Medical insurance is different in different regions, but the pages are not too different. It depends on the specific local laws and regulations, which can refer to the following
(Decree No.92 issued by Shanghai People's Government on October 2th, 2) BR/> Article 1 (Purpose and Basis)
In order to ensure the basic medical needs of employees, according to "Shanghai implements the State Council's basic medical insurance system, and urban employees are of >: The first chapter of the implementation plan, "formulation. Article
(Scope of Application)
This method is applicable to enterprises, institutions, organizations and private non-essential social enterprises (hereinafter referred to as employers) and their employees' medical insurance and related management activities within the urban area of this Municipality.
The term employee includes on-the-job employees, retirees and other insurances. Article
(Management)
medical insurance bureau (hereinafter referred to as medical insurance) is the city's basic medical insurance, and the city is the administrative department responsible for unified management. District and county medical insurance offices (hereinafter referred to as district and county medical insurance offices) are responsible for the management of basic medical insurance within their jurisdiction.
Municipal health, labor and social security, finance, auditing, drug supervision, civil affairs and other departments shall, according to their respective responsibilities, work together to manage basic medical insurance.
the social insurance agency in the assembly city responsible for medical insurance.
Shanghai Medical Insurance Service Management Center (hereinafter referred to as the Medical Center) is responsible for the settlement of medical expenses by medical insurance agencies in this Municipality, and the management of individual accounts for subsidizing basic medical insurance (hereinafter referred to as individual medical accounts).
Chapter II Registration and Payment
Article (Registration)
According to the regulations of the Municipal Medical Insurance Bureau, the employer has designated the social insurance agency to handle the basic medical insurance registration; The newly established employers shall register the basic medical insurance handle within 3 days.
if the employer terminates or changes the registration of basic medical insurance events according to law, it must cancel or change the registration of the original registration authority within 3 days according to relevant circumstances.
in the two paragraphs of this section, the pre-processing procedures of the social insurance agency shall be carried out according to the requirements of the audit municipal medical insurance bureau, and the employer shall timely notify the municipal medical insurance of the change of registration or cancellation of registration.
article (calculation method of employee contribution base and contribution rate)
my average monthly salary last year was the basic salary of employees. Last year, my average monthly salary in the past year was 3% of the average monthly salary of employees in the city, and the excess was not included in the payment base; Lower than the previous year, in more than one year as the base of payment, the average monthly salary of employees in the city is 6%, and the service is 6%.
individual service workers should pay the basic medical insurance premium at the rate of 2% of the payment base. Retired individuals do not pay the basic medical insurance premium.
article (employer's contribution base used for calculating and paying proportion)
employer's contribution base unit and basic salary of employees.
the employer shall pay 1% of the basic medical insurance premium in proportion to the base, and 2% of the local supplementary medical insurance premium according to its own base salary.
article 7 (channels for collecting medical insurance premiums) medical insurance premiums.
article 8 (collection management)
the calculation of the payment by employers and employees, the number of payment procedures and the collection of dispute settlement shall be carried out in accordance with the relevant provisions on the collection and management of social insurance premiums.
chapter iii individual medical accounts, pooling funds and additional funds
article 9 (basic medical insurance fund)
consists of pooling funds and basic medical insurance funds of individual medical accounts.
except for article 11.2, the third paragraph of the basic medical insurance paid by the employer is included in the personal medical account, and the rest is included in the overall fund.
article 1 (establishment of individual health account) employees shall be established in the municipal medical center and individual medical account.
11 (included in the personal medical account)
The paid service personnel are included in all my personal health accounts of the basic medical insurance.
The basic medical insurance premium paid by the employer is included in the personal medical account according to the following proportion of the employees:
(1) 34, .5 years old and under in the city according to the average salary of employees;
(2) 35 to 44 years old, according to 1% of the average wage of workers in the city in the previous year;
(3) Retirement at the age of 45, according to the previous year, the salary is 1.5% of the average urban worker.
Employers pay basic medical insurance premiums, and the proportion of retirees included in individual medical accounts is as follows:
(1) Retirement to 74 years old, based on the average annual salary of employees in the previous year, 4% in the whole city; 4.5%
(2) Over 75 years, according to the average wage of employees in the city in the previous year.
12 (funds in individual health accounts stop being included)
Employees should pay the basic medical insurance or enjoy the basic old-age insurance benefits without interruption, and stop this practice. Article 11 Both models are included in the funds or the third paragraph.
Article 13 (Use of Personal Medical Account and Interest-bearing Fund)
The law of multi-year carry-over and inheritance can be used for the personal health account funds owned by individuals.
individual medical accounts and funds in funds are included in the calendar year and divided into surplus funds.
the individual medical account fund shall bear interest according to relevant regulations and be included in the individual medical account.
