Chapter I General Provisions
Article 1 In order to ensure the basic medical care for urban residents, further improve the medical insurance system and build a harmonious society, according to the Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No.20), the Implementation Opinions of the People's Government of Hebei Province on Establishing the Basic Medical Insurance System for Urban Residents (Fa [2007] No.99) and the Implementation Plan of Basic Medical Insurance for Urban Residents in Hengshui City (Hengfa)
Article 2 The basic medical insurance system for urban residents adheres to the principle of low level and wide coverage, and makes corresponding institutional arrangements for medical security for different levels of groups. According to the level of economic development and the affordability of all aspects, the financing standards and security levels are reasonably determined, with emphasis on ensuring the medical needs of residents for hospitalization and outpatient serious diseases; Adhere to the principle of family as a unit, voluntary participation of the masses, and the combination of individual contributions and government subsidies; Adhere to the principle of overall planning, coordination and unified management, and do a good job in connecting the basic policies, standards and management measures among various medical security systems.
Third basic medical insurance for urban residents in the county as a whole unit, the county government is responsible for unified coordination and management. The county government set up a leading group for urban residents' basic medical insurance, which is responsible for organizing, coordinating and giving macro guidance, studying and formulating relevant policies, supervising and inspecting the implementation of policies, and coordinating and solving problems arising in the work. All relevant departments work closely together to do a good job in the basic medical insurance for urban residents.
Article 4 County Personnel, Labor and Social Security Bureau is the administrative department in charge of residents' medical insurance, and is responsible for the formulation, implementation, management and supervision of the basic medical insurance policies for urban residents; County Finance Bureau is responsible for the budget arrangement and disbursement of financial subsidy funds, strengthen the supervision and management of funds, implement matching funds, and ensure the funds needed for basic medical insurance for urban residents to be included in the fiscal budget; County Health Bureau is responsible for the supervision of medical institutions, improve the construction of community health service institutions, and provide basic medical services with high quality and low price for insured residents; County Education Bureau is responsible for the publicity and mobilization of primary and secondary school students and kindergarten children's insurance work, to implement the target responsibility system, the responsibility to schools, kindergartens, so that all insurance should be guaranteed; The county public security bureau is responsible for the household registration of the insured, providing relevant basic data and timely providing information on the settlement of newborns; County Civil Affairs Bureau is responsible for the identification of low-income families, low-income residents and elderly people over 60 years old, and cooperate with the labor and social security departments to do a good job in data statistics and insurance registration of poor people; County Disabled Persons' Federation is responsible for severe disability (1? 2) Personnel level appraisal, and cooperate with the labor and social security departments to register the disabled; The township government is responsible for the propaganda, mobilization and insurance of urban residents within the township; The county development and reform bureau, the US Food and Drug Administration and other departments are responsible for formulating relevant supporting policies and measures to assist in the basic medical insurance for urban residents. The above departments should do a good job in starting the basic medical insurance for urban residents in accordance with their respective responsibilities.
The county medical insurance center is specifically responsible for the basic medical insurance for urban residents in this county, and undertakes the insurance work for urban residents in this county (except schools and kindergartens). Township labor and social security service stations and schools are the agencies that handle the basic medical insurance for urban residents. Under the guidance of the labor and social security department, it undertakes the work of residents' insurance publicity and mobilization, insurance registration, qualification examination, basic information entry, change, summary report, medical insurance, ic card collection and distribution, etc.
Chapter II Insurance Scope
Article 5 Non-employed urban residents who have not participated in the basic medical insurance for urban workers may voluntarily participate in the basic medical insurance for urban residents within their respective administrative areas. Including:
(a) primary and secondary school students (including vocational education centers, high schools, junior high schools, primary school students and kindergarten children)
(2)/kloc-non-school residents under the age of 0/8 (inclusive);
(3) 18-year-old unemployed urban residents.
Sixth other people who meet the relevant national and provincial policies and regulations and the spirit of the document may voluntarily participate in the basic medical insurance for urban residents. Including:
(1) Flexible employees and migrant workers;
(two) the closure of retirees of bankrupt enterprises (including retirees who have not participated in the basic medical insurance for urban workers) and the closure of employees of bankrupt enterprises.
