In order to further improve the basic medical insurance system for urban and rural residents, reduce the medical burden of urban and rural residents in our city, and gradually realize the goal that everyone enjoys basic medical insurance, Linhai City has formulated the Interim Measures for Basic Medical Insurance for Urban and Rural Residents in Linhai City. Here is the full text of the Interim Measures for Basic Medical Insurance for Urban and Rural Residents in Linhai City. Welcome to browse!

Interim Measures for Basic Medical Insurance for Urban and Rural Residents in Linhai City Chapter I General Provisions

Article 1 In order to further improve the basic medical security system for urban and rural residents, reduce the medical burden of urban and rural residents in our city, and gradually realize the goal that everyone enjoys basic medical security, According to the State Council's Notice on Printing and Distributing the Implementation Plan for Deepening the Reform of the Medical and Health System during the Twelfth Five-Year Plan (Guo Fa [2012]1No.) and Zhejiang Provincial People's Government Office's Implementation Opinions on Developing Serious Illness Insurance for Urban and Rural Residents (Zhejiang Zhengban Fa [2012]/. Notice of the Office of Taizhou Municipal People's Government on Printing and Distributing the Interim Measures for the Basic Medical Insurance for Urban and Rural Residents in Taizhou (No.438 +046 [2065] of Taiwan Government Office), Implementation Opinions of Taizhou Municipal People's Government Office on Promoting Reasonable and Orderly Medical Care through Graded Diagnosis and Treatment (No.438 +05 [2065] of Taiwan Government Office) and "About Taizhou Municipal People's Government Office"

Article 2 The principles of establishing the basic medical insurance system for urban and rural residents (hereinafter referred to as "residents' medical insurance"):

First, adhere to wide coverage and focus on serious diseases;

Two, financing standards and security level and adapt to the economic and social development of our city;

Third, the combination of individual contributions and government subsidies;

Four, the medical insurance fund management should be based on the principle of fixed income and expenditure, balance of payments, a slight surplus.

Chapter II Organization and Management

Article 3 Medical insurance for residents shall be organized and guided by the municipal government and implemented by the municipal social security department. Towns (streets) are responsible for the publicity and implementation of relevant regulations, the registration of urban and rural residents within their jurisdiction (the signing and entry of village (community) residents who have implemented premium withholding and the reminder and supervision of payment), the collection of medical insurance pooling funds and the issuance of social security citizen cards. The municipal education department shall cooperate with the publicity notice of students' enrollment, the enrollment registration of non-Taizhou registered students, the collection of medical insurance funds and the issuance of social security citizen cards. The municipal social security agency is specifically responsible for the management of the medical insurance pooling fund.

Finance, taxation, auditing, public security, development and reform (price), health planning, market supervision, civil affairs, disabled persons' federations, municipal information center, citizen card service center and other departments shall, according to their respective functions and duties, assist in the implementation of residents' medical insurance.

Article 4 This Municipality implements the examination and approval system for designated medical institutions, implements dynamic management for designated medical institutions, and signs service agreements, which shall be examined and determined by the municipal social security department (refer to the designated medical institutions for basic medical insurance for employees in this Municipality). The main responsibilities of designated medical institutions are:

First, determine the person in charge, strictly implement the relevant provisions of residents' medical insurance management, and carry out timely and effective publicity of residents' medical insurance policies;

Two, confirm the identity of patients, and truthfully inform the residents of medical insurance related policies;

Three, responsible for providing quality medical services for insured patients;

Four, take the initiative to accept the assessment and supervision and inspection of the social security department, and cooperate with the social security department to do other work.

Chapter III Subject matter of Insurance

Article 5 The insured objects of residents' medical insurance are:

1. All urban and rural residents registered in Linhai who have not participated in social medical insurance such as basic medical insurance for employees (excluding commercial insurance);

2. Non-Taizhou registered students (hereinafter referred to as "college students") who study in all kinds of primary and secondary schools in Linhai City and full-time colleges and universities in Linhai City (including private colleges and universities) (not participating in social basic medical insurance such as new rural cooperative medical insurance and basic medical insurance for urban residents).

Chapter IV Raising and Management of Medical Insurance Co-ordination Fund

Article 6 Insured residents with household registration in Linhai City shall implement the whole household insurance system, that is, the insured must take the household registration population as the unit to participate in the whole household insurance (except family members who have participated in social medical insurance such as basic medical insurance for employees). The premium is collected annually and paid in one lump sum according to the principle of whole household insurance. Non-Taizhou registered students and all kinds of primary and secondary school students in the city are organized by the municipal education department and insured by the school. Residents' medical insurance is implemented with one person and one card (social security citizen card).

