Regulations of People's Republic of China (PRC) Municipality on Basic Medical Insurance for Urban Workers
Chapter I General Provisions
Article 1 In order to ensure the basic medical care for urban workers and rationally utilize medical resources, these Regulations are formulated in accordance with the relevant provisions of the state and combined with the actual situation of this province.
Article 2 The following units and their employees in towns of this province must participate in the basic medical insurance in accordance with these regulations:
(1) Enterprises and their employees;
(2) Organs, institutions, intermediaries, social organizations, private non-enterprise units and their employees;
(3) Employers of troops without military status and their employees.
These Regulations shall apply to the retirees of the above-mentioned units.
Article 3 The basic medical insurance fund for urban workers shall be established, and the system of combining individual medical accounts (hereinafter referred to as individual accounts) with basic medical pooling funds (hereinafter referred to as pooling funds) shall be implemented. The ownership of personal accounts belongs to individuals. The ownership of the overall fund belongs to all personnel participating in the basic medical insurance.
Article 4 The basic medical insurance premium shall be borne by both the employer and the employees.
Fifth basic medical insurance in principle to the city, county, autonomous county as a whole unit, the implementation of territorial management.
Article 6 The basic medical insurance premium shall be collected by the local tax authorities of this province (hereinafter referred to as the tax collection authorities).
Chapter II Collection and Payment of Basic Medical Insurance Fees
Article 7 The basic medical insurance premium shall be paid by both the employer and the employee. Among them, the employer pays 5%-7% of the total monthly salary of its employees, and the rate of employees paying basic medical insurance premium is not less than 2% of their total monthly salary.
Article 8 The amount of employees' monthly wages is determined according to their actual total wages, but it shall not be less than 60% of the average monthly wages of employees in the city, county and autonomous county where they are located. The following medical insurance premiums that should be paid by themselves shall be paid by the employer.
Article 9 If the total monthly salary of employees exceeds 300% of the average monthly salary of employees in cities, counties and autonomous counties in the previous year, the basic medical insurance premium will not be paid, nor will it be used as the base for checking the amount of personal accounts.
Article 10 The employing unit must register the basic medical insurance with the social insurance agency within 30 days from the date of obtaining the business license or being approved for establishment. When the registered items change or the payment obligation is terminated according to law, the registration shall be changed or cancelled in time. The social insurance agency shall promptly notify the tax authorities of the registration. The employing unit shall, within 10 days after going through the basic medical insurance registration formalities, go to the tax collection authority to pay and register the basic medical insurance premium in accordance with relevant regulations.
Article 11 The amount of basic medical insurance premiums that employers and employees should pay shall be reported to the tax collection organ by the employer on a monthly basis and approved by the tax collection organ. If the employer fails to declare the amount of the basic medical insurance premium that should be paid according to the regulations, the tax collection authority will temporarily determine the amount that should be paid according to 1 10% of the amount paid by the unit last month; If the amount was not paid last month, the tax collection organ shall determine the amount and amount of payment according to the economic situation of the unit and the number of employees. After the payer completes the declaration procedures and pays the basic medical insurance premium according to the specified amount, the tax collection organ shall settle the account according to the facts.
Twelfth basic medical insurance premiums are levied on a monthly basis, and employers and employees shall pay the basic medical insurance premiums to the tax collection authorities within the prescribed time limit. The part that individual employees should pay shall be withheld and remitted by the employer from their wages. The basic medical insurance premium shall not be reduced.
Thirteenth pay the total wages of basic medical insurance premiums, according to the relevant provisions of the state. The basic medical insurance premium paid by the employer shall be charged according to the relevant financial regulations of the state. The basic medical insurance premium is not included in the personal current wage income, and is exempt from personal income tax. The employing unit shall not lower the wage standard of employees on the grounds that they pay the basic medical insurance premium.
Fourteenth basic medical insurance payment to implement the annual inspection system. The administrative department for industry and commerce shall not handle the annual inspection procedures for industry and commerce for the employing units that have not gone through the annual inspection procedures for paying the basic medical insurance to the tax authorities. When the employer goes through the formalities for cancellation of the business license, the administrative department for industry and commerce shall first review the certificate of termination of the basic medical insurance relationship issued by the social insurance agency.
