The full text is as follows:
Regulations on the supervision and administration of the use of medical insurance funds
Chapter I General Provisions
Article 1 In order to strengthen the supervision and management of the use of medical insurance funds, ensure the safety of funds, promote the effective use of funds and safeguard the legitimate rights and interests of citizens' medical insurance, these Regulations are formulated in accordance with the Social Insurance Law of People's Republic of China (PRC) and other relevant laws.
Article 2 These Regulations shall apply to the use, supervision and management of basic medical insurance (including maternity insurance) funds, medical assistance funds and other medical insurance funds in People's Republic of China (PRC).
Article 3 The use of medical insurance funds shall be centered on people's health, and the level of protection shall be commensurate with the level of economic and social development, and the principles of legality, safety, openness and convenience shall be followed.
Article 4 The supervision and management of the use of medical insurance funds shall combine government supervision, social supervision, industry self-discipline and personal integrity.
Article 5 The people's governments at or above the county level shall strengthen their leadership over the supervision and management of the use of medical insurance funds, establish and improve the supervision and management mechanism and law enforcement system of the use of medical insurance funds, strengthen the capacity building of the supervision and management of the use of medical insurance funds, and provide guarantee for the supervision and management of the use of medical insurance funds.
Article 6 The administrative department of medical security in the State Council shall be in charge of the supervision and administration of the use of the national medical security fund. Other relevant departments in the State Council are responsible for the supervision and management of the use of medical insurance funds within their respective functions and duties.
The administrative department of medical security of the local people's governments at or above the county level shall be responsible for the supervision and management of the use of medical security funds within their respective administrative areas. Other relevant departments of the local people's governments at or above the county level shall be responsible for the supervision and administration of the use of medical insurance funds within their respective functions and duties.
Article 7 The state encourages and supports the news media to carry out public welfare publicity of medical insurance laws, regulations and medical insurance knowledge, and to supervise the use of medical insurance funds by public opinion. Publicity and reports on medical security should be true and fair.
The people's governments at or above the county level and their medical security administrative departments shall solicit opinions in writing, hold symposiums, listen to the opinions of deputies to the National People's Congress, members of the Chinese People's Political Consultative Conference and representatives of insured persons on the use of medical security funds, unblock social supervision channels, and encourage and support all sectors of society to participate in the supervision of the use of medical security funds.
Medical institutions, pharmaceutical business units (hereinafter referred to as pharmaceutical institutions) and other units and medical and health industry associations shall strengthen industry self-discipline, standardize medical service behavior, promote industry norms and self-discipline, and guide the rational use of medical security funds according to law.
Chapter II Utilization of Funds
Article 8 The use of medical insurance funds shall conform to the scope of payment stipulated by the state.
The scope of medical insurance fund payment shall be formulated by the administrative department of medical insurance in the State Council according to law. The people's governments of provinces, autonomous regions and municipalities directly under the Central Government shall, in accordance with the authority and procedures prescribed by the state, supplement the specific items and standards paid by the medical security fund within their respective administrative areas, and report them to the administrative department of medical security of the State Council for the record.
Article 9 The State shall establish and improve a unified national medical security handling management system, provide standardized and standardized medical security handling services, and realize full coverage of provinces, cities, counties, towns (streets) and villages (communities).
Article 10 Medical insurance agencies shall establish and improve business, financial, safety and risk management systems, do a good job in service agreement management, cost monitoring, fund allocation, treatment review and payment, etc., regularly disclose the income and expenditure and balance of medical insurance funds to the public, and accept social supervision.
Article 11 The medical security agency shall establish a collective consultation and consultation mechanism with the designated medical institutions, reasonably determine the budget amount and disbursement time limit of the medical security fund of the designated medical institutions, and sign a service agreement with the designated medical institutions according to the needs of safeguarding public health and managing services, standardize the medical service behavior, and clarify the behaviors and responsibilities of violating the service agreement.
The medical insurance agency shall promptly announce to the public the list of designated medical institutions that have signed service agreements.
The administrative department of medical security shall strengthen supervision over the conclusion and performance of service agreements.
Twelfth medical insurance agencies should be in accordance with the service agreement, timely settlement and disbursement of medical insurance funds.
Designated medical institutions shall provide medical services in accordance with regulations, improve service quality, rationally use medical security funds, and safeguard citizens' health rights and interests.
