Article 1 is based on the "Decision of the State Council on Establishing a Basic Medical Insurance System for Urban Employees"
Guofa [1998] No. 44) and the "Regulations of the People's Government of the Autonomous Region on The Notice on Issuing the Overall Plan for Establishing a Basic Medical Insurance System for Urban Employees in the Guangxi Zhuang Autonomous Region (Gui [1999] No. 61) formulates these measures.
The second principle of basic medical insurance is:
(1) "Basic level", that is, the level of basic medical insurance must be compatible with the city's socio-economic development level;
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(2) "Wide coverage" means that all employers and their employees must participate in basic medical insurance and implement territorial management. People with flexible employment can also participate in basic medical insurance;
(3) "Both parties bear", that is, the basic medical insurance premiums are jointly borne by both the employer and the employee;
(4)" "Integration of pooled accounts and accounts" means that the basic medical insurance fund is mainly based on the combination of social pooling and personal accounts, supplemented by separate pooling and pooling. Labor and security administrative departments at all levels shall uniformly raise, pay and manage funds in accordance with the principle of balancing revenue and expenditure.
Article 3 All urban employers within the jurisdiction of Wuzhou City, including enterprises (state-owned and state-controlled enterprises, collective enterprises, foreign-invested enterprises, joint-stock enterprises, private enterprises, private enterprises), agencies, institutions, Social groups, private non-enterprise units and their employees must participate in the basic medical insurance pool. Units and their employees located in Wuzhou municipalities, autonomous regions and other places participate in Wuzhou basic medical insurance in accordance with the principle of territorial management. Flexibly employed persons and self-employed individuals can participate in basic medical insurance.
Wuzhou City’s basic medical insurance is divided into municipal-level coordination and county (city)-level coordination, and will gradually transition to municipal-level coordination. All employers and their employees shall participate in the basic medical insurance in the coordinated area in accordance with the principle of territorial management, implement unified policies, unified implementation plans, and implement unified collection, use and management of basic medical insurance funds.
Article 4 Retired personnel, old Red Army soldiers and disabled revolutionary servicemen of Class B or above do not participate in the basic medical insurance for employees, and their medical expenses shall be governed by relevant measures.
On the basis of participating in basic medical insurance, national civil servants enjoy the medical subsidy policy. The specific measures are in accordance with the "Notice of the General Office of the State Council forwarded by the Ministry of Labor and Social Security and the Ministry of Finance on the Implementation of Medical Subsidy Opinions for National Civil Servants" (State Council Office Issued [2000] No. 37) for implementation.
Chapter 2 Basic Medical Insurance Management Institutions and Responsibilities
Article 5 The Wuzhou City Labor and Security Administration Department is the administrative department in charge of Wuzhou City’s basic medical insurance and is responsible for the city’s basic medical insurance. Management work, unified organization and guidance of the city's basic medical insurance management work. Its main responsibilities are:
(1) Implement relevant policies on basic medical insurance and formulate specific regulations and systems for basic medical insurance;
(2) Work with health, finance, prices, etc. Department, formulate and improve the basic medical insurance service scope, standards and medical expense settlement methods, based on the basic medical insurance drug catalog, diagnosis and treatment catalog and medical service facility standards formulated by relevant ministries and commissions of the State Council, as well as the qualification examination methods for designated medical institutions and retail pharmacies, Formulate corresponding management measures;
(3) Examine and approve the qualifications of designated medical institutions and retail pharmacies. Supervise and inspect the implementation of basic medical insurance regulations by designated medical institutions, retail pharmacies, insured units and insured persons, and investigate and deal with various violations of basic medical insurance regulations;
(4) Supervise the management of basic medical insurance The administrative agency shall implement administrative management and supervision;
(5) Coordinate the relationship between various departments in the basic medical insurance work, and mediate relevant disputes in basic medical insurance matters.
