In order to standardize the handling of basic medical insurance for urban and rural residents in our city, the Management Workflow of Basic Medical Insurance for Urban and Rural Residents in Nanchang City is formulated.
Management workflow of basic medical insurance for urban and rural residents in Nanchang In order to standardize the handling of basic medical insurance for urban and rural residents in our city, this workflow is formulated according to the Interim Measures for Basic Medical Insurance for Urban and Rural Residents in Nanchang (Hongfu Tingfa [2015] No.37).
Department job responsibilities
The basic medical insurance for urban and rural residents shall be handled with the assistance of the city, county (district), development zone (new district) (hereinafter referred to as county (district)), township (town) people's government (medical insurance office), street human resources and social security office (hereinafter referred to as labor insurance office or people's insurance office) and village (community) committee. Specific job responsibilities are as follows:
First, the municipal medical insurance agency
(a) responsible for the publicity and implementation of the basic medical insurance policy for urban and rural residents in the city;
(two) responsible for guiding the county (District) medical insurance handling work;
(III) Responsible for the approval and reporting of the insurance payment, general outpatient lump sum payment and hospitalization medical expenses of students in Chang in provincial universities and municipal universities;
(four) responsible for the collection, management and disbursement of the risk adjustment fund of the basic medical insurance for urban and rural residents in the city;
(five) responsible for drafting and signing service agreements with designated medical institutions in the city, and supervising and inspecting the service quality and standardized management;
(six) responsible for the signing of the medical insurance agreement for serious illness of urban and rural residents in the city, the application and disbursement of funds, and the annual assessment work.
Two, the county (District) medical insurance agencies.
(a) responsible for the county (District) of the basic medical insurance policy for urban and rural residents to publicize and organize the implementation;
(two) responsible for the business training of medical insurance staff at all levels in the county (district);
(three) responsible for checking and confirming the insured information of the insured residents, and applying for the payment of subsidies for special groups;
(four) responsible for the collection of medical insurance premiums for insured residents and the application for financial subsidies, as well as the management of the overall fund for hospitalization and general outpatient service; The allocation of risk reserve, serious illness insurance premium, hospitalization pooling fund and general outpatient pooling fund;
(five) responsible for the insured residents hospitalized due to illness, a single medical expenses of 5000 yuan (excluding 5000 yuan) above the data review, medical expenses payment;
(six) responsible for the production, management and distribution of social security cards for insured residents (hereinafter referred to as social security cards);
(seven) responsible for receiving policy advice from insured residents, conducting research on medical insurance for urban and rural residents, and guiding and managing the work of the township (town) medical insurance office;
(eight) to be responsible for the supervision and inspection of the medical service quality, charging standards, admission and discharge and medical expenses payment of the designated medical institutions for urban and rural residents' medical insurance;
(nine) responsible for the establishment, equipment purchase and daily maintenance of the medical insurance information management system for urban and rural residents.
Three, the township (town) people's government (medical insurance), street (labor insurance or insurance)
(a) responsible for the basic medical insurance for urban and rural residents within the jurisdiction of the policy propaganda, consultation and interpretation, as well as the list of insured persons and the collection, review and reporting of medical insurance premiums paid by individuals;
(two) responsible for the audit, comparison, entry and change of the basic information of the insured residents;
(three) to guide the village (community) committee to carry out the collection and payment of medical insurance premiums for urban and rural residents, and to be responsible for issuing payment notices and settlement bills for capital transactions;
(four) responsible for the collection and distribution of social security cards for insured residents;
(five) responsible for the transfer, continuation and termination of the medical insurance relationship of the insured residents;
(six) to be responsible for the examination and payment of reimbursement materials for medical treatment (including referral), maternity medical expenses and single medical expenses below 5,000 yuan (including 5,000 yuan) for insured residents in different places;
(seven) responsible for a single medical expenses below 5000 yuan (excluding 5000 yuan) the preliminary examination and submission of relevant information of insured residents;
(eight) responsible for the audit of the relevant materials for the application of special groups of urban and rural residents, and submit them to the county medical insurance bureau for examination;
(nine) to be responsible for the entry, statistics, management and reporting of medical information of urban and rural residents in this area, and to make the registration form of insurance information of each administrative village before the collection of medical insurance premiums in that year and hand it over to the village Committee staff;
(ten) responsible for the accounting of the medical insurance fund paid by the unit.
