Chapter I General Provisions
Article 1 In order to speed up the establishment of the basic medical insurance system for urban employees and ensure the basic medical care for employees, according to the State Council Customs,
Decision on Establishing the Basic Medical Insurance System for Urban Workers (Guo Fa [1998] No.44), about Jiangsu
Implementation Opinions on the Reform of Medical Insurance System for Urban Employees in Province (Su [1999] No.83) and related laws.
According to the actual situation of this Municipality, formulate laws, regulations and rules.
Article 2 The establishment of the basic medical insurance system for urban workers shall follow the following principles:
(a) the level of basic medical insurance should be adapted to the level of social and economic development in this Municipality;
(two) all employers and their employees in cities and towns should participate in the basic medical insurance and implement territorial management;
(three) the basic medical insurance premium shall be borne by both the employer and the employee;
(four) the basic medical insurance fund combines social pooling with individual accounts;
(5) Equal 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 include all kinds of domestic-funded enterprises, Hong Kong, Macao and Taiwan and foreign-invested enterprises.
Industry (except foreigners and Hong Kong, Macao and Taiwan personnel stationed in Nanjing), government agencies, institutions, social organizations and the people.
Non-enterprise units and their employees must participate in basic medical insurance in accordance with these regulations.
Departments, provincial and foreign units stationed in Nanjing and their employees shall participate in the basic medical insurance of this Municipality in accordance with the principle of territorial management.
Risk. The basic medical insurance for provincial organs and employees in Ningxia implements a unified policy and the units manage it separately.
Cross-regional and mobile railway, electric power, ocean transportation and other enterprises in Nanjing and their employees should stand on each other.
Concentrate on participating in the basic medical insurance in this city.
Owners and employees of urban individual economic organizations, freelancers, township enterprises and their employees participate in the base.
The specific measures for this medical insurance shall be formulated separately.
Chapter III Collection and Payment of Basic Medical Insurance Fees
Article 4 The basic medical insurance premium shall be paid by both the employer and the employees. The employer's total wages are calculated according to the on-the-job wages.
8% of the payment amount; On-the-job employees pay 2% of their salary, and individuals pay the basic medical insurance premium.
The employing unit shall deduct it from the wages of workers on a monthly basis.
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 60% of the average monthly salary of employees in this Municipality in the previous year, 60% shall be taken as the base; exceed
The part exceeding 300% is not used as the base for paying the basic medical insurance premium.
The basic medical insurance premium for laid-off workers of state-owned enterprises entering the re-employment service center (including unit payment and post)
Individual contributions of employees) by the re-employment service center according to the average monthly salary of employees in this city last year 60% plan hair.
Hand it in several times.
Article 6 The basic medical insurance premium shall be paid by the employer to Nanjing Medical Insurance Settlement Management Center (hereinafter referred to as "Medical Insurance Center").
Insurance center) or the local tax authorities to pay.
Seventh basic medical insurance premiums paid by the employer, the administrative organs and institutions according to the original allocation by the financial sector.
Funding channel solutions; Medical institutions owned by the whole people that implement quota or quota management shall be implemented in accordance with relevant state regulations.
ok； Other institutions from business income or operating income from medical funds; Enterprises come from
Employee welfare funds shall be charged.
Article 8 The basic medical insurance premiums owed by bankrupt enterprises shall not be reduced or exempted, which shall be based on the average monthly salary of employees in this Municipality last year.
As the base, according to the prescribed unit contribution rate, the retirees pay the basic medical insurance premium in one lump sum 10 year.
Insurance premium. The required funds shall be paid from the liquidation property (including land use right transfer income) according to law, and the insufficient part is insufficient.
Points, by the competent department of the enterprise to help solve.
The basic medical insurance premium of the merged enterprise shall be paid by the merged enterprise.
Ninth approved by the government authorized departments of poor enterprises, the basic medical insurance premium is calculated according to the total wages of employees of the unit.
6% of the payment is fully included in the overall fund. Workers enjoy the medical insurance benefits paid by the overall fund.
Tenth finance and employers to provide the necessary basic medical insurance start-up funds. Start-up capital is divided into two parts, unified
The fund-raising part is paid by the finance for one month at 5.36% of the average monthly salary of employees in the city last year; individual account
Part of the family fund is included by the employer at the time of employees' initial enrollment, and the inclusion standard is every employee.
200 yuan, retired (post) personnel each 300 yuan.