Seventh residents' medical insurance fund raising standard: the annual per capita fund raising standard is not lower than that of 670 yuan, in which individuals pay 240 yuan, and financial subsidies at all levels are not lower than that of 430 yuan (in which the town financial subsidy is 5 yuan).

Encourage qualified villages (communities) to give appropriate subsidies to the insured. For those who hold the minimum living guarantee card, rural five-guarantee recipients, urban "three noes" personnel, key special care recipients, those who hold the "People's Republic of China (PRC) and China Disabled Persons' Card" and have a disability level of Grade II or above, the elderly aged 80 and above, orphans, children in distress, family members who have lost their only child, and disabled people from marginal families with minimum living guarantee, the individual contributions shall be borne by the municipal finance.

Eighth medical insurance fund raising adhere to the principle of first-level responsibility, by the town government (street offices) overall responsibility. The municipal government and the town government (street offices) signed a letter of responsibility, and the town government (street offices) signed a letter of responsibility with the villages, which was included in the annual work assessment. Before the deadline of unified collection and payment, the town government (street office) will pay in full to the special account of the municipal medical insurance co-ordination fund.

Article 9 The residents' medical insurance co-ordination fund consists of the basic medical insurance fund and the serious illness insurance fund, which are managed by special financial accounts and earmarked for special purposes, and are subject to supervision and audit by the Municipal Finance Bureau and the Audit Bureau. It is strictly forbidden for any unit or individual to borrow or misappropriate. Those who violate the regulations shall be severely punished according to law.

When the annual fund-raising is completed within 1 month, the serious illness insurance premium of each insured person will be included in the serious illness insurance fund according to the standard of not less than 3% of the per capita fund-raising amount of residents' medical insurance in our city last year (adjusted appropriately according to the income and expenditure of the serious illness insurance fund).

Article 10 Insured persons with household registration in Linhai City shall, within the prescribed payment period, go through the registration and payment procedures in the village (community) where the household registration is located with their ID cards, household registration books and relevant exemption certificates. The premium of the insured must be paid to the village (community) before June 20th every year 165438+, and the village (community) must be paid to the local town (street) before June 25th 165438+. The town (street) or village (community) needs to input the insurance information into the platform of residents' medical insurance system before 165438+ 10. The insured person in the village (community) who has implemented premium withholding should hold his/her ID card, household registration book and relevant exemption certificate, sign the application form for insurance in the village (community) where his/her household registration is located, and timely deposit the premium in full into his/her social security citizen card bank account. The town (street) or village (community) should enter the list of contracted personnel into the platform of residents' medical insurance system before June 25th, 165438, to ensure the successful withholding of contracted personnel's premiums in time. Towns (streets) shall, before 1 1.30, uniformly turn over the town financial subsidy funds and the premiums of the insured objects (excluding the village (community) insured persons who implement premium withholding) to the special account of the municipal medical insurance pooling fund.

Non-Taizhou household registration students and all kinds of primary and secondary school students in this city should go through the registration and payment procedures at their schools with their household registration books and relevant exemption certificates within the prescribed payment period. Each school will pay the premium of the insured object to the special account of the municipal medical insurance co-ordination fund before 1 1.30, and at the same time input the information of the insured person into the resident medical insurance system platform. Insured students who fail to pay the premium within the specified time shall not be insured this year, but only in the next year.

After the end of the payment period, during the treatment period, if the insured person stops insurance for some reason, the paid fee will not be refunded. The time for the insured to enjoy medical insurance benefits is 10 month 1 to February 1 (hereinafter referred to as medical insurance year).

Eleventh urban and rural residents who meet the following conditions can participate in the residents' medical insurance and withdraw:

1. Newborns can apply for insurance registration within 90 days (inclusive) after birth, and their close relatives can pay personal expenses with the newborn's household registration certificate and enjoy annual medical insurance benefits from the date of birth. The individual payment standard is determined according to the number of months of treatment in the current year, and the government subsidy is calculated in proportion.

