Policy interpretation ↓↓↓
1. How many payment modes are there to participate in the basic medical insurance for employees?
Answer: There are two payment modes to participate in the basic medical insurance for employees. One is to establish individual accounts for employees' basic medical insurance for employees and retirees according to the unified account combination mode (the payment ratio is 12%, in which the unit pays 10% and the employees pay 2%). Newly insured employers and their employees should pay according to this model. The other is to participate in the insurance payment according to the serious illness co-ordination model (the payment ratio is 8%), and employees and retirees do not establish personal accounts, while flexible employees and poor enterprises participate in the insurance payment according to this model.
2. Can the two payment modes be exchanged?
Answer: Employers who have paid insurance premiums in accordance with the overall account model cannot change to pay insurance premiums in accordance with the overall illness model; The employer who has paid the insurance premium in accordance with the serious illness co-ordination model can apply to the social security agency for changing to pay the insurance premium in accordance with the co-ordination model after paying the medical insurance premium required by the individual account for 5 years in one lump sum for retirees, and since the month of change, employees and retirees have established individual accounts.
The formula for calculating the medical insurance premium required for a one-time payment of 5 years in the personal account of retirees is: (number of retirees under 70 years old in the payment month × number of retirees over 70 years old in 480 yuan × number of old workers before the founding of the People's Republic of China × number of 720 yuan) × 5 years.
3. Can the insured insure again?
Answer: Repeated participation refers to the same insured person's repeated participation in the same basic medical insurance system (repeated participation within the system) or repeated participation in different basic medical insurance systems (repeated participation across systems). Specifically, the same insured has two or more insurance information records of normal insurance payment status in the same time period. Since the settlement period of 202 1 and 1, people who have participated in the basic medical insurance and whose current payment status is normal are not allowed to participate in the insurance in principle. Those who have paid residents' medical insurance fees but have not entered the treatment enjoyment period to apply for employee medical insurance should also go through the refund procedures simultaneously.
4. How to pay the large amount of medical assistance for urban workers?
A: Since 20021,large medical assistance fees for urban workers have been paid monthly, and the insured have paid large medical assistance fees for urban workers since the month when they joined the employee medical insurance. Among them, employees pay 2 1 yuan/month in the first month of each quarter, and 22 yuan/month in other months; Retirees pay 30 yuan/month. The withholding method shall be implemented according to the original channels. In the past year, it will no longer pay a large amount of relief money for urban workers in the historical year.
5. What is considered as payment interruption?
Answer: If the employer and the insured fail to pay the current employee medical insurance premium according to the regulations, it will be regarded as the interruption of payment, and the payment will be interrupted during the suspension of medical insurance benefits.
6. Does the employer pay the medical insurance late fee during the interruption?
Answer: Employers and their employees should participate in the basic medical insurance for employees according to law, and pay the basic medical insurance premiums and large medical assistance fees for employees in full and on time. If the employer suspends the payment of employee medical insurance premiums for any reason, it may pay them back in accordance with the regulations. The employer and its employees shall pay the employee's basic medical insurance premium before 20 1 1 (inclusive), and interest shall be charged according to regulations. After July 20 1 1 (inclusive), the employee's basic medical insurance premium will be paid, and a late payment fee of 0.5 ‰ will be added every day.
7. Can I continue to enjoy medical insurance-related benefits after the payment is interrupted?
Answer: If the employees and flexible employees of the employer who have paid for six months continuously resume their normal payment within three months after the payment is interrupted, the medical expenses incurred in the month of payment will be reimbursed according to the regulations. If it is more than three months, the medical expenses incurred in the supplementary month will not be reimbursed.
8. Can the employer continue to enjoy maternity insurance benefits after the payment is interrupted?
Answer: If the employer suspends the payment of maternity insurance premiums for employees and resumes normal payment within three months, it can enjoy maternity insurance benefits for employees in the month of payment. If it is more than three months, the maternity expenses incurred in the supplementary month will not be reimbursed.
Insured female employees normally enjoy maternity insurance benefits in the month of childbirth or termination of pregnancy, and have paid maternity insurance premiums for more than six months (including overdue payment), and have the conditions to apply for maternity allowance; If the continuous payment is less than six months, you can apply for maternity allowance after six months. In the month of receiving maternity allowance, employees should normally enjoy maternity insurance benefits in accordance with regulations.
9. If the employer stops paying the basic medical insurance premium for employees for some reason, will the medical insurance-related benefits of retirees be affected?
Answer: If the employer and its employees stop paying the employees' basic medical insurance premiums for some reason, or no employees continue to pay the employees' basic medical insurance premiums, the medical expenses incurred by retirees will continue to be reimbursed according to regulations. Among them, the retirees of the employer who have been insured and paid according to the unified account combination model continue to establish personal accounts.