Chapter IV Coordinating Funds and Individual Accounts
Eleventh basic medical insurance fund consists of two parts: overall fund and individual account.
(a) Fund as a whole:
(1) The remaining part of the basic medical insurance premium paid by the employer after deducting it from the personal account;
(two) according to the provisions of the late fees charged;
(3) interest;
(4) financial subsidies;
(5) Other income.
(2) Personal account:
(1) basic medical insurance premium paid by individual employees;
(two) the part included in the basic medical insurance premium paid by the employer;
(3) interest;
(4) Other income.
Twelfth the basic medical insurance premium paid by the employer shall be credited to the personal account according to the following proportions:
35 years old and below, according to 1% of my contribution fund;
35 years old to 45 years old, according to 65438+ 0.4% of my payment base;
45 years old to retirement, according to 65438+ 0.7% of my insured base;
Retired (post) personnel are included in 5.4% of their average monthly pension in the previous year.
Thirteenth overall funds and individual accounts shall be managed and accounted for separately according to their respective payment scope, and shall not occupy each other.
Zhan.
Article 14 The pooling fund shall establish a minimum payment standard and a maximum payment limit.
Qifubiaozhun is determined according to the level of medical institutions, tentatively as: tertiary medical institutions 1200 yuan, 2.
800 yuan, a first-class medical institution, and 500 yuan, a first-class medical institution (including one below). Self-worker
However, if the patient is hospitalized for many times during the year, the Qifubiaozhun shall be reduced by 30%, but the minimum shall not be lower than that of 300 yuan. Outpatient service
The minimum payment standard for a specific project in a natural year is 1000 yuan.
In the natural year, the maximum payment limit of medical expenses paid by the overall fund in one lump sum or cumulatively is the previous year of this Municipality.
Four times the average social wage of workers.
Fifteenth overall fund is mainly used to meet the requirements of the basic medical insurance for inpatient and outpatient specific project costs.
Outpatient specific items are temporarily included in radiotherapy and chemotherapy for malignant tumors, uremia dialysis and anti-rejection treatment after kidney transplantation.
Treatment of three diseases (outpatient specific project management measures shall be formulated separately).
Sixteenth personal accounts are mainly used for conditional basic medical insurance outpatient expenses, drug purchase expenses of designated retail pharmacies and
When the personal account is insufficient, the individual shall bear the part of the expenses borne by the employees for specific items of hospitalization and outpatient service.
Pay.
Seventeenth personal accounts of the principal and interest owned by individuals, can be carried forward, transferred and inherited (personal account management
Measures shall be formulated separately).
Eighteenth basic medical insurance fund bank interest method: the part raised in the current year, according to the deposit interest rate.
Interest; 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; Social deposit
The deposit funds in the special financial account will be calculated according to the bank deposit interest rate of 3-year lump-sum deposit and withdrawal. Interest consolidation
Incorporate into the basic medical insurance fund.
Chapter V Basic Medical Insurance Benefits
Nineteenth staff hospitalization, outpatient specific items in line with the provisions of the basic medical insurance for medical expenses, overall payment.
The minimum payment standard and below shall be paid by the employee from his personal account or by himself; Above qifubiaozhun, the highest payment limit
Below the payment limit, according to the principle of "subsection calculation and cumulative payment", the funds and individuals shall use * * *.
Share it. The specific proportion is as follows:
Proportion of overall fund and individual sharing of hospitalization medical expenses
Primary medical machines, secondary medical machines and tertiary medical machines.
Master Plan Individual Master Plan Individual Master Plan Individual
The minimum payment standard is 10000 yuan 90%10% 88%12% 86%14%.
1000 1 yuan to 20000 yuan 92% 8% 90%10% 88%12%.
Above 2000 1 yuan 96%4%94%6%92%8%
The proportion of individual sharing of medical expenses for specific outpatient items is based on the standards of selected medical institutions at different levels.
All right.
The proportion of individuals who retire and resign is 70% and 80% of employees respectively. People's Republic of China (PRC) participated in revolutionary work before the founding of the People's Republic of China.
The individual sharing ratio of retired old workers is 50% of on-the-job workers.
Twentieth staff hospitalization expenses, which belong to the basic medical insurance payment, shall be borne by individuals first.
Pay 20% and the rest according to the relevant provisions of the basic medical insurance.
The medical expenses incurred by employees using "Class A" drugs are part of the basic medical insurance payment.
Use, the individual pays 20% first, and the rest is paid according to the relevant provisions of basic medical insurance.