Second, newborns born 90 days later, as well as those who interrupt (or terminate) the basic medical insurance relationship of employees after the annual collection deadline, demobilized soldiers, reformed personnel, and those who moved to our city because of marriage or university graduation accounts, can apply for insurance registration with relevant certification materials, pay personal expenses, and enjoy annual medical insurance benefits from the next month of payment. The individual payment standard is determined according to the number of months of treatment in the current year, and the government subsidy is calculated in proportion.

Third, for other personnel who require insurance after the annual collection deadline, the insurance premium is paid according to the annual per capita financing standard, and the government does not give subsidies. When the annual medical insurance benefits are enjoyed from the fourth month of the payment month.

Chapter V Basic Medical Insurance Benefits

Twelfth hospitalization reimbursement:

First, the scope of hospitalization reimbursement includes reportable expenses such as treatment expenses, medicine expenses, laboratory expenses, examination expenses, operation expenses, hospitalization expenses, outpatient medical expenses for special diseases (the specific drug list, medical service project list and other standards are implemented with reference to the relevant provisions of the basic medical insurance for employees in this Municipality).

The special diseases specified in the present Measures refer to malignant tumor radiotherapy and chemotherapy, dialysis treatment of severe uremia, anti-rejection treatment after organ transplantation, decompensated cirrhosis, aplastic anemia, systemic lupus erythematosus, psychosis, hemophilia, tuberculosis, phenylketonuria (10 years old) and childhood autism (the diagnostic criteria and treatment scope of the above special diseases are implemented with reference to the relevant provisions of the basic medical insurance for employees in this Municipality, and the treatment is limited. Insured persons suffering from special diseases should go through the examination and approval procedures at the municipal social security agency first, and then choose the designated medical institutions and submit the reimbursement directly by swiping the social security citizen card.

Second, the hospitalization reimbursement standard:

In a medical insurance year, hospitalization Qifubiaozhun: 600 yuan, Taizhou first-class and below medical institutions; 800 yuan, a second-class and above medical institution in Taizhou; Taizhou foreign-related secondary and above medical institutions 1000 yuan. For the second hospitalization in the same medical insurance year, the Qifubiaozhun is calculated at 50% of the hospitalization Qifubiaozhun, and the Qifubiaozhun is no longer calculated from the third hospitalization. The medical expenses of the following part of hospitalization Qifubiaozhun shall be borne by the individual. The medical expenses reported above the hospitalization Qifubiaozhun to the highest limit shall be shared by the medical insurance pooling fund and individuals. Within a medical insurance year, the hospitalization medical expenses borne by the medical insurance pooling fund shall be declared in sections and calculated cumulatively. The maximum amount of reportable expenses is 200,000 yuan.

(1)/kloc-minors under the age of 0/8 and/kloc-full-time students in this city over the age of 0/8 (hereinafter referred to as minors):

1. In a medical insurance year, hospitalization expenses incurred by minors that meet the requirements of these Measures can be reimbursed. The specific reimbursement standards are as follows:

Proportion of funds for medical expenses that can be declared.

Above deductible-10000 yuan 75%

1 10,000 yuan-80% above 30,000 yuan

If it exceeds 30,000 yuan, it is 90% of the maximum amount of reportable expenses.

2. If the insured is hospitalized in the designated medical institutions at Taizhou level and below, the payment ratio of the medical insurance pooling fund will be increased by 5 percentage points on the basis of the above standards; In Taizhou city, two designated medical institutions in hospital, according to the above standard 100% reimbursement; In Taizhou City, three designated medical institutions in hospital, according to the above standard of 80% reimbursement. In Taizhou City, two or more designated medical institutions were hospitalized, and the proportion of the overall fund was reduced by 5 percentage points on the basis of the proportion stipulated by the three designated medical institutions in Taizhou City.

(2) Other residents (hereinafter referred to as adults) who meet the reimbursement conditions of these Measures shall be borne by the medical insurance pooling fund: 80% of the designated medical institutions in Taizhou City and below; Taizhou secondary designated medical institutions 75%; 60% of the three-level designated medical institutions in Taizhou; 55% of the designated medical institutions outside Taizhou with level 2 or above.

(III) The hospitalization expenses incurred by the insured who are referred to the designated county hospitals in our city by the primary medical and health service institutions where the contracted doctors are located shall be settled by the social security agency according to the reimbursement ratio of the primary medical and health service institutions where the contracted doctors are located.

(four) within a year of medical insurance, the accumulated treatment expenses of special disease clinics are regarded as hospitalization medical expenses (no Qifubiaozhun is set).