10. How long can flexible employees who are insured for the first time enjoy medical insurance benefits?
A: A waiting period of 6 months is set for newly insured flexible employees, and medical expenses incurred during the waiting period will not be reimbursed by medical insurance. After six months of continuous payment, the medical expenses incurred shall be reimbursed by medical insurance according to regulations.
Flexible employment personnel in the treatment waiting period to interrupt payment within three months to resume normal payment and full payment, waiting period for continuous calculation. If it is more than three months, the waiting period will be recalculated from the month when the normal payment is resumed. After six months of continuous payment, the medical expenses will be reimbursed according to the regulations.
1 1. Can flexible employees pay medical insurance premiums during the interruption period?
Answer: The medical insurance premium during the interruption of payment can be paid back on the basis of paying the employee pension insurance premium, and the actual payment period of employee medical insurance can be accumulated in the month of payment. Flexible employees pay medical insurance premiums for employees and charge interest according to regulations. If they pay the medical insurance premium of the current year, they will not charge interest.
12. How do people who receive unemployment insurance benefits enjoy medical insurance benefits?
Answer: Those who receive unemployment insurance benefits will pay (repay) the basic medical insurance premium, large medical assistance fee and maternity insurance premium in full according to the serious illness co-ordination model. The required funds are paid from the unemployment insurance fund, and individuals do not need to pay fees and do not establish personal accounts. Since the month of unemployment insurance payment, the medical expenses incurred by medical insurance shall be reimbursed according to the regulations. Maternity insurance benefits in accordance with the relevant provisions of this Municipality.
13. Can the insured enjoy medical insurance benefits when he reaches the legal retirement age?
Answer: When the insured reaches the legal retirement age, if the accumulated payment period of employee medical insurance premium is not less than 25 years for men and not less than 20 years for women, and the actual payment period is not less than 5 years, he will no longer pay employee medical insurance premium after retirement, but he should pay a large amount of medical assistance fee and continue to enjoy employee medical insurance and other related benefits.
Those who are less than the above-mentioned years, after going through the retirement formalities, will make up the medical insurance premium for the poor years at one time, and enjoy the basic medical insurance and other related benefits for employees from the month of making up. Among them, the retirees of the employer shall be handled according to the payment method of the employer at the time of payment and the average monthly salary of employees in this city in the previous year; Flexible employees shall be handled in accordance with the payment ratio of the serious illness co-ordination model at the time of payment and the payment base of flexible employees in that year.
Original notice ↓↓↓
Original notice ↓↓↓
Municipal Medical Insurance Bureau, Municipal People's Social Security Bureau and Municipal Taxation Bureau
Thoughts on further standardizing the payment of basic medical insurance
Notice on issues related to the management of treatment enjoyment
District Medical and Social Security Bureau, District Human Resources and Social Security Bureau, District Taxation Bureau, Human Resources Department of each committee (group company) and relevant units:
In order to further standardize the management of medical insurance payment and treatment enjoyment in our city and safeguard the rights and interests of the insured, relevant issues are hereby notified as follows according to the Social Insurance Law, the Regulations of Tianjin Municipality on Basic Medical Insurance and the State Taxation Administration of The People's Republic of China Guiding Opinions of the Ministry of Finance and the National Medical Insurance Bureau (Guo Ban Fa [2020] No.33):
I. Employer's Insurance Payment and Treatment
The employing unit and its employees shall participate in the basic medical insurance for employees (hereinafter referred to as "employee medical insurance") according to law, pay the employee medical insurance premium and large medical assistance fee on time and in full, and reimburse the medical expenses incurred from the month when the insurance payment is made.
(1) Newly-insured employers and their employees shall pay the insurance premium according to the mode of unified account and combination (the payment ratio is 12%, of which the unit pays 10% and the employee pays 2%, the same below), and employees and retirees shall establish individual accounts for basic medical insurance for employees (hereinafter referred to as individual accounts).
(two) the employer and its employees have been in accordance with the serious illness model (the payment ratio is 8%, the same below), and employees and retirees do not establish personal accounts.
(three) the employer who has been insured according to the unified account mode can not be changed to the serious illness mode; The employer who has paid the insurance premium in accordance with the serious illness co-ordination model can apply to the social security agency for changing to pay the insurance premium in accordance with the co-ordination model after paying the medical insurance premium required by the individual account for 5 years in one lump sum for retirees, and since the month of change, employees and retirees have established individual accounts.
The formula for calculating the medical insurance premium required for a one-time payment of 5 years in the personal account of retirees is: (number of retirees under 70 years old in the payment month × number of retirees over 70 years old in 480 yuan × number of old workers before the founding of the People's Republic of China × number of 720 yuan) × 5 years.