Medical expenses incurred by employees using Class A drugs shall be paid according to the provisions of basic medical insurance. manufacture
The medical expenses incurred in the use of "Category B drugs" shall be paid by the employees according to a certain proportion, and the rest shall be paid by themselves.
Pay according to the provisions of the basic medical insurance (the specific proportion of individual pays shall be formulated separately).
Twenty-first employers and employees interrupt or fail to pay in full, and the medical insurance center will transfer them to individual accounts from the next month.
Fund, and suspend employees to enjoy the basic medical insurance benefits, payment period is not calculated. servant
Units and employees shall make up the arrears and late fees within three months, and the medical expenses incurred during the arrears shall be handled according to the regulations.
Fixed payment. If the payment is in arrears for more than three months, the employer and the employee can recover after repayment according to regulations.
Employee benefits meet the requirements, personal accounts are supplemented, and the payment period is calculated continuously, but it occurs during the arrears period.
Medical expenses pooling fund will not be paid.
Twenty-second employers have retired (post) personnel before the insurance does not pay the basic medical insurance premium. Retire after insurance
The number of years for paying the basic medical insurance premium during the on-the-job period (hereinafter referred to as the payment period) must be:
Men reach the age of 30 and women reach the age of 25. If the number of years is not enough, it shall be proposed by the employer or the employee when going through the retirement formalities.
The average monthly salary of employees in the city over the year of individuals is the base, and the difference is made up according to the total rate of units and individuals.
The annual basic medical insurance premium can enjoy the basic medical insurance benefits for retirees. Employee insurance precedent
The length of service or working years that meet the requirements of the state can be regarded as the payment period.
Twenty-third before the employer insured, employees due to illness, non-work-related disability completely lost the ability to work, according to state regulations.
Decided to retire early (Guo Fa [1978] 104 stipulates early retirement for special jobs)
Except for employees), the employer will pay 8% of the average monthly salary of this city in the previous year as a one-time payment.
After paying the basic medical insurance premium to the statutory retirement age, you can enjoy the basic medical care for retired (post) personnel.
Medical insurance benefits.
Twenty-fourth medical expenses incurred in the following circumstances shall not be paid:
(1) Work-related injuries (including occupational diseases), childbirth and its complications;
(two) violation of law and discipline caused harm;
(3) Traffic accidents;
(4) Suicide and self-mutilation (except mental patients);
(five) during the period of going abroad or leaving the country;
(6) Medical accidents;
(7) Others do not meet the payment scope of basic medical insurance.
Chapter VI Medical Assistance for Serious Illness and Supplementary Medical Insurance
Twenty-fifth employees who participate in the basic medical insurance for urban workers in this Municipality shall participate in medical assistance and medical treatment for serious illness.
In principle, the medical assistance fund shall be paid by employees (including retired and resigned personnel) according to the standard of 5 yuan per person per month.
Na, mainly used to solve the problem that the maximum payment limit of the basic medical insurance pooling fund is more than 6.5438+0.5 million yuan.
Medical expenses (medical assistance measures for serious illness shall be formulated separately).
Twenty-sixth qualified employers can establish supplementary medical insurance for enterprises on the basis of participating in basic medical insurance.
Risk. The part of enterprise supplementary medical insurance premiums within 4% of total wages shall be paid from employee welfare funds.
The insufficient support and welfare expenses shall be included in the cost after being approved by the municipal finance and taxation department.
Chapter VII Settlement of Basic Medical Insurance Expenses
Twenty-eighth in accordance with the basic medical insurance fund balance principle, according to the different levels and types of designated medical institutions.
Don't, in the expense settlement, "total control" is the main method, supplemented by service units, service items or various methods.
Combination of evaluation methods. Specific settlement measures by the municipal labor security administrative department in conjunction with the municipal finance and health.
Formulated by the health department.
Twenty-ninth workers in the designated medical institutions outpatient, take medicine or prescription in the designated retail pharmacies to buy medicine, use once.
Medical expenses paid by personal accounts are accounted by medical insurance cards, and the medical insurance center actually pays them according to personal accounts.
Students' medical expenses shall be settled with designated medical institutions or retail pharmacies.
Thirtieth medical expenses incurred by employees in designated medical institutions, which are paid by individuals, shall be borne jointly by themselves and designated medical institutions.
Institutional settlement, which belongs to the overall fund payment, shall be settled by the medical insurance center and the designated medical institutions.
