Public medical care and labor insurance medical care established in China in the early 195s are collectively referred to as social medical insurance for employees. It is an important part of the national social security system and one of the important items of social insurance.
China's medical insurance has played an active role in safeguarding workers' health and maintaining social stability for more than 4 years. However, with the establishment of the socialist market economic system and the deepening of the reform of state-owned enterprises, this system has been difficult to solve the problem of basic medical security for employees under the conditions of market economy.
in p>1988, the government of China began to reform the free medical care system of government agencies and institutions and the labor insurance medical care system of state-owned enterprises. In 1998, the China Municipal Government promulgated the Decision on Establishing the Basic Medical Insurance System for Urban Employees, and began to establish the basic medical insurance system for urban employees throughout the country.
the basic medical insurance system implements the principle of combining social pooling with individual account, organically combines social insurance and savings insurance, and realizes the organic combination of "horizontal" social security and "vertical" individual self-security, which is not only conducive to giving full play to the advantages of social pooling, but also beneficial to giving play to the advantages of individual account, which is more in line with China's national conditions and easy to be accepted by workers. This medical insurance model conforms to China's national conditions and is a social medical insurance system with China characteristics.
in principle, the basic medical insurance fund shall be co-ordinated at the municipal level. The basic medical insurance covers all employers and their employees in cities and towns; All enterprises, state administrative organs, institutions and other units and their employees must fulfill the obligation to pay the basic medical insurance premium. The employer's contribution ratio is about 6% of the total salary, and the individual contribution ratio is 2% of my salary. Part of the basic medical insurance premium paid by the unit is used to establish the overall fund, and part of it is included in the personal account; The basic medical insurance premiums paid by individuals are included in personal accounts. Pooling funds and individual accounts bear different responsibilities for payment of medical expenses. The overall fund is mainly used to pay for hospitalization and outpatient treatment of some chronic diseases, and the overall fund has Qifubiaozhun and maximum payment limit; Personal accounts are mainly used to pay for general outpatient expenses.
in order to ensure the insured employees enjoy basic medical services and effectively control the excessive growth of medical expenses, the China municipal government has strengthened the management of medical services, formulated the basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards, qualified medical institutions and pharmacies that provide basic medical insurance services, and allowed insured employees to choose. In order to cooperate with the reform of the basic medical insurance system, the state also promotes the reform of medical institutions and drug production and circulation system. By establishing the competition mechanism between medical institutions and the market operation mechanism of drug production and circulation, we will strive to achieve the goal of "providing better medical services at lower costs".
In addition to the basic medical insurance, mutual assistance systems for large medical expenses have been generally established in various places to solve the medical expenses above the maximum payment limit of social pooling funds. The state has established a medical subsidy system for civil servants. Conditional enterprises can establish supplementary medical insurance for employees. The state will also gradually establish a social medical assistance system to provide basic medical security for the poor.
The reform of basic medical insurance system in China is progressing steadily, and the coverage of basic medical insurance is expanding. By the end of 21, 97% of the cities in China had started the reform of basic medical insurance, and about 76.29 million employees participated in the basic medical insurance. In addition, free medical care and other forms of medical security system have covered more than 1 million urban people, and the China government is gradually bringing these people into the basic medical insurance system.
It has been learned from the Ministry of Human Resources and Social Security that the Guiding Opinions on Improving the Agreement Management of Designated Medical Institutions of Basic Medical Insurance has been published recently, which explicitly requires all co-ordination areas in China to completely cancel the qualification examination of "Designated Medical Institutions of Basic Medical Insurance" and "Designated Retail Drugstores of Basic Medical Insurance" implemented by social insurance administrative departments before the end of 215, improve the agreement management between social insurance agencies and medical institutions, and improve the management service level and funds.
