For more than 40 years, medical insurance in China has played an active role in safeguarding workers' health and maintaining social stability. However, with the establishment of the socialist market economic system and the deepening of the reform of state-owned enterprises, this system has been difficult to solve the basic medical security problems of employees under the conditions of market economy.
From 65438 to 0988, China government began to reform the free medical system of government agencies and the labor insurance medical system of state-owned enterprises. From 65438 to 0998, the China Municipal Government promulgated the Decision on Establishing the Basic Medical Insurance System for Urban Employees, and began to establish the basic medical insurance system for urban employees throughout the country.
The basic medical insurance system implements the principle of combining social pooling with individual accounts, organically combines social insurance with savings insurance, and realizes the organic combination of "horizontal" social security and "vertical" individual self-protection, which is not only conducive to giving play to the advantages of social pooling and individual accounts, but also conducive to giving play to the advantages of individual accounts' incentive and restraint functions, which is more in line with China's national conditions and is easily accepted by the broad masses of workers. This medical insurance model conforms to China's national conditions and is a social medical insurance system with China characteristics.
The basic medical insurance fund shall, in principle, implement municipal co-ordination. The basic medical insurance covers all employers and their employees in cities and towns; All enterprises, state administrative organs, institutions and other units and their employees must fulfill the obligation to pay the basic medical insurance premium. The employer's contribution ratio is about 6% of the total salary, and the individual contribution ratio is 2% of my salary. Part of the basic medical insurance premium paid by the unit is used to establish the overall fund, and part of it is included in the personal account; The basic medical insurance premiums paid by individuals are included in personal accounts. Pooling funds and individual accounts bear different responsibilities for payment of medical expenses. The overall fund is mainly used to pay for the hospitalization and outpatient treatment of some chronic diseases, and the overall fund has a minimum payment standard and a maximum payment limit; Personal accounts are mainly used to pay for general outpatient expenses.
In order to ensure that the insured employees enjoy basic medical services and effectively control the excessive growth of medical expenses, the China Municipal Government has strengthened the management of medical services, formulated the basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards, provided qualified medical institutions and pharmacies with basic medical insurance services, and allowed the insured employees to choose independently. In line with the reform of the basic medical insurance system, the state has also promoted the reform of medical institutions and drug production and circulation systems. By establishing the competition mechanism between medical institutions and the market operation mechanism of drug production and circulation, we will strive to achieve the goal of "providing better medical services at lower cost".
In addition to the basic medical insurance, large medical expenses mutual aid system is generally established in all localities to solve the medical expenses above the maximum payment limit of social pooling funds. The state has established a medical subsidy system for civil servants. Conditional enterprises can establish supplementary medical insurance for employees. The state will also gradually establish a social medical assistance system to provide basic medical security for the poor.
The reform of the basic medical insurance system in China has been steadily advanced, and the coverage of basic medical insurance has been continuously expanded. By the end of 20001,97% of cities and towns in China had started the reform of basic medical insurance, and the number of employees participating in basic medical insurance reached about 76.29 million. In addition, free medical care and other forms of medical security system have covered 1 100 million urban population, and China government is gradually bringing these people into the basic medical insurance system.
It was learned from Ministry of Human Resources and Social Security that "Guiding Opinions on Improving the Agreement Management of Designated Medical Institutions of Basic Medical Insurance" was recently issued. Among them, it is clearly required that all the overall planning areas in China should completely cancel the "two-fixed" qualification examination of "designated medical institutions for basic medical insurance" and "designated retail pharmacies for basic medical insurance" implemented by the social insurance administrative department before the end of 20 15, and simultaneously improve the agreement management between social insurance agencies and medical institutions to improve the management service level.