Article 13 If a designated medical institution violates the service agreement, the medical security agency may urge it to fulfill the service agreement, suspend or refuse to allocate the fees, recover the illegal fees, and suspend the medical services used by the relevant responsible personnel or departments involved in the medical security fund in accordance with the service agreement until the service agreement is terminated; Designated medical institutions and their relevant responsible personnel have the right to make statements and defend themselves.
If the medical security agency violates the service agreement, the designated medical institution has the right to request correction or submit it to the administrative department of medical security for coordination and rectification, and may also apply for administrative reconsideration or bring an administrative lawsuit according to law.
Fourteenth designated medical institutions shall establish an internal management system for the use of medical security funds, and specialized agencies or personnel shall be responsible for the management of the use of medical security funds, and establish and improve the evaluation system.
Designated medical institutions shall organize training on relevant systems and policies of medical security funds, regularly check the use of medical security funds of their own units, and promptly correct the irregular use of medical security funds.
Article 15 Designated medical institutions and their staff shall implement the regulations of real-name registration system Municipality on the administration of medical treatment and drug purchase, verify the medical insurance vouchers of the insured, provide reasonable and necessary medical services according to the diagnosis and treatment norms, and truthfully issue expense receipts and related materials to the insured, and shall not break down hospitalization or hanging bed hospitalization, break down prescriptions, prescribe drugs in excess or repeatedly, and shall not charge repeatedly, exceed the standard fees, break down items, or exchange drugs or medicines in violation of the diagnosis and treatment norms.
Designated medical institutions shall ensure that the expenses paid by the medical security fund meet the prescribed scope of payment; Except in special circumstances such as emergency and rescue, the provision of medical services beyond the scope of medical security fund payment shall be subject to the consent of the insured or their close relatives and guardians.
Article 16 Designated medical institutions shall keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, expense details, medicines and medical consumables in and out of storage records and other materials in accordance with regulations, timely, comprehensively and accurately transmit relevant data on the use of medical insurance funds through the medical insurance information system, report the information required for the supervision and management of the use of medical insurance funds to the administrative department of medical insurance, disclose medical expenses, expense structure and other information to the public, and accept social supervision.
Seventeenth insured medical treatment and drug purchase should hold my medical insurance certificate, and take the initiative to produce for inspection. Insured persons have the right to require designated medical institutions to truthfully issue expense documents and related materials.
Insured personnel should properly keep medical insurance certificates to prevent others from using them. If it is necessary to entrust others to purchase drugs for special reasons, the identity certificates of the principal and the trustee shall be provided.
Insured persons shall enjoy medical security benefits according to regulations and shall not enjoy them repeatedly.
Insured persons have the right to request medical insurance agencies to provide medical insurance consulting services and put forward suggestions for improvement in the use of medical insurance funds.
Eighteenth in the process of using the medical insurance fund, medical insurance and other administrative departments, medical insurance agencies, designated medical institutions and their staff shall not accept bribes or obtain other illegal income.
Nineteenth insured persons shall not take advantage of the opportunity to enjoy medical security benefits to resell drugs, accept cash or physical return or obtain other illegal benefits.
Designated medical institutions shall not provide convenience for the insured to resell drugs, and shall not accept cash or physical return or obtain other illegal benefits by enjoying medical security benefits.
Twentieth medical insurance agencies, designated medical institutions and other units and their staff and insured persons shall not forge, alter, conceal, tamper with or destroy medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials, and shall not fabricate medical services to defraud medical insurance funds.
Twenty-first medical insurance funds are earmarked, and no organization or individual may occupy or misappropriate them.
Chapter III Supervision and Administration
Twenty-second medical insurance, health, Chinese medicine, market supervision and management, finance, auditing, public security and other departments should cooperate with each other, establish communication and coordination mechanisms, case transfer and other mechanisms to do a good job in the supervision and management of the use of medical insurance funds.
The administrative department of medical security shall strengthen the supervision of medical services and medical expenses included in the payment scope of medical security funds, standardize the medical security handling business, and investigate and deal with illegal use of medical security funds according to law.
Twenty-third the State Council medical security administrative department is responsible for the formulation of service agreement management measures, standardize, simplify and optimize the designated application, professional evaluation and negotiation procedures of medical institutions, and formulate and regularly revise the model service agreement.
The administrative department of medical security in the State Council shall listen to the opinions of relevant departments, medical institutions, trade associations, the public and experts when formulating the measures for the administration of service agreements.