The Opinions put forward clear requirements on how to improve the agreement management after canceling the "two-fixed" qualification examination implemented by the social security administrative department. All kinds of medical institutions established according to law, regardless of their level, category and ownership nature, can voluntarily apply to the social security agency to become the designated medical insurance point according to the conditions, and the social security administrative department will no longer conduct pre-approval. At the same time, the agency should establish an open and transparent evaluation mechanism, explore ways to carry out evaluation through third-party evaluation, and select medical institutions with good service quality, reasonable price and standardized management to negotiate and sign service agreements. Chapter iii basic medical insurance
article 23 employees shall participate in the basic medical insurance for employees, and the employer and employees shall pay the basic medical insurance premiums in accordance with state regulations. Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees in the employer and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations. Article 24 The state establishes and improves the new rural cooperative medical system. Measures for the administration of the new rural cooperative medical system shall be formulated by the State Council. Article 25 The state establishes and improves the basic medical insurance system for urban residents. The basic medical insurance for urban residents combines individual contributions with government subsidies. Those who enjoy the minimum living guarantee, the disabled who have lost the ability to work, the elderly and minors who are over 6 years old in low-income families, etc., are subsidized by the government. Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations. Twenty-seventh individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, will not pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with state regulations; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state. Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency and rescue shall be paid from the basic medical insurance fund in accordance with state regulations. Twenty-ninth insured medical expenses should be paid by the basic medical insurance fund, by the social insurance agencies and medical institutions, pharmaceutical business units directly settled. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places, so as to facilitate the insured to enjoy the basic medical insurance benefits. Thirtieth the following medical expenses are not included in the scope of payment of the basic medical insurance fund: (1) should be paid from the industrial injury insurance fund; (2) It shall be borne by a third party; (three) shall be borne by the public health; (4) seeking medical treatment abroad. Medical expenses shall be borne by the third party according to law. If the third party fails to pay or cannot determine the third party, the basic medical insurance fund shall pay in advance. After the basic medical insurance fund has paid in advance, it has the right to recover from the third party. Thirty-first social insurance agencies can sign service agreements with medical institutions and pharmaceutical business units to regulate medical service behavior according to the needs of management services. Medical institutions shall provide reasonable and necessary medical services for the insured. Thirty-second individuals across the overall regional employment, the basic medical insurance relationship with my transfer, the cumulative payment period. (I) Establishment of Personal Account
The social medical insurance agency establishes a personal account of basic medical insurance for each insured person, with my ID number as the lifelong medical insurance number. The funds in the personal account of the basic medical insurance for employees are owned by individuals, which are used for medical consumption. If the overspending is not made up, the balance will be accumulated and no cash will be withdrawn. When the employee dies, the individual account shall be cancelled and the balance shall be inherited according to the regulations.
(II) Issuance of individual account cards
The employer shall apply for individual medical account settlement cards for employees while participating in basic medical insurance. Within 3 days from the date of joining the medical insurance, the employer shall apply to the social medical insurance agency and provide relevant information. The social medical insurance agency shall, after receiving the application from the employing unit for building a household for employees, carefully examine the relevant materials, establish individual accounts for employees within 15 days, and issue individual account settlement cards. Inject funds into the employee's personal medical account in time, and bear interest according to relevant regulations. Retirees placed in different places may not issue cards temporarily.
the insured person can take the personal medical account card to seek medical treatment and purchase medicines at any designated medical institution and designated pharmacy in the overall planning area. When the funds in the personal medical account are insufficient, they will be paid in cash.
(III) Transfer and inheritance of personal accounts
When the insured person is transferred from the local area, the funds in the personal medical account will be transferred with him. If it cannot be transferred, the balance in the personal account can be returned to him and the personal account will be cancelled at the same time.
if the insured dies, the balance of the personal account can be inherited by his legal heir.
(4) Loss reporting and replacement of personal account cards
Insured personnel shall properly keep personal account cards, and if they are damaged and need to be replaced with new cards, the costs and expenses shall be borne by individuals. If the personal account card is lost, it should be reported to the medical insurance agency or the designated unit with the relevant documents in time, and the medical insurance agency should immediately seal the account. If you can't find it within 3 days, you should apply for a new card at your own expense. The medical expenses incurred during the loss reporting period shall be partially paid by employees in cash in their personal accounts. If the personal account card is fraudulently used before reporting the loss, the loss shall be borne by the insured.
when the insured uses the card to purchase medicines and settle medical expenses, the service personnel of designated medical institutions and pharmacies should carefully check, and those who find forged or fraudulent loss reporting cards should be detained immediately and notified to the social medical insurance agency. Designated medical institutions and pharmacies shall not refuse card funds or exchange cash for cardholders.
In January, 21, Ministry of Human Resources and Social Security promulgated the Interim Measures for the Transfer and Continuation of the Basic Medical Insurance Relationship for Migrant Workers. This Measures stipulates that from July 1, 21, migrant workers can transfer their medical insurance relationship when they are employed across provinces, and their personal accounts will also be transferred. In addition to the inter-provincial transfer of medical insurance relations, with the change of the identity of the insured, three different types of medical insurance relations, namely employee medical insurance, resident medical insurance and new rural cooperative medical care, can also be transferred to each other. Migrant workers in cities can participate in the local basic medical insurance for employees at their places of employment, and they can bring it back to the countryside and turn it into the new rural cooperative medical insurance without interruption. (1) The collection department of the medical insurance institution accepts the "Declaration Form for the Change of Medical Insurance Payment Base" filled in by the insured unit, and requires the following information:
1. The salary payment schedule;
2. List of Increase and Decrease of Persons Participating in Medical Insurance
3. Other information specified by medical insurance institutions.
(II) Payment verification
1. The collection department of the medical insurance institution reviews the payment declaration verification form and relevant materials filled in by the insured unit. After the examination and approval, the insured shall go through the formalities of approval or increase or decrease.