Fifteenth employees after retirement, I will no longer pay the basic medical insurance premium, and the unit will no longer pay the basic medical insurance premium for them.
Article 16 If the employing unit goes bankrupt, closes down or terminates for other reasons according to law, or the number of employees is reduced by more than two thirds, and the basic medical insurance premium actually paid by retirees before retirement is less than 10 years, compensation shall be paid from the basic medical insurance fund. Fund compensation is calculated by multiplying the current age of 75 by the average basic medical expenses of retirees in the same period, and paid in one lump sum from the assets realized after liquidation. Really unable to pay, the treatment measures shall be formulated separately by the provincial people's government. Unless otherwise stipulated by the state, such provisions shall prevail.
Article 17 Where an employer terminates due to bankruptcy, cancellation, dissolution or other reasons, it shall pay off the unpaid basic medical insurance premium, interest, late payment fee and fine in accordance with the provisions of relevant state laws and regulations. When the employing unit is merged, divided or transferred, the merged, divided or transferee shall bear the unpaid basic medical insurance premium, interest, late payment fee and fine. Unless otherwise stipulated by the state, such provisions shall prevail.
Eighteenth medical expenses before the implementation of these regulations are still solved by the original channels.
Chapter III Management of Basic Medical Insurance Fund
Nineteenth basic medical insurance premiums paid by employees are all included in personal accounts. 25-35% of the basic medical insurance premium paid by the employer is used to establish individual accounts for retirees and employees, and the specific payment methods are formulated by the provincial people's government according to the principle of caring for the elderly; The remaining funds are used to establish a unified fund.
Article 20 The basic medical insurance fund shall be managed with two lines of revenue and expenditure, and shall be included in the financial special account of the social insurance fund, which shall be used exclusively for the basic medical care of employees and retirees, and shall not be used for other purposes.
Twenty-first basic medical insurance fund interest method according to the relevant provisions of the state, personal accounts and pooling funds due interest are calculated and included.
Twenty-second personal accounts may not withdraw cash, overdraw, overspend or roll over for personal use. When employees and retirees die, the balance of funds in their personal accounts can be inherited.
Article 23 An employing unit shall not, in violation of the provisions of these Regulations, increase personal account funds for employees or other personnel.
Twenty-fourth social insurance agencies should establish basic medical insurance files for employees and retirees, and issue basic medical insurance certificates.
Twenty-fifth to move out of the province or flow in the province, the balance of personal account funds can be transferred; If it can't be transferred, give it back to me. The basic medical insurance premium included in the overall planning fund belongs to all the insured persons of the original overall planning unit and shall not be transferred or returned.
Twenty-sixth basic medical insurance fund annual budget and final accounts shall be compiled and audited in accordance with the relevant provisions of the state and the province.
Chapter IV Basic Medical Insurance Benefits
Twenty-seventh employees of the employer who pay the basic medical insurance premiums in accordance with these regulations shall enjoy the basic medical insurance benefits.
Twenty-eighth personal accounts are used to pay medical expenses beyond the scope of the overall fund; If the personal account is insufficient to pay, it shall be borne by me.
Twenty-ninth serious illness hospitalization medical expenses, according to the following methods to pay:
(a) Qifubiaozhun in principle control in the city, county, autonomous county last year, the average social wage of workers 9%-0%.
(two) the maximum payment limit is controlled in principle at 3-5 times of the average social wage of employees in cities, counties and autonomous counties in the previous year.
(three) medical expenses above the minimum deductible and below the maximum payment limit are mainly paid by the overall fund, and individuals bear a certain proportion. Give appropriate care to the proportion of retirees who bear medical expenses. The scope of serious diseases, the specific standards of Qifubiaozhun and the maximum payment limit, and the proportion of sharing medical expenses above Qifubiaozhun and below the maximum payment limit shall be determined by the provincial people's government.
Thirtieth medical expenses below Qifubiaozhun and above the maximum payment limit shall not be paid by the overall fund.
