Article 1 These Measures are formulated in accordance with the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44) and the Overall Plan for Establishing the Basic Medical Insurance System for Urban Employees in Jiangxi Province (Gan Fu Fa [1999] No.27), and in order to actively and steadily promote the reform of the medical insurance system for urban employees in our city, combined with the actual situation of our city.

Article 2 The main task of medical insurance system reform is to establish a basic medical insurance system for urban workers, that is, to establish a social medical security system that meets the needs of the city's finance, enterprises and individuals and guarantees the basic medical needs of employees.

Third, establish the basic medical insurance system for urban workers in our city, and adhere to the level of basic medical insurance to adapt to the development level of productive forces in our city; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The basic medical insurance premium shall be borne by both employers and employees, and the basic medical insurance fund shall be based on the principle of combining social pooling with individual accounts.

Article 4 All employers in cities and towns in this Municipality include enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises). ), organs, institutions, social organizations, private non-enterprise units and their employees should participate in the basic medical insurance. Township enterprises and their employees, owners of urban individual economic organizations and their employees will not be included in the basic medical insurance for the time being, and will be included one by one when conditions are ripe.

Article 5 The basic medical insurance shall be co-ordinated by the whole city, with reference to these measures. At present, the city level and county (city) are the overall planning units, and zhanggong district is not the overall planning unit, so it is included in the overall planning of the city level. City level, counties (cities) in accordance with these measures to develop implementation details and related management measures. When the conditions are ripe, it will gradually transition to the city's overall planning.

Chapter II Raising of Basic Medical Insurance Fund

Article 6 The basic medical insurance premium shall be collected from the employing units and individual employees in the following ways.

(a) the employer shall pay 6% of the total monthly salary of its employees, and the individual employees shall pay 2% of their monthly salary, and retirees shall not pay the basic medical insurance premium. In the future, with the economic development and the operation of the medical insurance fund, with the approval of the provincial government, the proportion of units and individuals can be adjusted appropriately.

(two) the average monthly salary of employees is higher than the average monthly salary of employees in the city or county (city), and all units and individuals shall pay the basic medical insurance premium based on the average monthly salary of employees in the city or county (city); If the average monthly salary of employees is lower than 60% of the average monthly salary of employees in the city or county (city), all units and individuals shall pay the basic medical insurance premium according to 60% of the average monthly salary of employees in the city or county (city).

(three) the laid-off workers of state-owned enterprises who have entered the re-employment service center of the employing unit to receive the basic living expenses shall pay 60% of the average monthly salary of the society in the city and county (city) where they are located, and the contributions of units and individuals shall be paid by the center. Laid-off workers enjoy the same basic medical treatment as workers.

(four) private entrepreneurs and their employees to their respective cities and counties (cities) last year, the average monthly salary of employees as the base, according to the provisions of the payment of basic medical insurance.

After the termination of the labor contract, employees who are not re-employed shall continue to participate in the basic medical insurance, with the average monthly salary of employees in this city and county (city) as the base of payment, and all the basic medical insurance premiums shall be paid by individuals.

The basic medical insurance premium for long vacation, secondment, suspension and unpaid leave shall be collected and remitted by the unit that retains its personnel relationship.

When employees are transferred, the transferred-in and transferred-out units shall go to the medical insurance agency to verify the payment base and payment amount in the month after the personnel changes.

(5) The collection of the basic medical insurance premium can be withheld by the entrusted bank (visa-free agreement) or paid in cash, which is not limited by the starting point of the amount.

Seventh in order to ensure the normal operation of the basic medical insurance fund, employers and employees should pay the basic medical insurance premium one month in advance.

Article 8 The employer shall pay the fees through the following channels.

The administrative organ shall be arranged by the finance at the same level, the institutions with financial supply shall be arranged by the finance at the same level depending on the financial subsidies and business income, other institutions shall be charged in the medical fund extracted from business income or business income, and enterprises shall be charged in the employee welfare funds.