2. The collection department of the medical insurance institution shall timely record the enrollment time, current payment wages and other information for the newly insured persons according to the payment declaration and verification. The collection department of the medical insurance institution shall verify the current payment base according to the declaration of the insured unit.
3. The collection department of the medical insurance institution calculates the payable amount according to the approved current payment base and payment rate of the insured unit, and prints out the Notice of Medical Insurance Payment and feeds it back to the reporting unit, and collects it on this basis.
(III) Collection of fees
1. The medical insurance institution collects fees through the bank where the income account is opened, or by cheque, cash, telegraphic transfer or cashier's check, and issues special receipts. The financial management department of the medical insurance institution reconciles with the bank every month, and feeds back the receipt to the collection department.
2. The collection department of the medical insurance institution issues the Social Insurance Premium Reminder Notice to the insured unit that fails to pay the medical insurance premium in full or in time after the declaration according to the medical insurance premium payment feedback from the financial management department. If it is not implemented within the time limit, it shall provide relevant information and materials to the administrative department of labor security, and the administrative department of labor security shall make corrections within a time limit.
3. before 25th of each month, if the insured unit delays the payment, it will be charged a late fee of 2‰ on a daily basis from the date of default. Can be paid in one lump sum for one month, one quarter, six months or one year. If it is paid quarterly or annually, it should be paid at the beginning of the quarter or the beginning of the year. Temporarily unable to pay, apply for holdover, holdover time shall not exceed 2 months.
(4) Pay the arrears
1. The collection department of the medical insurance institution establishes the arrears data information according to the arrears of medical insurance, fills in the Notice of Payment of Social Insurance Premium, and informs the insured units to pay the arrears.
2. The collection department of the medical insurance institution will sign a social insurance payment agreement with the insured unit that cannot pay the arrears in full at one time due to financing difficulties. In case of merger, division, bankruptcy, etc. of the defaulting unit, an overdue agreement shall be signed according to the following methods.
(1) if the arrears unit is merged, it shall sign a payment agreement with the merging party.
(2) If the delinquent units are separated, they shall sign a payment agreement with each branch.
(3) If the defaulting unit enters bankruptcy proceedings, it shall sign a settlement agreement with the liquidation team.
(4) if the unit is sold or leased by auction, it shall sign a payment agreement with the competent department.
3. The insured unit shall pay back the social insurance premium according to the Notice of Payment of Social Insurance Premium or the payment agreement, and the collection department of the medical insurance institution shall accept it and notify the financial management department of the medical insurance institution to collect the payment.
4. The collection department of the medical insurance institution accepts the application put forward by the bankruptcy liquidation group of the bankrupt unit, and sends it to the audit and supervision department for handling.
5. The collection department of the medical insurance institution adjusts the arrears information of the insured units according to the information of overdue arrears received from the financial management department and the write-off information from the audit and supervision department. Settlement Procedures for Hospitalization and Outpatient Treatment of Special Diseases Designated medical institutions shall, before the 1th day of each month, report the expense statement, hospitalization statement and relevant materials of patients discharged from hospital last month to the medical insurance agency, which will be used as the basis for monthly pre-allocation and year-end final accounts after being audited by the medical insurance agency. Medical insurance agencies pre-allocate the overall expenses for hospitalization and outpatient treatment of special diseases last month.
Insured persons who are identified as suffering from special diseases should go to a designated medical institution designated by the labor and social security department for medical treatment and purchase medicines, and the medical expenses incurred should be directly accounted for and settled immediately.
(II) Emergency Settlement Procedures
The medical expenses incurred by the insured for emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by the individual or unit first. After the emergency rescue is over, the medical insurance agency shall go through the reimbursement procedures according to the regulations with the hospital emergency medical records, inspection, laboratory report, invoices and detailed list of medical charges.
(III) Settlement Procedures for Relocated Workers
1. Relocated workers in different places shall be assigned 1-2 designated medical institutions for their residence by their units and reported to the medical insurance agency for the record.
2. The medical expenses incurred by the designated medical institution in the place of residence where the staff in different places are ill will be paid in advance by the person or the unit where they work. After the treatment, the unit where they work will settle the medical certificate and medical records of the insured, valid expense bills, compound prescriptions, hospitalization expenses list, etc. at the social medical insurance agency on the specified date.
(4) Referral and settlement
1. The insured is limited by the conditions of designated medical institutions or because of specialties.