Chapter III Financing Standards and Subsidies
Seventh insured persons in addition to the central and provincial financial subsidies, the insufficient part of the county finance to make up.
Article 8
(a) all kinds of students, 18-year-old and non-school residents, the medical insurance premium financing standard is 160 yuan per person per year (including large medical insurance premium 10 yuan), individuals pay 30 yuan, and the rest are supplemented by the central, provincial and county finances.
(2)/kloc-The funding standard for medical insurance for urban residents aged 0/8 is 300 yuan per person per year (including 50 yuan with large medical insurance premium). Individual contribution 170 yuan, and the rest will be supplemented by the central, provincial and county finance. (Residents in 2009 1.8 will be charged medical insurance fees in the second half of the year. The standard is that individuals pay 85 yuan, including large medical insurance fees (25 yuan).
The medical insurance premiums of the residents with minimum living allowance, severe disability (1-2) and the elderly over 60 years old in low-income families are all borne by financial subsidies. In addition to the central and provincial financial subsidies, the rest are subsidized by the county finance.
Article 9 Eligible employers may give subsidies for insurance payment to the family members of employees, and the subsidy funds of the unit shall be paid before tax.
Chapter IV Insurance Registration and Fund Collection
Tenth all kinds of students and kindergarten children are designated as medical insurance managers by their schools and kindergartens, and they shall go through the insurance procedures in a unified way. Students and kindergarten children should provide their ID numbers when registering for insurance. I have two recent bareheaded photos of my second child. Schools and kindergartens should promptly submit the basic information of the insured and the collected medical insurance premium to the county medical insurance center or the designated bank account.
Urban residents hold their household registration book, the original and photocopy of ID card 1 copy, and two recent bareheaded color photos of their second child (photos are not required for children before kindergarten), and go to the county medical insurance center and the township labor security service station to go through the insurance payment procedures. After the county medical insurance center and the township labor and social security service station have passed the examination and approval of the residents' application materials, they will print the payment documents for the insured residents and go through the relevant registration procedures, and the insured residents will pay the medical insurance premium to the bank account designated by the medical insurance center.
The following personnel shall go directly to the county medical insurance center to handle the insurance formalities with valid proof materials such as low assurance and severe disability certificate (original and photocopy 1) issued by the civil affairs department or the Disabled Persons' Federation, and after posting no objection by the insurance registration department:
Minimum goal;
(two) severely disabled urban residents (including all kinds of students);
(three) the annual per capita income is less than one-third of the annual per capita disposable income of residents in this county, and the elderly over 60 years old (provide the low-income family certificate issued by the Civil Affairs Bureau).
Article 11 The insured residents take their families as the unit, and those who meet the basic medical insurance conditions for urban residents must be insured at the same time (except those who have participated in the basic medical insurance for urban workers and the new rural cooperative medical system), and all kinds of students take the school as the insured unit and collectively go through the insurance procedures.
Twelfth newborns should go through the insurance formalities within 3 months from the date of household registration.
Thirteenth medical insurance for urban residents to implement a one-year prepayment system, one year for a medical payment cycle.
(a) all kinds of students, kindergarten children according to the school year, at the beginning of each school year for insurance registration and change the relevant insurance information, pay the basic medical insurance premium for this school year, from June 30th of that year to September 30th of the following year for medical insurance benefits payment period.
(two) non-school residents under the age of eighteen and urban residents over the age of eighteen shall pay the annual fee. From September 1 day to1October 3 1 day every year, the registration, prepayment and change of residents' medical insurance information are centralized. In 2009, the medical insurance fee was collected for half a year, and the medical expenses for the second half of the year were reimbursed. The medical insurance premium for 20 10 is collected on 20 10, and the medical insurance premium is collected from September to June 10, June 1 to February 3 1 of the following year.
Article 14 The county medical insurance center shall report the number of insured residents and the amount of financial subsidies to the financial department before 1 1.30 every year, and incorporate them into the financial budget of the next year. The financial department will allocate the financial subsidy funds to the financial accounts of the county medical insurance center before the end of the following year 1.
Fifteenth basic medical insurance for urban residents only to build a unified fund, not a personal account.