Article 24 The administrative department of medical security shall strengthen information exchange and * * * sharing with relevant departments, innovate supervision and management methods, popularize the application of information technology, establish a national unified, efficient, compatible, convenient and safe medical security information system, implement real-time dynamic intelligent monitoring of big data, strengthen the whole process management of * * * shared data, and ensure data security.
Twenty-fifth medical security administrative departments shall, according to the medical security fund risk assessment, reporting complaints clues, medical security data monitoring and other factors, determine the focus of inspection, organize special inspections.
Twenty-sixth medical security administrative departments can conduct joint inspections with health, Chinese medicine, market supervision and management, finance, public security and other departments.
The use of cross-regional medical security funds shall be inspected by the administrative department of medical security designated by the administrative department of medical security at the next higher level.
Twenty-seventh medical security administrative departments in the implementation of supervision and inspection, can take the following measures:
(1) Entering the site for inspection;
(two) ask the relevant personnel;
(three) require the inspected object to provide documents and materials related to the inspection items, and make explanations and explanations;
(4) Collecting relevant information and materials by means of audio recording, audio recording, video recording, photographing or copying;
(5) sealing up materials that may be transferred, concealed or lost;
(six) to hire qualified accounting firms and other third-party institutions and professionals to assist in the inspection;
(seven) other measures stipulated by laws and regulations.
Twenty-eighth medical security administrative departments can entrust organizations that meet the statutory conditions to implement medical security administrative law enforcement.
Twenty-ninth supervision and inspection of the use of medical insurance funds, supervision and inspection personnel shall not be less than two, and shall produce law enforcement certificates.
When the administrative department of medical security conducts supervision and inspection, the inspected object shall cooperate and truthfully provide relevant data and information, and shall not refuse or obstruct the inspection or make false reports or conceal.
Thirtieth designated medical institutions suspected of defrauding medical insurance funds, during the investigation, the administrative department of medical insurance can take measures such as increasing the frequency of supervision and inspection and strengthening cost monitoring. , to prevent the loss from expanding. Designated medical institutions refused to cooperate with the investigation, with the approval of the main person in charge of the administrative department of medical security, the administrative department of medical security may request the medical security agency to suspend the settlement of the medical security fund. After investigation, those who defraud the medical insurance fund fees shall be dealt with in accordance with the provisions of Article 40 of these regulations; If it does not belong to defrauding medical insurance fund expenditure, it shall be settled in accordance with the provisions.
If the insured person is suspected of defrauding the medical insurance fund and refuses to cooperate with the investigation, the administrative department of medical security may request the medical insurance agency to suspend the online settlement of medical expenses. The medical expenses incurred during the suspension of online settlement shall be paid in full by the insured. After investigation, those who defraud the medical insurance fund fees shall be dealt with in accordance with the provisions of Article 41 of these regulations; If it does not belong to defrauding medical insurance fund expenditure, it shall be settled in accordance with the provisions.
Thirty-first medical security administrative departments shall listen to the statements and arguments of the parties before making administrative penalties or administrative decisions on acts in violation of these regulations; When making a decision on administrative punishment or administrative handling, the parties concerned shall be informed of their right to apply for administrative reconsideration or bring an administrative lawsuit according to law.
Article 32 Administrative departments such as medical insurance, medical insurance agencies, accounting firms and other institutions and their staff shall not use the data or related information of the respondents obtained and known in their work for purposes other than the supervision and management of the use of medical insurance funds, and shall not disclose, tamper with, damage or illegally provide personal information and business secrets of the parties to others.
Article 33 The administrative department of medical security in the State Council shall establish a credit management system for designated medical institutions and personnel, conduct supervision and management according to the credit rating, incorporate the results of daily supervision and inspection and administrative punishment into the national credit information sharing platform and other relevant information publicity systems, and impose penalties in accordance with relevant state regulations.
Article 34 The administrative department of medical security shall regularly announce the results of supervision and inspection on the use of medical security funds to the public, increase the exposure of cases of illegal use of medical security funds, and accept social supervision.
Thirty-fifth any organization or individual has the right to report and complain about violations of laws and regulations of medical insurance funds.
The administrative department of medical security shall smooth the channels for reporting and complaining, handle relevant reports and complaints in a timely manner according to law, and keep the information of informants confidential. Informants shall be rewarded in accordance with the relevant provisions of the state for reports that are verified.