Article 9 When the employing unit is divided, merged or terminated, it must first pay off the unpaid basic medical insurance premium, and go through the formalities of change registration or cancellation of registration with the medical insurance agency within 10 days from the date of approval; After the change, the lessee, the contractor, the merging party or the operator of the receiving party shall bear all the basic medical insurance responsibilities of the original unit and its employees. When the bankrupt enterprise liquidates its property, it shall pay off the basic medical insurance premium owed in the first order and pay the employee basic medical insurance premium 1 year.

Tenth employers and employees must pay the basic medical insurance premium in full every month. The basic medical insurance premiums payable by individual employees shall be withheld and remitted from their wages by their units. Fails to pay within the time limit, suspend the medical insurance benefits paid by its employees and retirees from the overall fund, and be punished in accordance with the relevant provisions of the Provisional Regulations on the Collection and Payment of Social Insurance Fees. It will be restored after payment. The medical expenses that should be paid by the overall fund during the suspension period will not be paid.

Chapter III Establishment and Use of Individual Medical Insurance Accounts

Eleventh medical insurance agencies should establish lifelong personal medical insurance accounts for employees who participate in basic medical insurance.

The individual medical insurance account consists of the part paid by the individual and the part credited according to the following provisions.

Employees under 35 years old (including 35 years old) pay 0.8% of their monthly salary; For employees aged 35 to 45 (including 45), the monthly salary is1%; For employees over 45 years old, 65438+ 0.2% of monthly salary. Retirees are paid at 3.4% of the monthly basic pension of the previous year.

Article 12 The principal and interest of an individual medical insurance account are owned by the individual employee and can be carried forward for use and inheritance.

Article 13 The personal medical insurance account is mainly used to pay the outpatient medical expenses of employees themselves, the hospitalization medical expenses below the deductible line and the medical expenses that should be borne by individuals within the scope of the overall fund payment.

Chapter IV Establishment and Use of Medical Pooling Fund

Article 14 The basic medical insurance premium paid by the employer for employees, after deducting the remaining part credited to the individual medical insurance account, will be incorporated into the medical pooling fund, and the medical insurance agency will centrally adjust and use it according to the principle of fixed income and fixed expenditure and balance of payments.

The scope of medical expenses paid by the overall fund shall conform to the spirit of relevant national and provincial documents.

Article 15 Qifubiaozhun for medical expenses paid by employee medical pooling fund is: the first hospitalization this year is10% of the average annual salary of employees in the city or county (city) where the previous year is located; The second hospitalization was 8%; The third and above hospitalizations were all 6%. The maximum payment limit is 4 times of the average annual salary of employees in the city and county (city) where it is located. Medical expenses below Qifubiaozhun shall be paid by individual medical accounts or individuals themselves, and medical expenses above the maximum payment limit shall be solved by mutual medical insurance for urban workers (specific measures shall be formulated separately).

Medical expenses above Qifubiaozhun but below the maximum payment limit are mainly paid by the overall fund, and individuals bear a certain proportion: above Qifubiaozhun to 8,000 yuan, 20% for employees and 0/8% for retirees/kloc-; 80,065,438+0-65,438+03,000 yuan, 65,438+08% for employees and 65,438+06% for retirees; 13001-17000 yuan, personal burden of employees 16%, personal burden of retirees14%; 1700 1 yuan to the maximum payment limit, personal burden of employees 14%, personal burden of retirees 12%. In the future, with the increase of the average wage of employees and the operation of the medical pooling fund, the amounts of the four payment sections will be adjusted accordingly.

For the medical expenses approved to be transferred to hospitals outside the overall planning area or on business trips, the personal burden ratio will rise by 20 percentage points on the basis of the second paragraph of this article.