Second, the payment and treatment of personal insurance
Individual industrial and commercial households without employees, part-time employees who have not participated in employee medical insurance in the employing unit and other flexible employees (hereinafter referred to as "flexible employees") can participate in the basic old-age insurance for employees in accordance with regulations, pay employee medical insurance premiums and large medical assistance fees in full and on time, and do not establish personal accounts. These include:
(a) the new insured establishes a waiting period of six months, and the medical expenses incurred during the waiting period will not be reimbursed. After six months of continuous payment, the medical expenses incurred shall be reimbursed by medical insurance according to regulations.
(two) with the employer to terminate or terminate the labor contract or receive unemployment insurance benefits within three months after the expiration of the insured payment, since the insured payment month, the medical expenses incurred by the medical insurance in accordance with the provisions of reimbursement.
Three. Payment interruption and supplementary payment
(1) Failing to pay the current employee medical insurance premium as required, it will be regarded as suspension of payment, and the medical insurance benefits will be interrupted during the suspension. The medical insurance premium during the interruption of payment can be paid on the basis of paying the basic old-age insurance premium for employees, and the actual payment period of employee medical insurance can be calculated in the month of payment.
1. Employees and flexible employees who participate in basic medical insurance for the first time will not be reimbursed for the medical expenses incurred one month before their first participation.
2. If the employees and flexible employees of the employer who have paid for six months continuously resume normal payment and pay back within three months after the payment is interrupted, the medical expenses incurred in the month of payment shall be reimbursed according to regulations. If it is more than three months, the medical expenses incurred in the overdue month will not be reimbursed by medical insurance.
3. If flexible employees resume normal payment within three months after interruption of payment during the waiting period, the waiting period shall be calculated continuously. If it is more than three months, the waiting period will be recalculated from the month when the normal payment is resumed. After six months of continuous payment, the medical expenses incurred will be reimbursed according to the regulations.
4. Before and after the insured person handles the transfer of the basic medical insurance for employees, the employee medical insurance will resume normal payment within three months after the interruption, and the medical expenses incurred in the supplementary month will be reimbursed according to the regulations.
(2) The employer and its employees shall pay the employee medical insurance premium not earlier than 200 1, 1 1, and the flexible employees shall not be earlier than July 2003. Pay back, should correspond to the provisions of the year, month, employee medical insurance payment base standard, and according to the following provisions:
1. The employer and its employees who pay the insurance premium according to the mode of unified account combination shall pay back the medical insurance premium of the employees before February 20 14 (inclusive), and the payment ratio shall be 0/0% for the employer and 2% for the employees, among which 9% for the employer and its employees who are managed according to the Civil Service Law. Pay back the medical insurance premium of employees from June 2065438+October 2005 10 (inclusive) to June 2065438+February 2007 (inclusive), and it shall be handled according to the payment ratio of employer 1 1% and individual employees of 2%. Employees after 2065438+2008 and 65438+2008 (inclusive) shall pay medical insurance premiums according to the payment ratio of the employer 10% and the employees' 2%. Personal accounts shall be repaid according to the payment base of the current year and the current month and the standards that should be included.
2. Employers and their employees or flexible employees who pay insurance premiums according to the serious illness co-ordination model shall pay back the employee medical insurance before 20 14 12 (inclusive), and the payment ratio is 7.3%; After 20 15 1 (inclusive), the employee's medical insurance payment shall be handled according to the payment ratio of 8%.
3. The employer and its employees shall pay the employee medical insurance premium before 20 1 1 (inclusive) and charge interest according to the regulations. Among them, the interest that should be included in the personal account is included in the personal account; Pay back the medical insurance premium of employees after July (inclusive) of 20 1 1, and pay a late fee of 5/10000 per day.
Flexible employees pay medical insurance premiums for employees and charge interest according to regulations.
4. The employees and flexible employees of the employing unit shall pay the medical insurance premium of employees before 20 1 1 (inclusive), and the calculation of interest payment shall start from March 2005.
5. Insured persons who enjoy Medicaid for civil servants or 1-6 disabled soldiers Medicaid should pay corresponding Medicaid at the same time, without additional interest or late fees. The reimbursement time of Medicaid for civil servants and Medicaid for disabled soldiers was not earlier than 10 in 2009 and+10 in March 2008, respectively.
6. Cross-planning into the basic old-age insurance for employees, the medical insurance premiums for employees during the period of paying the basic old-age insurance for employees in other provinces and cities will not be paid back.