Article 14 (Access to Personal Health Account Funds)
Staff can inquire and calculate the expenses. I have a personal medical insurance center in the capital account, which should be convenient for staff to inquire.
15 (extra funds)
If the employer pays extra medical insurance, it includes local additional medical insurance funds (hereinafter referred to as extra funds).
16 (Definitions of Designated Medical Institutions and Designated Retail Drugstores)
The term designated medical institutions means that medical institutions are allowed to establish basic medical insurance settlement relationship after being practiced and reviewed by the administrative department of health.
the term of designated retail pharmacies refers to the relationship between drug retail enterprises that have approved the business qualification of drug supervision and administration departments and have been approved to establish basic medical insurance after the examination and settlement of municipal medical insurance.
Article 17 (Designated Medical Institutions, Designated Retail Drugstores and Service Requirements)
Designated retail pharmacies should be medical institutions that provide services for workers, and settle accounts according to the scope of treatment schemes applied by basic medical insurance, medical services and drug standards and pay medical expenses.
18 (scope of diagnosis and treatment items, medical service facilities, drugs and payment standards)
For the scope and payment standards of basic medical insurance, medical services and drugs for urban diagnosis and treatment items, the municipal medical insurance and relevant departments shall be in accordance with national laws and regulations.
article 19 (medical treatment and pharmacy for employees)
workers can go to designated medical institutions for medical treatment in the whole city.
medical institutions that dispense medicines for workers may also dispense medicines in accordance with the provisions of designated retail pharmacies.
for emergency personnel who live or work in other provinces and outside cities, you can go to local medical institutions.
article 2 (health insurance certificate)
when a designated medical institution for employees fills a prescription in a city, it is required to produce a medical insurance certificate.
Workers in designated medical institutions, retail pharmacies or medical insurance certificates should be certified.
no individual may falsely use, forge, alter or lend medical insurance vouchers. Chapter
Payment of medical expenses Article 21 (Conditions for employees to enjoy basic medical insurance)
Medical insurance premiums paid by employers and employees According to regulations, employees enjoy basic medical insurance benefits; Without paying medical insurance premiums, workers cannot enjoy basic medical insurance benefits.
employer's application for deferred payment of health insurance According to the relevant provisions of the approved deferred payment period, employees will not stop enjoying the basic medical insurance benefits.
No employer or employee pays the medical insurance premium. After paying the medical insurance in full, employees can continue to enjoy the basic medical insurance benefits.
employers and employees have paid medical insurance premiums for more than 15 years (including deemed payment period), and employees can enjoy basic medical insurance benefits after retirement. The deemed payment period is calculated separately by the municipal government medical insurance. According to the relevant regulations, retirees enjoy basic medical insurance benefits without this part of the restrictions.
Article 22 (Outpatient Expenses of Emergency Medical Service Personnel)
In addition to Article 24 and Article 25, the expenses incurred by outpatient emergency medical service personnel or those who go to designated retail pharmacies for dispensing medicines shall be the specified funds in their personal medical accounts. The insufficient part shall be paid according to the following provisions (excluding the expenses incurred by the designated retail pharmacies):
(1) Born on December 31st, 1955, and joined the work in December 31st, 2, the individual shall pay 1% of the average wage of the workers in the city for one year first, and 7% of the extra funds for medical expenses shall be paid by the employees themselves.
(2) Born from January 1, 1956 to December 31, 1965, who joined the work before December 31, 2, the average salary of individual employees paid in the previous year in the whole city was 1%, which exceeded the additional 6% of medical expenses paid according to the fund, and the rest was borne by on-the-job employees.
(3) For those who were born on January 1st, 1966 and joined the work on December 31st, 2, 1% of the average salary of employees in the city in the first year will be paid by individuals, and 5% will be paid from the additional medical expenses fund, and the rest will be borne by the employees on the job.
(4) On January 1st, 21, the new trainees after work will be borne by the employees.
article 23 (medical expenses of retirees in emergency clinics)
except for article 24, the expenses incurred in medical clinics or emergency rooms for retirees in designated retail pharmacies in article 26 shall be covered by the prescribed account funds for personal medical treatment. The insufficient part shall be paid according to the following provisions (excluding the expenses incurred by designated retail pharmacies):
(1) Emergency outpatient medical institutions that have retired on December 31, 2, and the first person paid workers 2% of the city's average wage in the first year, paid 9% of the extra medical expenses from extra funds; In the outpatient emergency care of secondary medical institutions, the medical expenses exceed the extra funds to pay 85%; In the third-level emergency clinic, medical institutions and medical care costs exceeded some extra funds to pay 8%; The rest will be borne by retirees.