Fourth, the village (community) committee.
(a) responsible for the administrative village (community) residents' basic medical insurance policy propaganda, consultation and mobilization;
(two) responsible for the registration of insured residents, premium collection, fill in the information registration form of insured persons and the publicity of insured information, and timely turn over the collected medical insurance premiums to the township (town) medical insurance agencies and handle relevant procedures;
(three) responsible for the collection and distribution of social security cards for insured residents;
(four) responsible for the supervision and inspection of the medical expenses of the insured residents, and regularly publish them, and accept the supervision of the masses;
(five) responsible for issuing receipts for payment of medical insurance for urban and rural residents, and carefully checking, safekeeping and submitting them to the township (town) medical insurance agencies.
Insurance payment for all kinds of personnel
I. General urban and rural residents
(A) urban residents insured for the first time
For urban residents who are insured for the first time, during the period of 10- 12 every year, they shall go through the formalities of insurance payment according to the following procedures (they will enjoy the medical insurance benefits for the next year after insurance payment):
1. The insured person shall bring his/her household registration book, the original and photocopy of his/her ID card (one for each, and the photocopy of the household registration book shall include the home page of the household registration book and the page where the insured person is located, the same below) and a recent one-inch bareheaded color photo with a white background. For newborns, the original and photocopy of their birth certificates shall be provided at the same time, and the insured shall report to the street labor insurance office (PICC);
2, street labor insurance (PICC) acceptance and audit, to meet the conditions of insurance and complete information, collect relevant copies of the archive, and apply for insurance registration, generate personal social security number;
3, the insured person with personal social security number, to the designated bank to pay medical insurance premiums, receive bank bills;
4, street labor insurance (PICC) finishing the insured business card printing required information, submitted to the county (District) medical insurance bureau to declare the production of social security cards;
5, the county (district) medical insurance bureau submitted to the Provincial People's Social Welfare Department to complete the business card printing, receiving and forwarding it to the Street Labor Insurance Office (PICC), which will distribute it to the insured individuals.
(2) Rural residents are insured for the first time.
For rural residents who are insured for the first time, during the period of 10- 12 every year, they shall go through the formalities of insurance payment according to the following procedures (they will enjoy the medical insurance benefits for the next year after insurance payment):
1. The insured shall provide the original and photocopy of the household registration book and ID card, and a recent bareheaded one-inch color photo with a white background. Belong to the newborn, should also provide the original and a copy of the birth certificate, and declare the insurance to the village committee staff;
2, the village committee staff to conduct a preliminary examination, to meet the conditions and complete information, collect relevant copies, and apply for insurance registration, fill in the insurance information registration form (in duplicate), in accordance with the provisions, pay medical insurance premiums and issue a receipt (in triplicate, one for the insured, one for the village committee to keep, one for the report);
3, the village committee staff in the village insurance payment, unified to provide new insured information registration form, relevant copies, receipts (a) and other township (town) medical insurance certificate;
4, the township (town) medical insurance staff in the insurance information registration form, medical insurance fee receipt check, go through the registration formalities, input the computer system and generate payment information, issue a payment notice, by the village committee staff according to the requirements of the notice to the bank to pay;
5, the township (town) medical insurance according to the bank bill paid by the village committee, issued a bill of settlement of funds, and stamped on the registration form of insurance information, return a copy to the village committee;
6, the township (town) medical insurance office to sort out the information needed for the insured official card, submitted to the county (District) medical insurance bureau to declare the production of social security cards;
7, county (District) medical insurance bureau submitted to the Provincial People's Social Welfare Department to complete the business card printing, received and forwarded to the township (town) medical insurance, which was distributed to the village committee by the township (town) medical insurance, and then distributed to the insured individuals by the village committee.