Four. Treatment and subsidies for retirees
(1) When the insured reaches the statutory retirement age, the accumulated medical insurance premium for employees shall be no less than 25 years for men and no less than 20 years for women, and the actual payment period shall be no less than 5 years. After retirement, employees will no longer pay medical insurance fees, but they will pay a large amount of medical assistance fees and continue to enjoy medical insurance and other related benefits. Less than the above-mentioned years, after going through the retirement formalities, you can make up the medical insurance premium for the poverty-stricken years at one time in accordance with the following provisions, and enjoy the medical insurance and other related benefits for employees from the month of making up:
1. The retirees of the employer shall be handled according to the payment method of the employer at the time of payment and the average monthly salary of employees in this city in the previous year. Among them, if the payment is made according to the mode of unified account combination, the employer's payment will be included in his personal account, which will be supplemented according to 65438+ 0.2% of the average monthly salary of employees in this city in the previous year.
2. Flexible employees shall be handled according to the payment ratio of the serious illness co-ordination model at the time of payment and the payment base of flexible employees in that year.
(2) Retirees who have gone through retirement procedures before 20 15 12 and enjoyed medical insurance benefits for employees will continue to enjoy corresponding medical insurance benefits according to regulations. If the medical insurance payment period is insufficient, it will not be paid back, but a large amount of medical assistance will be paid year by year.
(3) If the employing unit and its employees stop paying the medical insurance premiums for employees for some reason, or no employees continue to pay the medical insurance premiums for employees, the medical expenses incurred by retirees will continue to be reimbursed according to the regulations. Among them, the retirees of the employer who have been insured and paid according to the unified account combination model continue to establish personal accounts.
Verb (short for verb) others
(a) the insured person terminates the employee's social insurance relationship for various reasons, and the balance of his personal account can be settled with the individual at one time.
(two) the personnel who participated in the basic medical insurance for urban and rural residents (hereinafter referred to as "residents' medical insurance") within three months after the expiration of the labor contract with the employer shall be reimbursed for the medical expenses incurred from the day after the insurance payment.
(III) Insured persons who have participated in the basic medical insurance for 2 years or more (excluding overdue payment) and re-participate in the annual residents' medical insurance within 3 months after the payment is interrupted shall enjoy the treatment from the day after the payment is made, and those who re-participate in the employee medical insurance shall enjoy the treatment from the month when the payment is made.
(4) Persons receiving unemployment insurance benefits shall pay (repay) the basic medical insurance premium, large medical assistance fee and maternity insurance premium in full according to the serious illness co-ordination model, and the required funds shall be paid from the unemployment insurance fund. Individuals do not need to pay fees and do not establish personal accounts. Since the month of unemployment insurance payment, the medical expenses incurred by medical insurance shall be reimbursed according to the regulations. Maternity insurance benefits for employees shall be implemented in accordance with the relevant provisions of this Municipality.
(five) if the employer suspends the payment of maternity insurance premiums for employees and resumes normal payment within three months, it can enjoy maternity insurance benefits for employees in the month of payment; If it is more than three months, the maternity expenses incurred in the supplementary month will not be reimbursed.
(6) Insured female employees normally enjoy maternity insurance benefits in the month of childbirth or termination of pregnancy, and have paid maternity insurance premiums continuously for more than six months (including overdue payment), and have the conditions to apply for maternity allowance; If the continuous payment is less than six months, you can apply for maternity allowance after six months. In the month of receiving maternity allowance, employees should normally enjoy maternity insurance benefits in accordance with regulations.
(7) Since 202 1, people who have participated in the basic medical insurance and whose current payment status is normal are not allowed to participate in the insurance in principle. Among them, those who have paid residents' medical insurance premiums but have not entered the treatment enjoyment period to apply for employee medical insurance should also go through the refund procedures simultaneously.
(8) Since 20021,the large medical assistance fee for urban workers has been paid on a monthly basis, and the insured person has paid the large medical assistance fee for urban workers on a monthly basis since the month when he participated in the medical insurance for employees. The withholding method is implemented according to the original channel. Cross-annual repayment, no longer pay a large amount of relief money for urban workers in the historical year.
This notice shall come into force on February 1 day, 2020, and shall be repealed on October 30 165438+ in 2025. The Notice of the Municipal Human Resources and Social Security Bureau on Issues Related to the Payment and Treatment of Employees' Basic Medical Insurance (No.65 issued by Tianjin Human Resources and Social Security Bureau [2015]) and the Reply of the Municipal Human Resources and Social Security Bureau on Issues Related to the Payment and Treatment of Employees' Basic Medical Insurance (No.387 issued by Tianjin Human Resources and Social Security Bureau [2015]) shall be abolished at the same time.
Municipal Medical Insurance Bureau, Municipal People's Social Security Bureau and Municipal Taxation Bureau
165438+2020123 October