Thirty-first basic medical insurance fund to pay part of the cost of diagnosis and treatment projects and class B drugs list, the proportion of individual pays, determined by the provincial people's government.
Thirty-second medical expenses of class A infectious diseases such as cholera and plague shall be paid by the overall fund. The medical expenses of explosive and epidemic infectious diseases confirmed by the administrative department of health shall be solved by the people's government.
Article 33 State civil servants and other qualified personnel shall, on the basis of participating in basic medical insurance, implement medical subsidies. In order to solve the medical expenses above the maximum payment limit for personnel other than those specified in the preceding paragraph, the provincial people's government may organize the implementation of supplementary medical insurance.
Article 34 Anyone who has reached the age of 50 at the time of participating in the basic medical insurance and has worked continuously or for less than 5 years according to state regulations can enjoy the treatment of pooling funds to pay medical expenses after participating in the basic medical insurance for 1 year.
Article 35 The payment period stipulated in these Regulations includes the actual payment period and the deemed payment period. The term "deemed payment period" as mentioned in the preceding paragraph refers to the continuous length of service or working years that meet the requirements of the state before the implementation of these regulations.
Thirty-sixth employees who retire after the implementation of these regulations shall pay the basic medical insurance premium for men for 30 years and women for 25 years. After retirement, their basic medical insurance benefits shall be implemented according to the provisions of these regulations. When an employee retires, if the payment period of the basic medical insurance premium does not reach the provisions of the preceding paragraph, the basic medical insurance benefits he enjoys after retirement will be reduced by 5% on the prescribed treatment standard for each full payment period 1 year.
Thirty-seventh retirees actually pay the basic medical insurance premium 10 years before retirement, and the original unit does not pay the basic medical insurance premium after retirement, which does not affect their enjoyment of the basic medical insurance benefits for retirees stipulated in these regulations. Retirees who actually paid the basic medical insurance premium before retirement were less than 10 years, and those who did not pay the basic medical insurance premium after retirement did not enjoy the basic medical insurance benefits for retirees stipulated in these regulations.
Thirty-eighth workers and retirees due to alcoholism, suicide, self-mutilation, illegal and criminal expenses, the overall fund will not pay. Medical expenses incurred due to traffic accidents and medical accidents shall be handled in accordance with relevant state regulations.
Thirty-ninth approved by the social insurance agencies in different medical institutions for medical treatment, retirees living in different places for more than 0 years, the basic medical insurance benefits in accordance with these regulations.
Fortieth medical expenses incurred by employees and retirees abroad or in Hongkong, Macao and Taiwan Province Province shall be implemented with reference to these Regulations.
Chapter V Medical Service Management of Basic Medical Insurance
Forty-first provincial labor and social security administrative departments in accordance with the relevant provisions of the state, in conjunction with the planning, trade, finance, health administration, drug supervision and management departments to determine the basic medical insurance drug list. The provincial labor and social security administrative department shall, in accordance with the relevant provisions of the state, jointly with the planning, finance, health administration and drug supervision and management departments, determine the basic medical insurance diagnosis and treatment project directory, the scope of medical service facilities and payment standards. The use of drugs, medical treatment projects and medical service facilities that are not included in the basic medical insurance coverage will not be paid by the overall fund.
Forty-second provincial labor and social security administrative departments in accordance with the relevant provisions of the state, in conjunction with the health administration, drug supervision and management departments to develop basic medical insurance designated medical institutions management approach. The provincial administrative department of labor and social security shall, in accordance with the relevant provisions of the state, formulate measures for the administration of designated pharmacies for basic medical insurance in conjunction with the pharmaceutical supervisory and administrative departments. Labor and social security, health administration and drug supervision and management departments shall implement dynamic management of the qualifications of designated medical institutions and designated pharmacies.
Article 43 Labor and social security, health administration, drug supervision and administration departments and social insurance agencies shall determine the designated medical institutions and pharmacies according to the Measures for the Administration of Designated Medical Institutions and Designated Drugstores, and in accordance with the principle of paying equal attention to Chinese and Western medicine, giving consideration to community, specialist and comprehensive medical institutions, and facilitating the insured to seek medical treatment, and announce them to the insured.