The opinions put forward clear requirements on how to improve the agreement management after canceling the "two-fixed" qualification examination implemented by the social security administrative department. All kinds of medical institutions established according to law, regardless of level, category and ownership nature, can voluntarily apply to social security agencies to become designated medical insurance according to conditions, and the social security administrative department will no longer conduct pre-approval. At the same time, the agency should establish an open and transparent evaluation mechanism, explore ways to carry out evaluation through third-party evaluation, and select medical institutions with good service quality, reasonable price and standardized management to sign service agreements through consultation. Chapter III Basic Medical Insurance
Twenty-third employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations. 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 can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations. Article 24 The state establishes and improves the new rural cooperative medical system. Measures for the administration of the new rural cooperative medical system shall be formulated by the State Council. Article 25 The state establishes and improves the basic medical insurance system for urban residents. The basic medical insurance for urban residents combines individual contributions with government subsidies. People who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people and minors over 60 years old in low-income families, etc. , subsidized by the government. Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations. Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will no longer pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state. Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations. Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits. Thirtieth the following medical expenses are not included in the basic medical insurance fund payment scope: (1) should be paid by the industrial injury insurance fund; (2) It shall be borne by a third party; (three) shall be borne by public health; (4) Go abroad for medical treatment. Medical expenses that should be borne by a third party according to law. If the third party is unable to pay or cannot determine the third party, the basic medical insurance fund will pay in advance. After the basic medical insurance fund pays in advance, it has the right to recover from the third party. Thirty-first social insurance agencies may, according to the needs of management services, sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior. Medical institutions shall provide reasonable and necessary medical services for the insured. Thirty-second individuals across the overall regional employment, the basic medical insurance relationship with my transfer, the cumulative payment period. (A) the establishment of personal accounts
The social medical insurance agency shall establish a personal account of basic medical insurance for each insured person, and take my ID number as the lifelong medical insurance number. The funds in the employee's personal account of basic medical insurance are owned by individuals and used for medical consumption. Overexpenditure is not covered, balance is accumulated, and cash is not withdrawn. When an employee dies, his personal account is cancelled and the balance is inherited according to regulations.
(2) Issuance of personal account cards
The employing unit shall handle the personal medical account settlement card for employees while participating in the basic medical insurance. Within 30 days from the date of participating in medical insurance, the employer shall apply to the social medical insurance agency and provide relevant information. After receiving the application from the employer to establish a household for employees, the social medical insurance agency will carefully review the relevant materials, establish a personal account for employees within 15 days, and issue a personal account settlement card. Inject funds into the employee's personal medical account in time, and bear interest according to relevant regulations. Retirees placed in different places may not issue cards temporarily.
Insured persons can purchase drugs at any designated medical institutions and pharmacies in the overall planning area with personal medical account cards. When the funds in the personal medical account are insufficient, they will be paid in cash.
(3) Transfer and inheritance of personal accounts
When the insured person is transferred out, the funds in the personal medical account will be transferred together. If you can't transfer, you can return the balance of your personal account to me and cancel your personal account at the same time.
If the insured dies, the balance of the personal account can be inherited by his legal heir.
(4) Loss reporting and replacement of personal account cards.
The insured shall properly keep the personal account card, and if it is damaged, it needs to be replaced with a new card, and the expenses shall be borne by the individual. If the personal account card is lost, it should be reported to the medical insurance agency or designated unit with relevant documents in time, and the medical insurance agency should immediately seal the account. If you can't find it within 30 days, you should apply for a new card at your own expense. The medical expenses incurred during the loss reporting period shall be paid in cash by the employee's personal account. If the personal account card is fraudulently used before reporting the loss, the insured shall bear the loss.
When the insured person purchases medicine for medical treatment and uses a card to settle medical expenses, the designated medical institutions and pharmaceutical service personnel should carefully verify, and those who find forged or fraudulently use the loss reporting card should be detained immediately, and the social medical insurance agency should be notified. Designated medical institutions and pharmacies shall not refuse the funds in the card or exchange cash for the cardholder.
In June, 2065438+00, Ministry of Human Resources and Social Security promulgated the Interim Measures for the Transfer and Continuation of the Relationship of Basic Medical Insurance for Migrant Workers. The method stipulates that from 20 10 and1July, migrant workers can transfer their medical insurance relationship and their personal accounts. In addition to the inter-provincial transfer of medical insurance relations, with the change of the identity of the insured, three different types of medical insurance relations, namely employee medical insurance, resident medical insurance and new rural cooperative medical care, can also be transferred to each other. Migrant workers can participate in the local basic medical insurance for employees at their places of employment, and can bring them back to the countryside to change to the new rural cooperative medical system without interruption. (a) to declare the acceptance of medical insurance institutions, the collection department accepts the "medical insurance payment base change declaration form" submitted by the insured units, and requires the following information:
1. Salary Payment Schedule;
2 to participate in medical insurance personnel list.