(3) Persons who have not obtained household registration for the first time.
Those who have not obtained household registration shall go through the insurance payment procedures according to the following procedures during the period of 10- 12 every year (they will enjoy the medical insurance benefits for the next year after the insurance payment):
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1. The insured person applies to the community (street) with a recent bareheaded one-inch color white background photo. After the community (street) verifies the situation, it will issue the identity certificate of the insured person, clarify the name, date of birth and other related information of the insured person, register the insured person, enter personal information into the information system, and generate the personal social security number;
2, the insured person with personal social security number, to the designated bank to pay medical insurance premiums, receive bank bills;
Rural resident
1. The insured applies to the local village committee with a recent one-inch color photo with a white background and no hat. After verifying the situation, the village committee will issue the identity certificate of the insured person, clarify the insured person's name, date of birth and other relevant information, register the insured person, fill in the information registration form of the insured person (in duplicate), and issue a receipt (in triplicate, one for the insured person, one for the village committee and one for the report) after collecting the medical insurance premium according to the regulations.
2, the village committee staff in the village insurance payment, unified summary insurance information registration form, receipt (a) and other township (town) medical insurance (follow-up procedures according to the normal rural residents for the first time insurance payment procedures).
Township (town), street medical insurance agencies will be related to the insured information submitted to the county (District) medical insurance agencies, county (District) medical insurance agencies unified production of temporary medical insurance cards.
County (District) medical insurance agencies will issue temporary medical insurance cards to township (town) and street medical insurance agencies to the insured.
After the insured, the insured will continue to pay insurance premiums according to the normal urban and rural residents where the insured is located.
(four) foreign enterprises or migrant workers who are insured for the first time.
Foreign and migrant workers and their minor children who have lived in this city for more than 1 year and have not participated in the basic medical insurance in their places of origin can go through the insurance procedures in our city according to the following procedures (they can enjoy the medical insurance benefits for the next year after paying the insurance premium):
1, the insured person shall provide the certificate of medical insurance of origin, ID card and its copy, temporary residence permit or township (street) certificate, and recent one-inch bareheaded color photo with white background, and go to the medical insurance agency in the county (district) where he lives to register for insurance;
2, county (District) medical insurance agencies to accept and review, to meet the conditions and complete information, collect relevant copies of the archive, and apply for insurance registration, generate personal social security number;
3, the insured person with personal social security number, to the designated bank to pay medical insurance premiums, receive bank bills;
4, the county (District) medical insurance bureau to sort out the information needed for the insured official card, submitted to the provincial social security department to make a social security card, after the completion of the receipt and distribution to the insured individual.
After the insured, the insured will continue to pay the normal fees according to the general urban and rural residents where the insured is located in the future.
(5) Payment by urban and rural residents.
1, urban residents pay fees normally. Urban residents who have been insured pay medical insurance premiums at the designated online bank with their personal social security number during the annual centralized payment period, and receive the bills issued by the bank.
2. Rural residents pay normal fees.
(1) During the annual centralized payment period, the village committee will arrange villagers' groups (with two or more staff members in each group) to collect the medical insurance premiums payable on an individual basis and issue receipts (in triplicate, one for the insured, one for the village committee and one for the report);
(2) After the payment is completed, the villagers' group will report the collected insurance premium and the' collection receipt' that should be retained to the village committee;
(3) After checking the insurance premium amount and documents, the village committee shall collect and register, fill in the registration form of the insured, and keep one of the receipts;
(4) Within the specified time, submit the Registration Form of Insurance Payment Information and the payment receipt (one copy) to the township (town) medical insurance office;
(5) After the township (town) medical insurance office checks the information registration form, payment status and receipt of the insured, it generates payment information through the information system, issues a payment notice, and the village committee staff pays the fee at the bank according to the notification requirements;
(6) The township (town) medical insurance institute shall issue a fund settlement bill according to the bank bill paid by the village committee, stamp the information registration form of the insured, and return a copy to the village committee for retention.