(2) Born on December 31, 1955, who worked on December 31, 2 and retired after January 1, 21, the first person paid 5% of the average salary of employees in the city in the previous year, and paid 85% from the medical expenses with extra funds in emergency outpatient medical institutions; Emergency clinics in secondary medical institutions, from more funds to pay 8% of the additional medical expenses; In the third-level medical outpatient emergency, 75% is paid from the medical expenses with extra funds; The rest will be borne by retirees.
(3) For those who were born from January 1, 1956 to December 31, 1965, and retired from work after December 31, 2 and January 1, 21, the first person who paid 5% of the average salary of the previous year worked in the city, and in the emergency outpatient medical institution, he paid 7% of the additional medical expenses from more funds; In the second-level medical institutions outpatient emergency payment, 65% of the extra medical expenses from the fund; In tertiary medical institutions, 6% of the extra medical expenses are paid from more funds, and the retirees in outpatient emergency departments are responsible for their rest.
(4) The first person who was born after January 1, 1966, joined the work and retired after December 31, 2 and January 1, 21, paid 5% of the average salary of employees in the previous year in the emergency outpatient medical institutions in the city, and paid 55% from the medical expenses with extra funds; Emergency clinics in secondary medical institutions, from more funds to pay 5% of the additional medical expenses; In the third-level medical outpatient emergency, 45% of the medical expenses with extra funds will be paid; The rest will be borne by retirees.
(5) After January 1, 21, the first person paid 1% of the average wage of the workers in the first year in the city, and the level of emergency outpatient medical institutions exceeded the additional 55% of the medical expenses paid according to the fund after partial retirement; In the outpatient emergency department of secondary medical institutions, 5% of the medical expenses with excess extra funds will be paid; In tertiary medical institutions, 45% of the other funds pay for the extra medical expenses, and the rest of the outpatient and emergency services are borne by retirees.
Article 24 (Outpatient Diseases and Family Bed Medical Expenses)
After the occurrence of outpatient dialysis, cancer chemotherapy and radiotherapy (hereinafter referred to as outpatient medical diseases), the service personnel will pay 85% by pooling funds; 92% of the overall fund paid by retirees. Over the years, the funds paid by the unemployed part, the balance of personal medical account, and the rest are at your own risk.
8% of the overall fund is paid by the employees who have incurred the medical expenses for family sickbeds, and the balance of the personal medical account that has been deeply funded for many years due to the lack of workers, and the rest is at their own expense.
Article 25 (Hospitalization, Emergency Medical Expenses for On-the-job Employees)
The medical expenses paid by the fund as a whole by the service personnel in the hospital emergency department or hospitalization shall be deductible. Qifubiaozhun The average wage of 1% workers in this city in the same period last year.
for the part of hospitalization medical expenses accumulated over Qifubiaozhun during one-year hospitalization or emergency observation, employees within 85% of the fund shall be co-ordinated.
for the occurrence of on-the-job employees whose medical expenses are below the minimum threshold, after the balance of individual medical accounts exceeds the remaining part of the difference through pooled funds, the on-the-job employees will pay the annual payment funded by medical expenses.
medical expenses paid by (hospitalization, emergency medical expenses of retirees)
medical expenses paid by the qifubiaozhun pooling fund after hospitalization or emergency observation of retirees. On December 31, 2, the retirement threshold was 5% of the average wage of workers in the city last year; Joined the work on December 31, 2 and 21, and retired after January 1, the minimum wage is the average annual salary of the first 8% of the workers in the city; Continue to work after January 1, 21, and after retirement, the minimum wage is 1% of the average urban wage of the same period last year. Retirees whose medical expenses incurred during one-year hospitalization or emergency observation have accumulated more than 92% of the overall fund to pay the Qifubiaozhun portion. Below the threshold
the medical care expenses of retirees and the rest of the overall fund, the medical expenses incurred after the fund's personal medical account balance has been paid for many years, and the retirees who are not enough.
Article 27 (Pooling Funds and Exceeding Maximum Payment Expenses)
The maximum payment limit, pooling funds, is four times that of last year, and the average wage of workers in cities. Employees who have been hospitalized for one year, while observing the emergency hospitalization Qifubiaozhun, observe what will happen to the medical expenses, and the outpatient medical expenses for serious illness or family beds, shall be paid in accordance with Article 24 and Article 25 of the present Measures to pay Article 26.
The maximum payment limit above the overall fund is paid by an additional 8% fund, and the rest is borne by employees.
Article 28 (Special Diseases Paid by Medical Expenses) Family Planning Operation and Its Sequela Occurred for Employees.