Thirty-first employees go out on business or leave, the first aid, rescue hospitalization medical expenses, by the single.
Settle with the medical insurance center according to the regulations.
Thirty-second retired (post) personnel resettled in different places or insured employees who have worked and studied abroad for more than six months must
Seek medical treatment in the local designated medical institutions declared by them. The specific project of hospitalization and outpatient medical expenses, by
After the unit is summarized, it shall be settled with the medical insurance center according to the regulations.
Chapter VIII Management of Medical Services
Thirty-third basic medical insurance is managed by designated medical institutions and designated retail pharmacies. Under the supervision of the health and drug administration
Medical institutions and retail pharmacies approved by the administrative department may apply to the administrative department of labor security for acceptance.
Do a good job in basic medical insurance medical services. After obtaining the designated qualification through examination, the administrative department of labor security
Issue fixed-point qualification certificates.
Article 34 The medical insurance center shall reasonably determine the designated medical institutions according to the workers' willingness to choose and the distribution of health resources.
Structure and retail pharmacies, and signed agreements with designated medical institutions and retail pharmacies, clear
Their respective responsibilities, rights and obligations, and be responsible for supervising and inspecting the implementation of the agreement.
Thirty-fifth workers can be in their own choice of three or more different levels of fixed-point comprehensive medical institutions for outpatient or inpatient treatment. acquire
Chinese medical institutions and specialized medical institutions with designated qualifications can be used as designated medical machines for all employees.
Structure.
Employees can buy drugs at designated retail pharmacies in the city with external prescriptions.
Thirty-sixth designated medical institutions and retail pharmacies should formulate and improve the necessary management system to provide low prices.
Cheap and good service. And accept the supervision and inspection of relevant departments.
Chapter IX Management and Supervision of the Basic Medical Insurance Fund
Thirty-seventh basic medical insurance funds shall be managed by special financial accounts, which shall be used for special purposes, and no unit or individual may misappropriate them.
Misappropriation. The basic medical insurance fund and its interest are exempt from taxes and fees.
The business funds of the medical insurance center shall be solved by the financial budget, and shall not be extracted and charged from the medical insurance fund.
Branches.
Article 38 The administrative department of labor security and the financial department shall strengthen the management and supervision of the basic medical insurance fund. examination
The accounting department shall regularly audit the income and expenditure and management of the fund.
Article 39 A representative meeting composed of representatives from relevant government departments, employers, medical institutions, trade unions and relevant organizations shall be established.
Experts to participate in the basic medical insurance fund supervision committee, strengthen the supervision of social basic medical insurance fund.
Supervision.
Chapter X Medical Treatment of Relevant Personnel
Forty-first retired personnel, the old Red Army medical treatment unchanged, medical expenses according to the original funding channels to solve, payment is indeed.
Difficult, by the people's government at the same level to help solve. (Specific management measures shall be formulated separately)
Forty-second second-class B or above (including second-class B) disabled revolutionary servicemen's medical treatment remains unchanged, and medical expenses remain at the original level.
Funding channels to solve, medical expenses are insufficient, by the people's government at the same level to help solve. (specific
Management measures shall be formulated separately)
Forty-third workers to support their immediate family members of medical expenses, still according to the original method, the funds from the original channels to solve.
Forty-fourth now enjoy medical expenses of college students at public expense, still according to the original method, capital.
Gold is solved from the original channel.
Article 45 The medical expenses incurred by the unemployed during the period of receiving unemployment insurance benefits shall be implemented according to document Su (1999) 107.
Implementation of the regulations.
Chapter XI Reward and Punishment
Forty-sixth excellent service, perfect management, remarkable achievements in controlling medical expenses, and employee satisfaction.
Structure, designated retail pharmacies and their staff to give appropriate recognition or reward.
Article 47 If an employer fails to go through the formalities of social insurance registration, change or cancellation of registration in accordance with the provisions, it shall not go through the formalities in accordance with the provisions.
Declaration of the basic medical insurance payment base, by the municipal administrative department of labor security on the basis of "social insurance"
The Interim Regulations on the Collection and Payment of Fees shall be punished.
Forty-eighth employees have one of the following acts, resulting in the loss of the basic medical insurance fund, the medical insurance center to recover.
Medical expenses in violation of regulations, and the administrative department of labor and social security shall impose a fine of more than 1000 yuan on the person directly responsible.