3. Urban and rural residents interrupt payment.
If urban and rural residents fail to pay insurance premiums within the prescribed payment period, when the follow-up insurance is interrupted, the medical insurance premiums that individuals should pay during the interruption period will be paid. If urban and rural residents stop paying fees, they will pay them back every year from 10 to 12 according to the payment process of relevant identity groups, and enjoy basic medical insurance benefits from the next year after payment.
Second, college students.
The first insured
(1) During the period of centralized insurance payment, college students should bring their ID card and photocopy, and a recent one-inch color photo with a white background without a hat, register in a unified manner and fill in the insurance registration form;
(2) The school collects the registration form and related information, and submits it to the Nanchang medical insurance agency;
(3) After the audit of the medical insurance agency in Nanchang, the insurance registration formalities shall be handled, and the accounting list of college students' insurance subsidies shall be generated by the information system, and reported to the provincial and municipal financial departments respectively according to the affiliation of the school;
(4) After the financial department allocates the college students' insurance subsidies to the financial accounts of college students' basic medical insurance, the Nanchang medical insurance agency shall handle the posting procedures in time;
(5) The municipal medical insurance agency collates the printed data of the business cards of the insured college students and submits them to the Provincial People's Social Information Office for making social security cards; After the production is completed, it will be received and handed over to the school for distribution to the insured.
(2) Normal update
(1) During the period of centralized insurance payment, the insured students shall fill in the information registration form by the school according to the notice of the municipal medical insurance agency, and report it to the municipal medical insurance agency after summary and verification by the school;
(2) the municipal medical insurance agency audit, check with the insured information in the information system, and confirm it in the system after the audit is correct;
(III) The municipal medical insurance agency shall summarize the insurance situation, generate a list of college students' insurance subsidy funds, report them to the provincial and municipal financial departments respectively according to the affiliation of the school, and timely allocate them to the financial accounts of college students' basic medical insurance.
Third, special people.
(a) the financial subsidy payment object
According to the policy, the insured urban and rural residents belong to the minimum living security object, severely disabled students and children, disabled people who have lost their ability to work, minors from low-income families and elderly people over 60 years old, unemployed retired soldiers who are not included in the basic medical insurance for urban workers, key entitled groups, rural five-guarantee objects, urban "three noes" objects, orphans, and elderly people over 70 years old (including 70 years old) who are insured by the whole family. And 1 1 other qualified special personnel, individual contributions shall be borne by financial assistance, and insurance contributions shall be handled according to the following procedures:
1, a 70-year-old man in urban family overall insurance.
(1) During the annual insurance payment period, I or my relatives bring my social security card, ID card and photocopy, household registration book and all members' insurance payment vouchers in the household registration book to report to the medical insurance agency in the county (district) where the insurance is registered;
(2) the county (District) medical insurance agencies to accept and review, to meet the conditions, registration and confirmation in the information system;
(3) the county (District) medical insurance agencies to generate the insured list, accounting for the amount of subsidy funds, unified to the county (District) financial application for disbursement.
2. 70-year-old rural residents who are insured as a whole.
(1) During the annual insurance payment period, I or my relatives bring my social security card, ID card and its copy, household registration book and all members' insurance payment vouchers in the household registration book to report to the local village committee;
(2) the village committee shall conduct the preliminary examination, and those who meet the requirements shall report to the township (town) medical insurance office for examination after receiving the application materials and registering, and then the county (district) medical insurance agency shall conduct the examination;
(3) the county (District) medical insurance agencies to accept and review, to meet the conditions, registration and confirmation in the information system;
(4) the county (District) medical insurance agencies to generate the insured list, accounting for the amount of subsidy funds, unified to the county (District) financial application for disbursement.