Sixteenth urban residents' basic medical insurance payment will not be refunded after it is included in the overall fund.
Chapter V Medical Insurance Benefits
Article 17 The basic medical insurance for urban residents in Hebei Province shall implement the list of drugs, the list of medical treatment items, the scope and standards of medical service facilities and other relevant provisions of the basic medical insurance for urban employees, and on this basis, appropriately increase the variety and scope of drugs used by children. The expenses incurred in hospitalization shall be settled directly with the designated medical institutions except for the individual, and the rest shall be settled with the designated medical institutions by the county medical insurance center.
Eighteenth overall fund payment scope includes:
(a) to pay the hospitalization expenses of non-student urban residents who meet the requirements of the basic medical insurance for urban residents and the outpatient expenses of taking anti-rejection drugs after radiotherapy and chemotherapy for malignant tumors, outpatient dialysis for uremia and liver and kidney transplantation;
(II) Pay all kinds of students, 18-year-old non-registered residents' hospitalization expenses for diseases and accidental injuries, outpatient expenses for radiotherapy and chemotherapy of malignant tumors, outpatient expenses for dialysis of uremia, outpatient expenses for taking anti-rejection drugs after liver and kidney transplantation, and outpatient expenses for aplastic anemia and hematological diseases in remission stage of leukemia.
Nineteenth urban insured residents need to bear a certain amount of medical expenses each time they are hospitalized, that is, Qifubiaozhun. Qifubiaozhun is determined according to different levels of medical institutions: first-level designated medical institutions in 300 yuan (including designated community health service centers), second-level designated medical institutions in 500 yuan and third-level designated medical institutions in 700 yuan.
The proportion of hospitalization reimbursement for insured residents is: 70% for designated medical institutions at the first level (including designated community health service centers) above Qifubiaozhun, 60% for designated medical institutions at the second level and 50% for designated medical institutions at the third level.
The maximum annual payment limit of the overall fund is 30,000 yuan per person.
Twentieth belong to the basic medical insurance for urban residents to pay part of the cost of diagnosis and treatment projects, as well as the use of basic medical insurance for urban residents drug list? Class B drugs? Yes, the individual pays 10% first, and the remaining 90% is paid by the individual and the overall fund according to the prescribed proportion.
Article 21 Insured residents (65, 438+08-year-old students and non-school residents, including aplastic anemia and leukemia in remission) who take anti-rejection drugs after outpatient radiotherapy and chemotherapy for malignant tumors, outpatient dialysis for uremia and liver and kidney transplantation need outpatient treatment, and report to the labor and social security department for confirmation. Outpatient treatment can be included in the scope of payment of the basic medical insurance fund for urban residents. The annual Qifubiaozhun is 500 yuan, and the medical expenses above Qifubiaozhun and below the maximum payment limit shall be implemented according to the relevant provisions of hospitalization in the county-level designated medical institutions.
Twenty-second payment period and medical insurance benefits linked. The proportion of urban residents' basic medical insurance fund payment will increase by 3% every five years, and the cumulative maximum will not exceed 9%. If the insured residents interrupt the payment, the payment period shall be recalculated according to the new insurance.
Twenty-third referring to the operation mode of large-scale medical insurance for urban workers, the large-scale medical insurance for urban residents shall be implemented at the municipal level, and the municipal medical insurance agency shall apply to the commercial insurance company in a unified manner. If the hospitalization and outpatient expenses of the insured exceed the maximum payment limit of the basic medical insurance fund for urban residents, and meet the requirements of the basic medical insurance for Class A medical expenses, 75% shall be paid by large medical insurance, 25% by individuals, and 10% by Class B, and then paid according to this ratio. The maximum payment limit of large medical insurance in a settlement year is 70000 yuan.
Chapter VI Medical Management
Twenty-fourth basic medical insurance for urban residents to implement designated medical management. When the insured residents need medical treatment due to illness, they should choose medical treatment with their medical insurance IC card and medical insurance in the designated medical institutions of medical insurance announced by the labor and social security department.