3. Other information stipulated by the medical insurance institution.
(2) Payment verification
1. The collection department of the medical insurance institution shall review the payment declaration and approval form and related materials provided by the insured unit. After passing the examination, the insured shall go through the formalities of approval or increase or decrease.
2. The collection and payment department of the medical insurance institution shall, according to the declaration and verification of payment, record the time of enrollment and the current payment of wages and other information for the new insured in time. The collection and payment department of the medical insurance institution shall declare and approve the current payment base according to the insured unit.
3. The collection and payment department of the medical insurance institution shall calculate the payable amount according to the approved current payment base and payment rate of the insured unit, print the Notice of Medical Insurance Payment, and feed it back to the reporting unit for collection and payment on this basis.
(3) Charge
1. Medical insurance institutions can collect fees through the "income deposit" bank, or by cheque, cash, wire transfer or cashier's check, and issue special receipts. The financial management department of the medical insurance institution reconciles with the bank every month and feeds back the receipt to the collection department.
2. The collection and payment department of medical insurance institutions shall, according to the payment of medical insurance premiums fed back by the financial management department, issue a "Social Insurance Premium Reminder Notice" to the insured units that fail to pay medical insurance premiums in full and on time after the declaration. If it is not implemented within the time limit, it shall provide relevant information and materials to the administrative department of labor security, which shall make corrections within a time limit.
3. Before 25th of each month, if the insured unit fails to pay the fee, a late fee of 2‰ will be charged on a daily basis from the date of default. It can be paid in one lump sum for one month, one quarter, six months or one year. If it is paid quarterly or annually, it should be paid at the beginning of the quarter or the beginning of the year. Temporarily unable to pay, you can apply for holdover, holdover time shall not exceed 2 months.
(4) Payment of arrears
1. The collection department of the medical insurance institution shall establish arrears data information according to the arrears of medical insurance, fill in the Notice on Payment of Social Insurance Premium, and notify the insured unit to pay the arrears.
2. Due to financing difficulties, it is impossible to pay off the arrears of the insured unit in full in one lump sum, and the collection department of the medical insurance institution shall sign a social insurance payment agreement with it. In the case of merger, division, bankruptcy, etc. For defaulting units, overdue agreements shall be signed in the following ways.
(1) If the defaulting units merge, a payment agreement shall be signed with the merging party.
(2) If the arrears unit is separated, it shall sign a payment agreement with each branch.
(3) If the defaulting unit enters bankruptcy proceedings, it shall sign a settlement agreement with the liquidation group.
(4) If the unit is sold or leased by auction, an overdue agreement shall be signed with the competent department.
3. The insured unit shall pay the social insurance premium according to the Notice of Payment of Social Insurance Premium or the payment agreement, and the collection department of the medical insurance institution shall accept the payment and notify the financial management department of the medical insurance institution to collect it.
4. The bankrupt unit can't pay off the arrears in full, and the collection department of the medical insurance institution accepts the application put forward by the bankruptcy liquidation group of the unit, and then sends it to the auditing and supervision department for handling.
5. The collection department of the medical insurance institution shall adjust the arrears information of the insured unit according to the overdue arrears information of the financial management department and the verification information of the audit supervision department. Settlement Procedures for Hospitalization and Outpatient Treatment of Special Diseases Designated medical institutions will report the expense list, hospitalization list and related materials of patients discharged last month to the medical insurance agency before each month/kloc-0, and the medical insurance agency will review them as the basis for monthly pre-allocation and year-end final accounts. The medical insurance agency pre-allocated the hospitalization and outpatient expenses for special diseases last month.
Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately.
