Interim Provisions on the Basic Medical Insurance for Urban Employees in Nanjing

Chapter I General Provisions

Article 1 In order to speed up the establishment of the basic medical insurance system for urban employees and ensure their basic medical care, according to the Decision of the State Council Municipality on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44) and On the Reform of the Medical Insurance System for Urban Employees in Jiangsu Province

,

Article 2 The establishment of the basic medical insurance system for urban workers should follow the following principles:

(1) The level of basic medical insurance should be compatible with the social and economic development level of this Municipality;

(2) All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management;

(3) The basic medical insurance premium shall be borne by both the employer and the employee;

(4) The basic medical insurance fund combines social pooling with individual accounts;

(5) Equality of rights and obligations.

chapter ii scope and object of implementation

article 3 all employers in cities and towns within the administrative area of this municipality, including all kinds of domestic-funded enterprises, Hong Kong, Macao and Taiwan, enterprises with foreign investment

(excluding foreigners and personnel stationed in Nanjing from Hong Kong, Macao and Taiwan), government agencies, institutions, social organizations, non-enterprise units run by the people

and their employees, must participate in basic medical insurance in accordance with these provisions.

Ministry, provincial and foreign units stationed in Nanjing and their employees should participate in the basic medical insurance in this city according to the principle of territorial management. The basic medical insurance for provincial organs and employees in Ningxia shall be implemented in a unified policy and managed by units alone.

Cross-regional and mobile enterprises such as railway, electric power and ocean transportation in Nanjing and their employees should participate in the basic medical insurance in this city in a relatively centralized way.

The specific measures for the owners of urban individual economic organizations and their employees, freelancers, township enterprises and their employees to participate in this medical insurance shall be formulated separately.

chapter iii collection and payment of basic medical insurance premiums

article 4 the basic medical insurance premiums shall be paid by both the employer and the employees. The employer shall pay 8% of the total amount of on-the-job wages < P >; On-the-job employees pay 2% of their salary, and the basic medical insurance premium paid by individuals < P > is withheld from employees' salary by the employer on a monthly basis.

the total wages are calculated according to the statistical median stipulated by the state.

article 5 if the average monthly salary of employees is lower than 6% of the average monthly salary of employees in this municipality last year, 6% shall be taken as the base; The part exceeding

3% shall not be used as the base for paying the basic medical insurance premium.

the basic medical insurance premium for laid-off workers from state-owned enterprises who enter the re-employment service center (including the unit payment and the individual payment of employees

) is paid by the re-employment service center based on 6% of the average monthly salary of employees in this city last year.

Article 6 The basic medical insurance premium shall be paid by the employer to the Nanjing Medical Insurance Settlement Management Center (hereinafter referred to as the Medical Insurance Center) or the local tax department on a monthly basis.

Article 7 The basic medical insurance premium paid by the employing unit shall be settled by the administrative organs and institutions fully funded by the finance according to the original

funding channels; Medical institutions owned by the whole people with fixed quota or fixed item management shall carry out < P > according to the relevant provisions of the state; Other institutions from the business income or operating income from the medical fund expenses; The enterprise shall be paid from the employee welfare fund.

Article 8 The basic medical insurance premium owed by bankrupt enterprises shall not be reduced or exempted, and the basic medical insurance premium for 1 years shall be paid for retirees (employees) in one lump sum based on the average monthly salary of employees in the previous year in the whole city

according to the stipulated unit contribution rate. The required funds shall be allocated from the liquidation property (including the income from the transfer of land use rights) according to law, and the insufficient funds shall be divided into

points, which shall be solved by the competent department of the enterprise.

the basic medical insurance premium of the merged enterprise shall be paid by the merged enterprise.

Article 9 The basic medical insurance premium of the poverty-stricken enterprises approved by the government authorized departments shall be paid at 6% of the total wages of the employees of the unit

, and the full amount shall be included in the overall fund. Workers enjoy the medical insurance benefits paid by the overall fund.

article 1 the finance and the employing unit shall provide the necessary starting funds for basic medical insurance. Start-up funds are divided into two parts, and the fund-raising part is advanced by the finance for one month according to 5.36% of the average monthly salary of employees in the city last year; The personal account

household fund shall be transferred by the employing unit at the time when the employees are insured for the first time. The transfer standard is 2 yuan for every

employee and 3 yuan for every retired employee.

chapter iv pooling funds and individual accounts

article 11 the basic medical insurance fund consists of pooling funds and individual accounts.

(1) Overall fund:

(1) The remaining part of the basic medical insurance premium paid by the employer after deducting it from the personal account;

(2) late fees charged according to regulations;

(3) interest;

(4) financial subsidies;

(5) other income.

(2) Personal account:

(1) Basic medical insurance premium paid by employees;

(2) the part included in the basic medical insurance premium paid by the employer;

(3) interest;

(4) other income.