A fine of less than 5,000 yuan, which constitutes a crime, shall be investigated for criminal responsibility according to law:
1. Lend the medical insurance card to non-employees;
2. Forging or altering prescriptions, expense documents and other vouchers;
3, false, impersonator medical expenses;
4, other acts in violation of the provisions of the basic medical insurance management.
Forty-ninth designated medical institutions and their staff have one of the following acts, and the medical insurance center will recover the money that violates the regulations.
Medical expenses, and the administrative department of labor security shall impose a fine of 5000 yuan to 20000 yuan on the designated medical institutions.
The person directly responsible shall be fined 1000 yuan to 5,000 yuan; A serious situation
, cancel its fixed-point qualification; If the case constitutes a crime, criminal responsibility shall be investigated according to law:
1, diagnosis and treatment, accounting did not carefully check the "medical insurance card", the medical expenses of non-insured objects and
The expenses of non-basic medical insurance items are included in the payment scope of basic medical insurance;
2, do not implement the provisions of medical service charges and drug prices, without raising the fees;
3, patients in hospital or decomposition of hospitalization times;
4, other acts in violation of the provisions of the basic medical insurance management.
Fiftieth designated retail pharmacies and their staff have one of the following acts, the medical insurance center will recover the illegal payment.
Medical expenses, and the administrative department of labor security shall impose a fine of 5000 yuan to 20000 yuan on the designated retail pharmacies.
The following fines; Impose a fine of more than 5000 yuan 1000 yuan on the person directly responsible; The situation is grim.
, cancel its fixed-point qualification; If the case constitutes a crime, criminal responsibility shall be investigated according to law:
1, not taken strictly according to the prescribed dosage;
2. Confuse the pricing of self-funded drugs and drugs reimbursed by basic medical insurance;
3. Prescription drugs are health care products and daily necessities. For patients;
4, do not implement the relevant provisions of the drug price, resulting in the loss of the basic medical insurance fund;
5. Providing counterfeit drugs or expired drugs to patients;
6, other acts in violation of the provisions of the basic medical insurance management.
Fifty-first the relevant administrative departments of the government, medical insurance centers and their staff have one of the following acts, which shall be handled by the relevant departments.
Depending on the seriousness of the case, the door shall be investigated for administrative responsibility or criminal responsibility:
1, violating the regulations on the management of basic medical insurance funds, resulting in fund losses;
2, corruption, misappropriation of basic medical insurance fund;
3, other acts in violation of the provisions of the basic medical insurance management.
Article 52 If a party refuses to accept the punishment decision, he may apply to the next higher authority within 60 days from the date of receiving the punishment decision.
The administrative department or the people's government at the same level shall apply for administrative reconsideration. Refuses to accept the decision of administrative reconsideration, can be accepted.
Bring an administrative lawsuit to the people's court within 15 days from the date of administrative reconsideration decision; Failing to apply for a reply within the time limit
Discussion, neither bring a lawsuit nor issue a decision on punishment, the administrative organ that made the decision on punishment may apply to the applicant.
The people's court enforces it.
Chapter XII Supplementary Provisions
Article 53 Class A infectious diseases are caused by irresistible factors such as large-scale outbreaks, epidemic infectious diseases or natural disasters.
The medical expenses incurred in the treatment of acute, dangerous and serious patients shall be solved by the people's government at the same level.
Fifty-fourth insured units, employees, designated medical institutions, designated retail pharmacies and medical insurance centers.
Medical insurance disputes shall be settled by the people's government of the municipality directly under the central government where both parties to the dispute are located; If negotiation fails, labor security can be submitted.
Administrative department ruling.
The proportion of payment, the proportion of individual accounts, the threshold of pooling funds, the maximum payment limit and
If the proportion of individual contributions needs to be adjusted, it shall be proposed by the administrative department of labor security and reported to the Municipal People's government for approval.
Announced by the society.
Article 56 The administrative department of labor security shall be responsible for organizing the implementation of medical insurance for urban workers in this Municipality. Finance, health
Departments of health, price, auditing, taxation, drug supervision and administration shall cooperate with labor according to their respective responsibilities.
The administrative department of social security shall do a good job in the formulation of relevant supporting documents and other medical insurance-related work.
Fifty-seventh the implementation of city and county levels of overall management. Provisions, combined with local conditions to develop implementation measures, the Municipal People's government for approval before implementation.
Fifty-eighth these Provisions shall be interpreted by the municipal labor security administrative department.
Article 59 These Provisions shall come into force as of the date of promulgation.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.