(five) after emergency observation, direct hospitalization, Qifubiaozhun is calculated at one time. Those who are not hospitalized after staying in the hospital for observation are not hospitalized.

(six) transfer, Qifubiaozhun one-time calculation. When transferring from a low-level hospital to a high-level hospital, the Qifubiaozhun is calculated according to the high-level hospital; When transferring from a high-level hospital to a low-level hospital, the Qifubiaozhun will not be adjusted.

(7) If the insured person is hospitalized in a medical institution outside the city, it is limited to the designated medical institution with remote medical network settlement in Taizhou, and the designated medical institution above the second level outside Taizhou (the second level outside the province is limited to the public). To seek medical treatment outside Taizhou, you need to be referred by a designated medical institution at or above the second level in our city and reported to the social security agency for the record. If you go out for medical treatment without filing, you should take care of yourself according to 10% first, and then handle it according to the relevant provisions of these Measures. Critical patients who need to take emergency measures, elderly people over 70 years old, infants aged 0-3, pregnant women, severely disabled people and patients who have worked and lived outside the city for more than 3 months and cannot be diagnosed and treated in the city can choose designated medical institutions for diagnosis and treatment. Patients with key infectious diseases should go to designated medical institutions for diagnosis and treatment. The hospitalization expenses incurred by the above-mentioned objects need to provide relevant information to the municipal social security agency for declaration.

(8) Accidental injury hospitalization reimbursement: If the insured is hospitalized due to accidental injury, it shall be handled according to the Social Insurance Law of People's Republic of China (PRC) and other relevant regulations after being audited by the municipal social security agency.

Thirteenth outpatient reimbursement:

First, the general outpatient reimbursement:

1. When the insured person goes to the designated medical institution for outpatient treatment, he/she will be reimbursed directly with his/her social security citizen card and ID card (or household registration book) (the specific drug list, medical service item list and other standards shall be implemented according to the relevant provisions of the basic medical insurance for employees in this Municipality). If you don't swipe your card directly, you don't have to go through the reimbursement procedures separately.

2 in the city level and the following designated medical institutions outpatient expenses, the overall fund to pay 50%; In the city's two designated medical institutions outpatient treatment of Chinese herbal pieces can be reported, and the overall fund will bear 20%. Taizhou mutual recognition designated medical institutions outpatient reimbursement standards with reference to the provisions of our city. The outpatient expenses of medical institutions above the second level in the city and outside the city will not be reimbursed.

3. Within a medical insurance year, the accumulative outpatient payment limit of the residents' medical insurance pooling fund is 700 yuan (including general medical expenses and outpatient treatment expenses). For those who see a doctor in our city, the cumulative payment limit for outpatient service is 1000 yuan.

4 in our city to see a doctor, the general medical expenses shall be borne in full by the overall fund.

Second, minor accidental injury outpatient reimbursement:

In case of accidental injury, the outpatient medical expenses paid in accordance with the regulations can be reported for more than 80% in each 50 yuan, and the maximum payment limit for the whole year is 8,000 yuan.

Article 14 Maternity allowance:

If the insured person gives birth legally within the guarantee period, he can enjoy 500 yuan maternity grants in the municipal social security agency with the social security citizen card, identity card, baby birth certificate, certificate issued by the family planning department and the original receipt of medical expenses, and be reimbursed according to the hospitalization reimbursement regulations after deducting maternity grants from cesarean section.

Fifteenth insured medical expenses due to the following circumstances, the medical insurance fund will not pay:

1. Work-related injuries and their recurrence;

Second, it shall be borne by the third party;

Third, it should be borne by public health;

4. Go abroad for medical treatment;

Five, the basic medical insurance drug list and medical service list outside the scope;

Six, non basic medical insurance designated medical institutions of medical expenses;

Seven, family planning medical expenses included in the scope of maternity insurance;

Eight, other medical expenses not paid in accordance with the provisions.

Sixteenth insured persons suffering from large-scale outbreak of infectious diseases or affected by large-scale natural disasters caused by medical expenses, by the Municipal People's government to study and solve.

Seventeenth insured persons shall not repeatedly enjoy medical insurance benefits.

Chapter VI Treatment of Serious Illness Insurance

Article 18 In a medical insurance year, the compliance medical expenses incurred by the insured in hospitalization (including special disease outpatient service), the accumulated personal burden after the burden of the basic medical insurance fund, and the special drug expenses of serious illness insurance exceeding 25,000 yuan shall be paid by the serious illness insurance fund according to the following proportions: 50% of the part from 25,000 yuan to 50,000 yuan (inclusive); 50,000 yuan and above, pay 60%.