Article 12 The basic medical insurance premium paid by the employer shall be credited to the personal account according to the following proportions:

For those under p>35 years of age, it shall be credited to 1% of my contribution fund;

from p>35 years old to 45 years old, according to 1.4% of my payment base;

from the age of p>45 to before retirement, 1.7% of my enrollment base will be included;

Retirees (posts) are included at 5.4% of their average monthly pension in the previous year.

Article 13 Pooled funds and individual accounts shall be managed and accounted for separately according to their respective payment ranges, and shall not be mutually occupied

.

Article 14 The pooling fund shall set the minimum payment standard and the maximum payment limit.

qifubiaozhun is determined according to the classification of medical institutions, and it is tentatively set as: RMB 1,2 for tertiary medical institutions, 8 yuan for secondary medical institutions, and 5 yuan for primary medical institutions (including those below the first level). If an employee is hospitalized for many times in a year, the minimum threshold will be reduced by 3%, but the minimum threshold shall not be lower than that in 3 yuan. Outpatient

The minimum payment standard for specific items in a natural year is 1 yuan.

The maximum payment limit of medical expenses paid by the overall fund once or cumulatively in a natural year is 4 times of the social average wage of employees in this city last year

.

Article 15 The overall fund is mainly used for specific items of hospitalization and outpatient service that meet the basic medical insurance.

outpatient specific items are temporarily included in three disease items: radiotherapy, chemotherapy, uremia dialysis and anti-rejection treatment after renal transplantation (management measures for outpatient specific items shall be formulated separately).

Article 16 The personal account is mainly used for outpatient expenses of conditional basic medical insurance, drug purchase expenses of designated retail pharmacies and

the part that the individual bears in the expenses of specific items of hospitalization and outpatient service for employees. When the personal account is insufficient, it will be paid by the individual

.

article 17 the principal and interest of an individual account are owned by the individual and can be carried forward, transferred and inherited (the measures for the administration of individual accounts

shall be formulated separately).

Article 18 Bank interest calculation method for the basic medical insurance fund: the part raised in the current year shall be calculated at deposit interest rate

; The fund principal and interest carried forward from the previous year shall bear interest at the bank deposit rate of lump-sum deposit for 3 months; Deposited in the agency

will guarantee the deposited funds in the financial special account, and it will be calculated at the bank deposit interest rate of 3-year lump-sum deposit. Interest and

into the basic medical insurance fund.

Chapter V Basic Medical Insurance Benefits

Article 19 The medical expenses that meet the requirements of basic medical insurance for specific items of employees' hospitalization and outpatient service shall be paid by employees from their personal accounts or paid by themselves under the minimum threshold of overall planning

; Qifubiaozhun above, maximum

pay below the limit, according to the principle of "calculation by sections, cumulative payment", by pooling funds and individuals * * * with

share. The specific sharing ratio is as follows:

the proportion of pooling funds and individuals for hospitalization medical expenses

the first-class medical machine, the second-class medical machine and the third-class medical machine

pooling individuals, pooling individuals

The minimum payment standard is 1 yuan, 9%, 1%, 88%, 12%, 86%, 14%

11 yuan to 2 yuan, 92%.

the share ratio of retired individuals and retired individuals is 7% and 8% of the employees respectively. Before the founding of the People's Republic of China, the proportion of retired old workers who participated in revolutionary work was 5% of the on-the-job workers.

Article 2 If the expenses of medical treatment items incurred by employees in hospital are part of the expenses paid by the basic medical insurance, the individual shall

pay 2% first, and the rest shall be paid according to the relevant provisions of the basic medical insurance.

the medical expenses incurred by employees using "Class A List" drugs belong to the basic medical insurance to pay part of the expenses.

Individuals should pay 2% first, and the rest should be paid according to the relevant provisions of the basic medical insurance.

medical expenses incurred by employees using drugs listed in Category A shall be paid according to the provisions of basic medical insurance. The medical expenses incurred by

using "Category B" drugs shall be paid by the employees at a certain proportion, and the rest shall be paid according to the provisions of basic medical insurance (the specific proportion of individual self-payment shall be formulated separately).

article 21 if the employer and employees stop or fail to pay in full, the medical insurance center will transfer

funds to individual accounts from the next month, and suspend employees from enjoying basic medical insurance benefits, and the payment period will not be calculated during the unpaid period. If the employer

and employees make up the arrears and late fees within three months, the medical expenses incurred during the arrears period will be paid according to the regulations

. If the arrears are more than three months, the employer and the employees can resume their eligibility for the treatment of employees < P > after paying them back in accordance with the regulations, and make up their personal accounts. The payment period will be calculated continuously, but the < P > medical expenses incurred during the arrears period will not be paid.