Article 44 With a personal account, patients can seek medical treatment and purchase medicines at any designated medical institution or pharmacy. According to the provisions of the medical expenses paid by the overall fund, patients should go to designated medical institutions for medical treatment.
Forty-fifth medical expenses paid by the overall fund can be implemented in advance according to the principle of total control. Social insurance agencies can regulate the number of prepaid pooling funds according to the quantity and quality of medical services provided by designated medical institutions and the protection of the legitimate medical rights and interests of the insured.
Forty-sixth designated medical institutions and pharmacies shall abide by the provisions of the state and province on medical and health care and basic medical insurance, and shall not damage the legitimate medical rights and interests of the insured in any way. Designated medical institutions must inform patients of the details of medical services and charges.
Article 47 The charging standard for basic medical services shall be formulated and revised by the provincial labor and social security and price management departments in conjunction with the health administration and finance departments, and submitted to the provincial government for approval. The price of basic medical insurance drugs shall conform to the relevant state provisions on drug pricing. In violation of the basic medical service charges and drug price regulations, the basic medical insurance fund account does not pay the medical expenses that exceed the standard.
Chapter VI Organization, Management and Supervision of Basic Medical Insurance
Forty-eighth provincial labor and social security administrative department is the administrative department in charge of the basic medical insurance for urban workers in this province, and its duties are:
(a) the preparation of the basic medical insurance development plan for employees;
(two) in conjunction with the relevant departments to develop the basic medical insurance fund financial management system, statistical system and internal audit system;
(three) the supervision and management of the province's basic medical insurance work, exercise the right of administrative punishment according to law;
(four) to announce the work of basic medical insurance to the public every year;
(5) Other duties that should be performed by administrative organs.
The administrative departments of labor security of cities, counties and autonomous counties shall, in accordance with the provisions, manage and supervise the work of basic medical insurance for urban workers within their respective administrative areas.
Forty-ninth social insurance agencies are responsible for the management of the basic medical insurance business for urban workers, and their duties are:
(a) responsible for the registration of basic medical insurance;
(2) Managing the basic medical insurance fund;
(three) to supervise the medical services of the basic medical insurance;
(four) responsible for the payment of basic medical insurance benefits;
(five) to make suggestions on the budget and final accounts of the basic medical insurance fund expenditure;
(six) entrusted by the administrative department of labor security to carry out inspections and investigations related to basic medical insurance;
(seven) in accordance with the provisions of the state responsible for the maintenance and appreciation of the basic medical insurance fund;
(eight) to provide policy advice and other services related to basic medical insurance;
(nine) responsible for handling other basic medical insurance matters stipulated by the state and the province.
Fiftieth tax authorities shall be responsible for the payment registration of basic medical insurance; Put forward suggestions on the budget and final accounts of the income of the basic medical insurance fund; Collecting basic medical insurance premiums according to law; To supervise, inspect and deal with the violations of the basic medical insurance premiums paid by the payment units and individuals.
Fifty-first health administrative departments and drug supervision and management departments should strengthen the management and supervision of designated medical institutions and pharmacies, and assist social insurance agencies to carry out basic medical insurance work.
The administrative department of health shall deal with the acts of medical institutions that violate the relevant provisions of medical and health care and basic medical insurance and damage the legitimate medical rights and interests of insured persons. The drug supervision and administration department shall strengthen drug supervision and administration to ensure that medical institutions and designated pharmacies provide qualified, safe and effective drugs for patients; Dealing with drug accidents in designated medical institutions and pharmacies according to law. The price management department shall inspect and supervise the charging items and standards of basic medical insurance, strengthen management, and deal with acts of increasing charging items and raising charging standards without authorization according to law.
Fifty-second social insurance agencies should send a list of personal account records to the paying individuals at least once a year. The employing unit shall announce the payment of basic medical insurance premiums to employees and retirees every year and accept their supervision.