(2) Emergency settlement procedures
The medical expenses incurred by the insured due to emergency rescue to non-designated medical institutions in this city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall handle the reimbursement procedures according to the provisions with the emergency hospitalization medical records, inspection, laboratory test sheets, invoices and detailed list of medical expenses.
(three) resettlement procedures for resettlement personnel in different places
1. The resettlement personnel in different places are designated as 1-2 designated medical institutions by their units and reported to the medical insurance agency for the record.
2. The medical expenses incurred by the off-site staff in their place of residence in the outpatient department of designated medical institutions shall be paid in advance by themselves or their units. After the treatment, the unit holding the insured's diagnosis and medical records, effective bills, compound prescriptions and hospitalization expenses list shall settle the accounts with the social medical insurance agency on the specified date.
(4) Referral and settlement.
1. If the insured person is transferred to other medical institutions for diagnosis and treatment due to the conditions of designated medical institutions or specialized diseases, the approval form for referral and transfer shall be filled in. The reason for referral and transfer is put forward by the attending physician, the director of the department puts forward the opinion of referral and transfer, the medical institution medical insurance office reviews it, the dean in charge signs it, and it can be transferred only after being reported to the municipal medical insurance center for examination and approval.
2. Referral and transfer in principle, the city should be outside the city, and the province should be outside the province first. The city's referral regulations are carried out between designated medical institutions. The referral outside the city is proposed by the designated medical institutions above Grade III in this Municipality.
3. The medical expenses incurred after the insured person is referred to another hospital shall be paid by the individual or unit in cash. After the medical treatment, the insured person or his agent will submit the referral approval form, medical record certificate, prescription and valid documents to the medical insurance agency for reimbursement of hospitalization expenses that fall within the scope of the overall fund payment. For all participants, the reimbursement process is as follows:
(a) participating farmers to "new rural cooperative medical certificate" in the designated institutions for outpatient treatment, by the designated medical institutions according to the "new rural cooperative medical certificate" family outpatient account existing amount directly reduce medical expenses, the excess paid by participating farmers. Designated medical institutions shall settle accounts with agricultural medical institutions in a timely manner.
(two) participating farmers in the city, county and township designated medical institutions for hospitalization, directly subsidized by the designated medical institutions. Audit the medical expenses incurred by designated medical institutions, and prepay the subsidy amount according to the standards stipulated in the implementation measures.
Participating farmers in the provincial designated medical institutions and non-designated medical institutions hospitalization, compensation by the township agricultural cooperative medical institutions. Hospitalization medical expenses, one-time less than 2000 yuan (including 2000 yuan), by the township (town) agricultural medical reimbursement, hospitalization data by the township (town) agricultural medical examination and approval before reimbursement.
(1) When applying for compensation, I need to bring my ID card, household registration book, new rural cooperative medical certificate (the original copies of these three certificates are kept below), valid hospitalization invoice of medical institution, discharge summary (or medical record), expense list and referral certificate.
(II) The participating farmers suffering from outpatient serious illness (chronic disease) shall go to the township (town) Agricultural Medical Office with their ID card, household registration book, new rural cooperative medical system, outpatient invoice and list, outpatient medical records, inspection report, and outpatient serious illness (chronic disease) certificate from a second-class hospital or a specialized hospital.
(III) For participating farmers who have participated in commercial insurance and students who have participated in student medical insurance, when both commercial insurance compensation and new rural cooperative medical system compensation are required after discharge, participating farmers should first submit the original hospitalization invoice and a copy of the invoice to the Agricultural Institute or the designated medical institution at the county level for compensation, and then pay the original hospitalization invoice to the commercial insurance company. Copies of invoices shall be kept by county-level agricultural medical institutions or designated medical institutions, but trauma patients can only be reimbursed by the original (except students).
(4) The hospitalization expenses shall be settled within a limited time, and the compensation and settlement procedures can be handled at any time within three months after discharge. Those who spend more than three months are deemed to have given up compensation on their own (migrant workers may delay until the end of the year). The amount of compensation payable by the Agricultural Medical Institute according to the standards stipulated in the Implementation Measures shall be paid to the participating farmers within 10 working days.
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