Sixteenth a hospitalization refers to the whole process of admission and discharge procedures for patients. Emergency rescue and hospitalization are uninterrupted, which is regarded as a hospitalization. If the transfer is approved and the transfer process is within 5 days, two hospitalizations can be regarded as one hospitalization. A hospitalization or emergency rescue process across the year, according to the end of the diagnosis and treatment time to determine the settlement year.

Seventeenth workers in hospital, emergency rescue during the special inspection, special treatment, individuals to bear 20%, the remaining 80% according to the provisions of article fifteenth. When the drugs used by employees during hospitalization and emergency rescue belong to "Drug List" and "Category B List", the individual shall bear 10% first, and the remaining 90% shall be implemented according to the provisions of Article 15. In the future, new national and provincial regulations will be implemented according to the new regulations.

Eighteenth medical insurance personnel due to illegal crimes, alcoholism, fighting, suicide and self-mutilation, traffic accidents and medical accidents, medical expenses, the overall fund will not pay.

Nineteenth retirees in different places, the implementation of medical expenses quota management. After the personal account funds are allocated to me, the hospitalization expenses paid by the overall fund shall be subject to the per capita hospitalization expenses of retirees in the original retirement city and county (city) last year.

Standard, the implementation of quota management of the annual audit report, I when the annual quota of medical expenses balance of 50% reward to individuals, overruns will not be reimbursed.

Chapter V Management and Supervision of the Basic Medical Insurance Fund

Twentieth basic medical insurance funds by the city and county (city) medical insurance agencies to raise, manage and use.

Twenty-first basic medical insurance funds into the financial accounts of social insurance funds at the same level, the implementation of two lines of revenue and expenditure management, earmarking, no unit or individual may misappropriate. The business expenses of the medical insurance agency shall not be drawn from the fund and shall be solved by the financial budget at the same level.

The medical insurance fund and its interest are exempt from taxes and fees.

Twenty-second basic medical insurance fund bank interest method: the part raised in the current year, according to the 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; The deposited funds deposited in the social security financial account shall bear interest at the three-year savings deposit rate.

Twenty-third medical insurance agencies should establish and improve the budget and final accounts system, financial accounting system and internal audit system.

Twenty-fourth labor and finance departments shall supervise and manage the basic medical insurance fund, and the audit department shall regularly audit the fund income and expenditure and management of the medical insurance agency. The fund medical insurance supervision committee shall supervise and inspect the management of the basic medical insurance fund.

Twenty-fifth employees who participate in medical insurance have the right to supervise the implementation of the basic medical insurance policy and fund management. Complaints and reports made by employees to relevant units and personnel are protected by law.

Twenty-sixth the employer shall regularly announce the payment of basic medical insurance premiums to employees. Laborers have the right to inquire about their total wages and personal account income and expenditure from employers and basic medical insurance agencies. Authorized by the labor administrative department at the same level, the medical insurance agency shall review the relevant accounts, statements, wages, pension payment and employee roster, insured persons and payment base.

Chapter VI Management of Medical Services

Twenty-sixth basic medical insurance shall be managed by computer network. Use a unified IC card, medical insurance and medical records.

Twenty-eighth medical insurance agencies are responsible for determining the designated medical institutions and pharmacies, and according to the spirit of relevant national and provincial documents, signed an agreement with the designated medical institutions and pharmacies, clarifying the responsibilities, rights and obligations of both parties.

Article 29 With the approval of the medical insurance agency, the employing unit and its employees can choose 2 13 designated medical institutions to seek medical treatment and purchase medicines with IC cards, medical insurance and medical records, or they can buy medicines at designated pharmacies with prescriptions.

Thirtieth designated medical institutions and pharmacies should set up computer terminals according to the requirements of computer network construction of basic medical insurance, and the operators should be trained by medical insurance agencies and hold certificates.

Thirty-first workers who need to be transferred to hospitals should be approved by designated medical institutions, and can be transferred to specialized hospitals in this city gradually, but effective measures should be taken to strictly control the transfer.