Twenty-fifth insured residents hospitalized due to illness, it is really necessary to transfer, must fill out the "Anping County Urban Residents Referral Transfer Approval Form", submitted to the county medical insurance center for approval. If you need to be hospitalized in a non-designated hospital due to emergency, you should notify the county medical insurance center for the record within 3 days after admission. Transfer to a foreign hospital or a non-designated hospital for treatment. After discharge, report to the county medical insurance center for review before 10 every month on the basis of the examination and approval procedures of the county medical insurance center, the copy of hospitalization medical records, the diagnosis certificate, the expense schedule and the valid expense documents, and submit an expense account according to the regulations. The county medical insurance center will not accept all medical expenses incurred in not being admitted to the hospital according to the procedures.
Twenty-sixth insured residents medical expenses, one of the following circumstances, the basic medical insurance fund for urban residents will not pay:
(a) receiving treatment abroad or in Hongkong, Macao and Taiwan Province;
(2) Suicide, intentional self-injury or self-injury;
(3) Injuries caused by fighting, alcoholism, drug abuse and other illegal and criminal acts;
(four) the liability for compensation for traffic accidents, medical accidents, accidental injuries (except students), work-related injuries or medical expenses shall be borne by the other party;
(five) other circumstances in which the payment is not made according to the relevant provisions.
Twenty-seventh county medical centers should sign fixed-point service agreements with designated medical institutions, clarify the rights and obligations of both parties, and standardize supervision and management. In violation of the provisions of the agreement, recover the illegal funds and impose liquidated damages, which can be used for rewards, publicity and other expenses; If the circumstances are serious, the agreement shall be terminated.
Twenty-eighth labor and social security departments should organize finance, health, price and other departments to strengthen the supervision and inspection of the service and management of designated medical institutions. In violation of the provisions of the designated medical institutions, labor and social security departments according to different situations, shall be ordered to make corrections within a time limit, or informed criticism, or cancel the designated qualification.
Twenty-ninth insured residents resort to deceit, take concealment, fraud and other means to defraud the residents' medical insurance fund, medical insurance agencies will not pay; If it has been paid, it shall be recovered; If the case constitutes a crime, it shall be handed over to judicial organs for handling.
Chapter VII Fund Management and Services
Thirtieth basic medical insurance fund for urban residents consists of medical insurance premiums paid by insured residents, financial subsidies at all levels, fund interest and value-added income, and funds raised by other channels.
Thirty-first basic medical insurance fund for urban residents into the financial accounts. At the same time, the medical insurance center set up income households and expenditure households, and implemented the management of two lines of revenue and expenditure, with separate accounts and separate accounting, which were earmarked for the basic medical insurance for urban residents, and implemented a unified social insurance budget and final accounts system, financial accounting system and audit supervision system.
Thirty-second urban residents' basic medical insurance fund shall be exempted from various taxes and fees in accordance with state regulations.
Thirty-third labor and social security departments and financial departments, strengthen the supervision and management of the basic medical insurance fund for urban residents, and regularly audit the income and expenditure and management of the basic medical insurance fund for urban residents.
Article 34 The labor and social security department shall, jointly with the financial department, formulate the payment standard, financial subsidy and medical treatment of the basic medical insurance for urban residents according to the social and economic development, finance, the improvement of residents' income and the operation of the basic medical insurance fund for urban residents.
Medical insurance benefits, etc. shall be adjusted accordingly and implemented after being approved by the county government.
Thirty-fifth medical insurance agencies according to the number of insured residents in proportion to the increase in personnel, the use of re employment public welfare post indicators equipped with medical insurance coordinator.
Thirty-sixth county finance departments should provide start-up funds for medical insurance agencies, and give financial subsidies to medical insurance centers, township labor security service stations, schools and kindergartens according to the number of urban residents insured. The subsidy standard is 2 yuan/person/year, and the start-up expenses and subsidy funds are included in the county-level fiscal year budget.
Thirty-seventh labor and social security departments are responsible for the management, business training and salary payment of medical insurance coordinators.
Chapter VIII Supplementary Provisions
Thirty-eighth medical expenses caused by major epidemics, disasters and emergencies shall be solved by the county government.
Thirty-ninth the detailed rules for the implementation of the county labor and social security department is responsible for the interpretation of.
Fortieth these rules shall come into force as of July 6, 2009.
;