Article 22 The employees who have retired before the employer participates in the insurance shall not pay the basic medical insurance premium. The years of basic medical insurance premiums paid by retired

personnel during their employment (hereinafter referred to as payment years) must be:

3 years for men and 25 years for women. For those who have less years, when going through the retirement formalities, the employer or employees

will take the average monthly salary of employees in the last year of the city as the base, and make up the basic medical insurance premium in the year of difference

according to the total rate of the units and individuals, and they can enjoy the basic medical insurance benefits for retirees. The employee's pre-insurance sign

the length of service or working years that meet the national regulations can be regarded as the payment period.

Article 23 Before the employing unit joins the insurance, employees who have completely lost their ability to work due to illness or non-work-related disability, and other people who have taken early retirement according to national regulations (except those who have taken early retirement in special jobs as stipulated in document No.14 [1978] of the State Council), the employing unit will pay the basic medical insurance premium at a lump sum of 8% of the average monthly salary of employees in the previous year in the whole city

until they reach the statutory retirement age.

Article 24 Medical expenses incurred in the following circumstances shall not be paid:

(1) Work-related injuries (including occupational diseases), maternity and its complications;

(2) injury caused by violation of law and discipline;

(3) traffic accidents;

(4) Suicide and self-mutilation (except mental patients);

(5) during going abroad or leaving the country;

(6) medical accidents;

(7) Other items that do not meet the payment scope of basic medical insurance.

Chapter VI Medical Assistance for Serious Illness and Supplementary Medical Insurance

Article 25 All employees who participate in the basic medical insurance for urban employees in this Municipality shall participate in medical assistance for serious illness. In principle, the medical assistance fund for serious illness shall be paid by employees (including retired and resigned personnel) according to the 5 yuan standard per person per month, which is mainly used to solve the medical expenses (from the highest payment limit of the basic medical insurance pooling fund to less than 15, yuan).

article 26 qualified employers may establish supplementary medical insurance for enterprises on the basis of participating in basic medical insurance. The part of enterprise supplementary medical insurance premiums within 4% of total wages shall be listed as < P > from employee welfare funds, and the part with insufficient welfare funds shall be included in the cost after being approved by the municipal finance and taxation departments.

Chapter VII Settlement of Basic Medical Insurance Expenses

Article 28 In accordance with the principle of balance of income and expenditure of basic medical insurance funds, according to the different levels and categories of designated medical institutions, the method of "total amount control" shall be adopted as the main method in the settlement of expenses, supplemented by service units, service items or a combination of various methods. Specific settlement measures shall be formulated by the municipal labor and social security administrative department in conjunction with the municipal finance and health departments.

Article 29 When an employee goes to a designated medical institution for outpatient service, takes medicine or buys medicine at a designated retail pharmacy with an external prescription, the medical expenses paid with a

personal account shall be charged to the Medical Insurance Card, and the medical expenses actually paid by the medical insurance center according to the personal account shall be settled with the designated medical institution or the designated retail pharmacy.

Article 3 The medical expenses incurred by employees in hospitalization in designated medical institutions are paid by individuals and settled by themselves and designated medical institutions

, and those paid by pooling funds are settled by medical insurance centers and designated medical institutions.

Article 31 During the period when employees are on business trip or on leave, the medical expenses of first aid and rescue hospitalization shall be settled with the medical insurance center by the place where they work

.

Article 32 A retired (post) employee who has been resettled in another place or an insured employee who has worked and studied abroad for more than six months must

seek medical treatment at the local designated medical institution he declared. The medical expenses for specific items of hospitalization and outpatient service shall be settled with the medical insurance center according to regulations after being summarized by the Institute < P >.

Chapter VIII Management of Medical Services

Article 33 The basic medical insurance shall be managed by designated medical institutions and retail pharmacies. Medical institutions and retail pharmacies established with the approval of the administrative department of health and drug administration may apply to the administrative department of labor and social security to undertake the medical service business of basic medical insurance. After obtaining the designated qualification through examination, the administrative department of labor security

issues the designated qualification certificate.

Article 34 The medical insurance center shall reasonably determine the designated medical machine

structure and designated retail pharmacies according to the employee's choice intention and the distribution of health resources, and sign agreements with the designated medical institutions and retail pharmacies respectively to clarify their respective responsibilities, rights and obligations, and shall be responsible for supervising and inspecting the implementation of the agreements.

Article 35 Employees may go out for outpatient service or stay in hospital in three or more designated comprehensive medical institutions of different levels selected by them. Chinese medical institutions and specialized medical institutions with

designated qualifications can be used as designated medical institutions for all employees.

employees can buy medicines at designated retail pharmacies in the city with external prescriptions.

Article 36 Designated medical institutions and retail pharmacies should formulate and improve the necessary management systems and provide low

price and excellent quality services. And accept the supervision and inspection of relevant departments.

Chapter IX Management and Supervision of Basic Medical Insurance Fund