3. Other 10 group
In addition to "over 70 years of age with family as the unit", other 10 special groups, such as low-income recipients, must be reported to the civil affairs department for approval. The specific process is as follows:
(1) During the centralized insurance payment period, the insured person shall carry the materials for enjoying the benefits or relevant certification materials, household registration book, ID card and its copy, and those who join the insurance for the first time shall also provide a recent one-inch color photo with a white background, and report to the local village (community) committee;
(2) After the preliminary examination by the village (community) committee, those who meet the requirements shall receive the application materials and register them, report them to the township (town) and street civil affairs departments for review, and then report them to the county (district) civil affairs departments for review;
(3) qualified after examination, confirmed by the county (District) civil affairs department, and confirmed in the medical insurance system; At the same time, the electronic version and paper version of the list of such personnel shall be submitted to the county (district) medical insurance agency;
(IV) The county (district) medical insurance agency shall collect the personnel information, generate a list of financial subsidy funds, report it to the financial department at the same level for allocation, and timely allocate the allocated funds to the financial accounts of the basic medical insurance for urban and rural residents.
(2) Newborns are insured in the current year.
Newborns are regarded as participating in the basic medical insurance for urban and rural residents from the date of birth, but they need to go through the registration and payment procedures within six months after birth (they can enjoy medical insurance benefits from the year of birth after payment). The specific process is as follows:
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1. The parents of the insured bring their household registration book, the original and photocopy of the birth certificate, and one-inch bareheaded color photos with a white background to report to the medical insurance agency in the county (district) where the household registration is located;
2, county (District) medical insurance agencies to accept and review, to meet the conditions of insurance and complete information, collect relevant information and apply for insurance registration, generate personal social security number;
3, the insured person with personal social security number, to the designated bank to pay medical insurance premiums, receive bank bills;
4. The county (district) medical insurance bureau sorts out the information needed for the official card of the insured, submits it to the Provincial People's Social Security Department to make a social security card, and receives and distributes it to the insured individuals after completion;
Rural resident
1. The parents of the insured bring their household registration book, the original and photocopy of the birth certificate, and one-inch bareheaded color photos with a white background, and apply for insurance to the staff of the village committee where the household registration is located;
2, the village committee staff to accept and review, to meet the conditions of insurance and complete information, collect relevant information and apply for insurance registration, fill in the insurance information registration form (in duplicate), in accordance with the provisions, pay the medical insurance fee and issue a receipt (in triplicate, one for the insured, one for the village committee, one for the report);
3, the village committee staff in the village insurance payment, within a certain period of time unified summary of new insured information registration form, receipt (a) and his hometown (town) medical insurance (follow-up procedures according to the normal rural residents for the first time insurance payment procedures).
(III) Veterans, college graduates who returned to work in our district, new immigrants from other places, overseas returnees, newborns, people who have been disqualified from subsistence allowances, people who are unemployed again after employment, prisoners undergoing reform through labour, new immigrants from other provinces, and free people over 70 years old were insured in that year.
Veterans, college graduates who return to work in our district, new immigrants from other places, overseas returnees, newborns, people who have been disqualified from subsistence allowances, people who are unemployed again after employment, prisoners who have been reeducation through labor, new immigrants from other provinces, and free people over 70 years old should go through the insurance procedures within three months. The specific process is as follows:
65438+ (6) Unemployed people need to provide proof of unemployment when they re-employ; (7) Newborns need to provide birth certificates and apply for insurance at the medical insurance agency in the county (district) where the household registration is located;
2, county (District) medical insurance agencies to accept and review, to meet the conditions of insurance and complete information, collect relevant copies of the archive, and apply for insurance registration, generate personal social security number;
3, the insured person with personal social security number, to the designated bank to pay medical insurance premiums, receive bank bills;
4, the county (District) medical insurance bureau to sort out the information needed for the insured official card, submitted to the provincial information center to make a social security card, after the completion of the receipt and distribution to the insured individual.
Four, the insured residents insured change
(1) Changes in basic information
1. When the insured residents need to change their names, ID numbers, contact numbers and other basic information, they should go to the township (town) or street medical insurance agency where they are insured with their household registration book, social security card and department certification materials;
2. After the data verified by the township (town) and street medical insurance agencies are correct, change the residents' insurance information in the computer system, change the name, nationality and ID number, and issue a new social security card.
If a new card is issued, the township (town) and street medical insurance agencies shall collect the required relevant materials and report them to the county (district) medical insurance agency in accordance with the business card printing process.