Chapter IV Legal Liability
Thirty-sixth medical insurance agencies in any of the following circumstances, the administrative department of medical security shall order it to make corrections, and the directly responsible person in charge and other directly responsible personnel shall be punished according to law:
(1) The business, finance, safety and risk management systems have not been established and improved;
(2) Failing to perform the duties of service agreement management, cost monitoring, fund allocation, treatment review and payment;
(three) the income, expenditure and balance of the medical insurance fund are disclosed to the public from time to time.
Article 37 Where a medical security institution falsifies, alters, conceals, falsifies or destroys medical documents, medical certificates, accounting vouchers, electronic information and other related materials or fictitious medical service items to defraud the medical security fund, the administrative department of medical security shall order it to return, and impose a fine of more than 2 times and less than 5 times the amount defrauded, and punish the directly responsible person in charge and other directly responsible personnel according to law.
Thirty-eighth designated medical institutions in any of the following circumstances, the administrative department of medical security shall be ordered to make corrections, and can interview the relevant person in charge; If losses are caused to the medical insurance fund, it shall be ordered to return it, and a fine of 1 times and 2 times shall be imposed; Refusing to correct or causing serious consequences, the designated medical institutions shall be ordered to suspend the use of medical services involved in the medical security fund for more than 6 months and less than 6+0 years; Violation of other laws and administrative regulations shall be dealt with by the relevant competent departments according to law:
(a) decomposition of hospitalization, hanging bed hospitalization;
(two) excessive diagnosis and treatment, excessive examination, prescription decomposition, excessive prescription, repeated prescription or other unnecessary medical services in violation of the norms of diagnosis and treatment;
(3) Repeated charges, over-standard charges and broken down charges;
(4) Exchanging medicines, medical consumables, diagnosis and treatment items and service facilities;
(five) to provide convenience for the insured, to resell drugs by taking advantage of the opportunity of enjoying medical security benefits, to accept cash or physical return or to obtain other illegal benefits;
(six) medical expenses that are not covered by the medical insurance fund shall be included in the medical insurance fund settlement;
(seven) other illegal acts that cause losses to the medical security fund.
Thirty-ninth designated medical institutions in any of the following circumstances, the administrative department of medical security shall be ordered to make corrections, and can interview the relevant person in charge; Those who refuse to make corrections shall be fined 1 10,000 yuan but not more than 50,000 yuan; Violation of other laws and administrative regulations shall be dealt with by the relevant competent departments according to law:
(a) the internal management system for the use of medical insurance funds has not been established, or there is no specialized agency or personnel responsible for the management of the use of medical insurance funds;
(2) Failing to keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and inspection records, expense details, medicines and medical consumables in and out of storage records and other materials in accordance with regulations;
(3) Failing to transmit data related to the use of medical insurance funds through the medical insurance information system in accordance with regulations;
(four) failing to report to the administrative department of medical security the information needed for the supervision and management of the use of medical security funds in accordance with the regulations;
(five) failing to disclose medical expenses, cost structure and other information to the public in accordance with the regulations;
(6) Providing medical services beyond the payment scope of the medical security fund without the consent of the insured or his close relatives or guardians, except in special circumstances such as emergency and rescue;
(seven) refusing the supervision and inspection of the administrative departments such as medical security or providing false information.
Fortieth designated medical institutions cheat medical insurance fund expenditures by the following ways, and the administrative department of medical security shall order them to return, and impose a fine of 2 to 5 times the amount defrauded; Ordering designated medical institutions to suspend the use of medical services involved in the medical insurance fund for more than 6 months 1 year, until the medical insurance agency terminates the service agreement; Qualified, the relevant competent department shall revoke its qualification according to law:
(1) Inducing or assisting others to seek medical treatment or purchase medicines under false pretenses, providing false certification materials, or colluding with others to forge expense documents;
(2) Forging, altering, concealing, tampering with or destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials;
(3) Fictitious medical service items;
(four) other acts of defrauding the medical security fund.
Designated medical institutions for the purpose of defrauding the medical security fund, the implementation of the provisions of article thirty-eighth of the act, resulting in the loss of medical security fund, in accordance with the provisions of this article.
Forty-first individuals in any of the following circumstances, the administrative department of medical security shall order them to make corrections; Causing losses to the medical security fund, shall be ordered to return; For the insured, the online settlement of medical expenses will be suspended for 3 months to 12 months:
(1) handing over my medical insurance certificate to someone else for use under an assumed name;
(two) repeated enjoyment of medical security benefits;
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