Article 32 A medical supervision system shall be established. Medical insurance agencies should regularly supervise and inspect designated medical institutions and pharmacies.

Chapter VII Settlement of Medical Expenses

Article 33 The medical expenses incurred by employees using personal medical insurance accounts in designated medical institutions or pharmacies and the medical expenses paid by medical insurance agencies to patients with serious and serious diseases discharged from the hospital in the disease catalogue in the current month belong to the medical expenses paid by the overall fund, and the medical insurance agencies are responsible for reviewing relevant materials and settling accounts with designated medical institutions and pharmacies once a month.

Article 34 Medical insurance agencies shall formulate quota standards with reference to the average hospitalization days of employees, average hospitalization expenses and hospitalization times in the previous year, and the number of employees and retirees in insured units, and report them to the medical reform leading group for approval, and implement total medical expenses control and quota management for designated medical institutions.

Chapter VIII Management Organization and Responsibilities

Thirty-fifth city leading group for the reform of the basic medical insurance system for urban workers is responsible for studying and formulating the overall planning and relevant policies and regulations for the reform of the medical insurance system in our city.

The office of the leading group for the reform of the basic medical insurance system for urban workers is located in the Municipal Labor Bureau, responsible for the implementation, supervision and inspection of the city's medical insurance system, and all relevant units implement medical insurance policies and regulations to solve related problems in the implementation process.

A medical insurance supervision committee led by the administrative department of labor and social security and attended by the departments of economic restructuring, finance, auditing, price, health, medicine, people's bank and trade unions shall be established. The medical insurance agency shall supervise and inspect the income and expenditure, operation, management and service of the basic medical insurance fund, and publicize it to the public regularly.

Counties (cities) set up corresponding coordination and management institutions to clarify their responsibilities.

Chapter IX Supplementary Provisions

Thirty-sixth workers due to work-related injuries and maternity medical expenses, according to the relevant provisions of work-related injuries and maternity insurance. Those who did not participate in work-related injury and maternity insurance were solved according to the original funding channels.

Thirty-seventh the implementation of these measures at the same time, the insured units and employees will no longer implement the original free medical care and labor insurance medical care. Before the implementation of these measures, the medical expenses of employees and retirees (combined medical care) are still solved according to the original channels.

Thirty-eighth retired personnel, the old Red Army medical treatment unchanged, medical expenses according to the original financing channels to solve, payment is indeed difficult, by the people's government at the same level to help solve. The medical treatment of disabled revolutionary servicemen above Grade B remains unchanged, and the medical expenses are solved according to the original funding channels. The insufficient payment of medical expenses shall be solved by the local people's government, but management shall be strengthened to prevent waste (specific management measures shall be formulated separately).

Thirty-ninth national civil servants on the basis of participating in the basic medical insurance, enjoy the Medicaid policy, according to the relevant provisions of the provincial people's government.

Specific industries (units) with high medical consumption level can establish enterprise supplementary medical insurance for employees on the basis of participating in basic medical insurance. The part of enterprise supplementary medical insurance premium within 4% of total wages is paid from employee welfare funds, and the part with insufficient welfare funds is included in the cost after being approved by the financial department at the same level.

Fortieth employees' families, ordinary middle schools and college students will not be included in the basic medical insurance for the time being, and their medical expenses will be properly solved according to the original method.

Forty-first low-income, family life difficulties, because of the high medical expenses affect the basic family life, the unit where the employee works shall give subsidies from welfare funds.

Forty-second medical expenses incurred in the treatment of large-scale critically ill patients caused by irresistible factors such as sudden epidemic diseases and natural disasters shall be comprehensively coordinated by the local government.

Forty-third approach by the municipal administrative department of labor security is responsible for the interpretation of.

Article 44 These Measures shall be implemented as of the date of promulgation. If other provisions are inconsistent with these Measures, these Measures shall prevail.