Article 53 The tax collection organ, the administrative department of labor security and the social insurance agency shall have the right to inspect the employee list, payroll, financial accounting books and other relevant materials of the employing unit, and the auditing department shall cooperate with them when necessary. The departments or institutions involved in the verification shall keep the business secrets of the employing units. The employing unit shall truthfully provide the roster of employees, salary list, financial accounting books and other relevant materials, and shall not forge, alter, falsely report, conceal or conceal them.
Fifty-fourth administrative departments of labor security and social insurance agencies have the right to check the implementation of basic medical insurance provisions in the process of diagnosis, inspection, treatment, drug supply and charging by designated medical institutions and pharmacies; Have the right to review medical prescriptions (doctor's orders), diagnosis and treatment reports, medical records, expense receipts and other related materials before paying medical expenses. When necessary, the health administration, drug supervision and administration and price management departments shall provide assistance. Designated medical institutions, designated pharmacies or other parties shall truthfully provide medical prescriptions (doctor's orders), diagnosis and treatment reports, medical records, expense receipts and other related materials, and shall not forge, alter, falsely report, conceal or conceal them.
Fifty-fifth designated medical institutions and pharmacies in violation of the relevant provisions of the basic medical insurance, the administrative department of labor security shall, according to different circumstances, order them to make corrections within a time limit, and if they fail to make corrections within the time limit, they may cancel their designated qualifications.
Fifty-sixth financial, auditing, supervision and other departments and the board of supervisors of social insurance funds shall supervise the collection and management of basic medical insurance funds according to law, and strengthen the supervision of employers and employees paying basic medical insurance premiums according to law.
The annual income and expenditure of the basic medical insurance fund shall be audited by the auditing organ, and announced to the public before June 30 of the following year, subject to social supervision.
Fifty-seventh employers and individuals have the right to inquire about the payment of basic medical insurance premiums, personal account payment records and the enjoyment of basic medical insurance benefits, and tax collection agencies, social insurance agencies or other relevant institutions shall provide services. Employers and individuals have the right to supervise the basic medical insurance premiums levied by tax authorities and the basic medical insurance work of social insurance agencies; Have the right to apply for administrative reconsideration or bring a lawsuit against the basic medical insurance dispute related to me according to law.
Article 58 Employers and individuals have the right to report illegal acts in the collection and payment of basic medical insurance premiums and basic medical insurance benefits. After receiving the report, the administrative supervision department of labor security shall promptly investigate and deal with it in accordance with the relevant provisions, and keep the informant confidential.
Fifty-ninth basic medical insurance funds managed by social insurance agencies shall be included in the fiscal budget at the same level.
Chapter VII Legal Liability
Article 60 If an employer fails to register, change or cancel the registration of basic medical insurance in accordance with the provisions of these Regulations, the administrative department of labor security shall order it to make corrections within a time limit; If the circumstances are serious, the directly responsible person in charge and other directly responsible personnel may be fined more than 5000 yuan 1000 yuan; If the circumstances are particularly serious, the directly responsible person in charge and other directly responsible personnel may be fined not less than 5000 yuan but not more than 65438 yuan but not more than 0,000 yuan.
Article 61 If the employer fails to declare the amount of the basic medical insurance premium that should be paid in accordance with the provisions of these Regulations, the tax collection organ shall order it to make corrections within a time limit; If the circumstances are serious, the directly responsible person in charge and other directly responsible personnel may be fined more than 5000 yuan 1000 yuan; If the circumstances are particularly serious, the directly responsible person in charge and other directly responsible personnel may be fined not less than 5000 yuan but not more than 65438 yuan but not more than 0,000 yuan.
Article 62 If the employer fails to pay and withhold the basic medical insurance premium in accordance with the amount and time limit stipulated in these Regulations, the tax collection organ shall order it to pay the unpaid amount and interest within a time limit; Fails to pay, in addition to repay the arrears, from the date of default, a daily overdue fine of 2‰ of the arrears will be charged, but interest will not be paid at the same time. Late fees are incorporated into the basic medical insurance pooling fund.
