurance benefits during hospitalization (such as residents' medical insurance is changed to employees' medical insurance, or employees' medical insurance is changed to residents' medical insurance), it will be settled by stages, and the medical treatment standard will be calculated according to the relevant standards that should be enjoyed when handling the settlement, and only one hospitalization Qifubiaozhun will be paid.

Eight, sporadic medical expenses reimbursement

(twenty-nine) the scope of reimbursement for sporadic medical expenses.

The following expenses belong to the scope of sporadic medical expenses reimbursement:

1. Upon approval, the insured actually incurred medical expenses that meet the requirements due to special needs such as emergency treatment or rescue, illness, hospitalization or emergency observation in non-designated social insurance medical institutions in this city;

2. Due to objective reasons, the basic medical expenses that have not been settled in the designated medical institutions and the designated medical institutions cannot make up for the system settlement and have been paid by the insured;

3, residents' medical insurance benefits can be traced back to the designated medical institutions for reimbursement of general outpatient (emergency) diagnosis of sporadic basic medical expenses;

4, in accordance with the provisions of article seventeenth of these rules, the basic medical expenses for medical treatment in different places.

(30) Sporadic reimbursement methods

The insured shall, within 3 months from the date of settlement of medical expenses, apply for sporadic reimbursement to the municipal medical insurance center with the following information.

1, the original and the front and back copies of the resident medical insurance card;

2. Detailed list of medical expenses (or list of manual records certified by medical institutions);

3. Receipts or invoices for medical charges printed by the financial and tax departments;

4, "medical insurance outpatient medical records" or "remote medical records" and other information.

In the case of complete information, the municipal medical insurance center will complete the audit and settlement within 40 working days, and transfer the expenses paid by the residents' medical insurance fund to the bank personal settlement account of the insured residents' medical insurance card; If it is a difficult case or requires special circumstances such as on-site verification, it will take no more than 90 working days to complete the audit and close the case.

City medical insurance center to confirm the information is incomplete, should be informed of the missing information at one time; If the conclusion of no compensation is made after examination, the insured shall be informed within 40 working days.

Nine. others

(thirty-one) social medical assistance management

Residents with difficulties confirmed by the civil affairs department shall enjoy social medical assistance in accordance with relevant regulations after enjoying medical insurance benefits for residents. Specific measures shall be implemented in accordance with the relevant provisions of the civil affairs department.

(thirty-two) the start time and duration of implementation

These rules shall come into force as of the date of promulgation and shall be valid for three years. After expiration, it should be evaluated and revised according to the implementation.

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