Article 19 Compliance medical expenses refer to the medical expenses (excluding self-funded expenses and self-care expenses) within the medical insurance expenses stipulated in the Catalogue of Medicines for Basic Medical Insurance, Work Injury Insurance and Maternity Insurance and the Catalogue of Medical Services for Basic Medical Insurance in Zhejiang Province, which occurred in designated medical institutions within a medical insurance year.

Twentieth a single visit to the serious illness insurance compliance medical expenses and special drug expenses exceed the Qifubiaozhun, be paid in the basic medical insurance settlement; If you see a doctor many times in a year, you will be paid for each settlement. For the major illness insurance compliance medical expenses and special drug expenses for a single diagnosis and treatment, if the expenses do not exceed the deductible standard and the diagnosis and treatment are repeated within the year, they shall be paid when the accumulated expenses exceed the deductible standard.

Twenty-first serious illness insurance is managed, organized and coordinated by the government. At the same time, we can also entrust commercial insurance institutions to undertake serious illness insurance, make use of the professional advantages of commercial insurance institutions, give play to the role of market mechanism, and improve the operating efficiency, service level and quality of serious illness insurance.

Social insurance agencies are responsible for the transfer and settlement of serious illness insurance funds, the review and payment of serious illness insurance benefits, and guide and supervise commercial insurance institutions to carry out serious illness insurance work.

Chapter VII Reimbursement Process

Twenty-second in order to improve the management level of residents' medical insurance and facilitate people's reimbursement, our province has established an information network of residents' medical insurance and implemented information management. The insured person will be reimbursed directly by swiping his social security citizen card and ID card at the designated medical institutions in this city and the "one card" designated medical institutions in Zhejiang Province; After being discharged from the local designated medical institutions outside Linhai (excluding the "one-card" designated medical institutions in the province for direct credit card reimbursement), the insured person or his family members will bring the following information to the social security agency in Linhai for reimbursement:

First, the original and photocopy of the insured's ID card or household registration book, and the original social security citizen card.

Two, outpatient medical records, discharge summary and a copy of the original, the original receipt of medical expenses, detailed list of expenses. The original documents must be legible and shall not be altered. A copy of the original receipt cannot be used for reimbursement.

Three, if you entrust others to handle reimbursement, you need to provide the identity card and a copy of the trustee. The pre-trial system shall be implemented for the reimbursement of hospitalization medical expenses that cannot be directly reimbursed by the insured. The municipal social security agency will review the reimbursement within ten working days (except for accidental injuries).

Four, the city social security institutions that need to provide other materials.

Twenty-third insured persons should generally be reimbursed within the reimbursement year after discharge, and those who go out can be postponed until April 30th of the following year.

Twenty-fourth of these measures take the year as the settlement unit, and the cross-year hospitalization is settled according to the discharge year.

Chapter VIII Supervision and Administration

Twenty-fifth in the implementation of the residents' medical insurance policy, in violation of the relevant provisions of the "People's Republic of China (PRC) Social Insurance Law", the relevant administrative departments shall be punished according to law.

Twenty-sixth provisions on the handling of fraud:

First, it has been verified that there are medical personnel who practise fraud when providing vouchers, and the municipal public health administrative department instructs their medical units to make corresponding treatment according to the seriousness of the case. If the circumstances are particularly serious and constitute a crime, they shall be handed over to judicial organs for handling, and the unit leaders shall be held accountable accordingly;

Second, the insured who practices fraud will not be reimbursed after investigation, and those who have been reimbursed will be recovered through persuasion and judicial channels. If the circumstances are particularly serious and constitute a crime, they shall be handed over to judicial organs for handling.

Chapter IX Supplementary Provisions

Article 27 The insured age shall be calculated on the basis of 65438+February 3 1 per year.

Twenty-eighth approach by the municipal social security department is responsible for the interpretation of.

Article 29 These Measures shall be implemented as of 20 17 1, and the Notice of the former Linhai Municipal People's Government Office on Printing and Distributing the Interim Measures for the Basic Medical Insurance for Urban and Rural Residents in Linhai City (Pro Zheng Ban Fa [2015]149) shall be abolished at the same time.

Thirtieth during the implementation of these measures, if the superior has a new policy, it shall be implemented according to the provisions of the new policy.

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