Article 63 If an employing unit violates the laws, regulations and relevant provisions of the state on finance, accounting and statistics, forges, alters, falsely reports, conceals or intentionally destroys the roster of employees, payroll, financial accounting books and other materials, or fails to set up accounting books, thus making it impossible to determine the payment base of basic medical insurance premiums, it shall be given administrative punishment, disciplinary punishment and criminal punishment in accordance with the provisions of relevant laws and regulations. If the payment is overdue, the tax collection organ shall, in accordance with the provisions of the preceding article, decide to impose a late payment fee, and impose a fine of not less than 5,000 yuan but not more than 20,000 yuan on the directly responsible person in charge and other directly responsible personnel.
Sixty-fourth social insurance agencies fail to pay the basic medical insurance benefits according to the regulations, and the administrative department of labor security shall order them to pay; Refusing to pay, the relevant responsible persons shall be given administrative sanctions. If the designated medical institution fails to pay the basic medical insurance benefits according to the regulations, the administrative department of labor security or the social insurance agency shall order it to pay; Refuse to pay, by the administrative department of labor security or social insurance agencies in accordance with the relevant provisions to give corresponding treatment. If a party refuses to accept the decision, it may apply for administrative reconsideration or report or accuse according to law.
Article 65 If the administrative department of labor security, the financial department, the tax collection organ or the social insurance agency violates the provisions of these Regulations and commits any of the following acts, the administrative organ at a higher level shall order it to make corrections within a time limit and recover the misappropriated or lost basic medical insurance fund; Illegal income, confiscate the illegal income, incorporated into the basic medical insurance fund; The main person in charge of the unit and the person directly responsible shall be investigated for administrative responsibility respectively; If the case constitutes a crime, criminal responsibility shall be investigated according to law:
(a) the basic medical insurance premium is not credited to the individual account and the overall fund as required;
(2) Failing to transfer the basic medical insurance fund into the special financial account of the basic medical insurance fund in accordance with regulations;
(3) embezzling or misappropriating the basic medical insurance fund;
(four) in violation of the provisions of the basic medical insurance fund management, resulting in the loss of the fund;
(five) to reduce or increase the basic medical insurance premiums that employers and employees should pay without authorization;
(six) to change the basic medical insurance benefits without authorization.
Article 66 Where the administrative department of labor and social security, the auditing department, the tax collection organ or the social insurance agency and their staff disclose the business secrets of the employing unit, they shall be investigated for legal responsibility in accordance with the provisions of relevant state laws and regulations.
Article 67 If a designated medical institution, drugstore or other party commits one of the following acts to defraud the basic medical insurance premium, the social insurance agency shall refuse to pay the basic medical insurance premium or fully recover the paid basic medical insurance premium and interest; If the circumstances are serious, the administrative department of labor security or other administrative departments shall impose a fine of 2 times on the relevant medical institutions, pharmacies or other parties; If the case constitutes a crime, criminal responsibility shall be investigated according to law:
(1) Forging or altering medical insurance vouchers, doctor's orders, medical records and medical expense vouchers;
(two) false, false list of medical personnel, treatment items, treatment time, medical materials, drugs;
(three) in violation of government price regulations, false diagnosis and treatment items, medical materials and drug prices.
Article 68 If an employer or any other party refuses to accept the decision made by the tax collection organ or the administrative department of labor and social security to collect the basic medical insurance premium, interest, late payment fee and punishment, it may apply for reconsideration or bring an administrative lawsuit according to law. If it fails to apply for reconsideration, bring a lawsuit or perform the decision within the time limit, the tax collection organ or the administrative department of labor security may apply to the people's court for compulsory execution.
Chapter VIII Supplementary Provisions
Sixty-ninth retired personnel, the old Red Army, second-class disabled retired revolutionary soldiers medical treatment in accordance with the relevant provisions of the state.
Article 70 Whether employees of urban individual economic organizations and township enterprises participate in basic medical insurance shall be decided by the provincial people's government.
Article 71 The provincial people's government may formulate detailed rules for implementation according to these regulations.
Article 72 These Regulations shall come into force as of the date of promulgation.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.