Article 6 The Wuzhou Employee Basic Medical Insurance Management Office (hereinafter referred to as the Medical Insurance Office) under the Wuzhou Municipal Labor and Social Security Administration Department is the Wuzhou Municipal Basic Medical Insurance Agency. Its main responsibilities are:
(1) Handle and coordinate the registration, change registration and cancellation of basic medical insurance for employers and individuals in the region;
(2) Responsible for the collection, management and payment of basic medical insurance funds;
(3) Responsible for preparing the budget and final accounts of the basic medical insurance fund, and submitting various financial and statistical reports for basic medical insurance on time;
(4) Responsible for signing basic medical insurance contracts with designated medical institutions and retail pharmacies. The medical insurance service agreement guides and manages the implementation of basic medical insurance, and inspects and supervises the implementation of relevant provisions of basic medical insurance by designated medical institutions and retail pharmacies according to the agreement;
(5) Coordination of insurance participation Disputes related to medical insurance business between personnel and designated medical institutions and retail pharmacies;
(6) Accept consultation on basic medical insurance business from insured units and their employees;
( 7) Propose suggestions and opinions on improving and perfecting basic medical insurance;
(8) Do a good job in supporting basic medical insurance;
(9) Responsible for large medical insurance premiums Collection, management and payment;
(10) Handling and coordinating the income and payment of medical subsidy insurance premiums for regional civil servants;
(11) Handling and coordinating the income and payment of regional retirees, old Red Army and Second Army personnel Income and payment for medical expenses for revolutionary disabled servicemen of Grade B and above.
Article 7 The insured unit shall establish a basic medical insurance management agency and staff it with full-time (part-time) personnel. Its responsibilities are:
(1) Promote and implement basic medical insurance policies and regulations;
(2) Truthfully declare the basic medical insurance payment base for employees of the unit and fill in the basic medical insurance report for the unit Prepare relevant reports and pay medical insurance premiums in full and on time;
(3) Regularly announce basic medical insurance payment status to employees of the unit;
(4) Report to employees of the unit in a timely manner on a monthly basis Responsible for handling changes in basic medical insurance related procedures;
(5) Manage basic medical insurance affairs for employees of the unit, and timely and accurately communicate and implement the spirit of relevant documents.
Article 8 Designated medical institutions and retail pharmacies should set up basic medical insurance management offices with full-time (part-time) personnel. Its responsibilities are:
(1) Promote and implement the policies and regulations of basic medical insurance;
(2) Responsible for managing the specific work of the unit’s basic medical insurance, formulating and implementing the unit’s basic medical insurance Management measures;
(3) Entrusted by the Medical Insurance Management Office, review and approve special examinations, special treatments, special materials and medication items within the scope of authority;
(4) Supervision and inspection The implementation of the unit's basic medical insurance policies and regulations;
(5) Accept the guidance, supervision and inspection of medical insurance management-related business;
(6) Report according to the medical insurance management regulations Send relevant basic medical insurance reports and transmit basic medical insurance related data.
Article 9 The administrative funds of Wuzhou City’s labor and social security administrative department and its affiliated medical insurance management office shall be disbursed from the fiscal budget and shall not be disbursed from the basic medical insurance fund.
Chapter 3 Raising Basic Medical Insurance Funds
Article 10 Basic medical insurance premiums shall be raised by the Medical Insurance Management Office and paid by the employer and its employees.
(1) Employers can participate in basic medical insurance according to the unified accounting method or the individual construction method:
1. If they participate in the basic medical insurance according to the unified accounting method, the basic medical insurance Fees are paid by the employer and individual employees.
The basic medical insurance premiums paid by the employer are based on the total wages of employees in the previous year, and the payment rate is 6.8; the basic medical insurance premiums paid by individual employees are 2% of their salary income in the previous year, and are withheld and paid by the employer;
2. If the insured person participates in the insurance according to the individual building overall planning method, the employer shall pay the basic medical insurance premium. The total salary of employees in the previous year and the total pension of retirees in the previous year shall be the payment base. The payment rate is 4.8. Insured persons enjoy the hospitalization benefits of basic medical insurance.
(2) According to the unified account combined with the insured, the basic medical insurance premium paid by the employer is divided into two parts, one part is used to establish the overall fund, and the other part is credited to the individual of the insured account. The proportion credited to the individual account is about 30% of the employer's payment; according to the individual construction plan, all the basic medical insurance premiums paid are used to establish the overall fund.
(3) The payment principles of basic medical insurance are:
1. If the insured person’s payment base exceeds 300, the average social wage in the region in the previous year, 300 will be used as the payment base; if it is less than 60, 60 will be used as the payment base;
2. If there is no salary income data for the previous year , the basic medical insurance payment base shall not be less than 60% of the average social wage in the region in the previous year.
Article 11 The setting and calculation method of the insurance payment period:
(1) For those who have not participated in the city’s basic medical insurance on June 30, 2001, their current employer The working years of the unit are confirmed as the payment years in accordance with the relevant regulations of the state and the autonomous region; for those who participated in the city's basic medical insurance before June 30, 2001, their working years before participating in the insurance are regarded as the payment years. If the payment period is determined to be more than 25 years, it can be converted into the actual payment period: every time it exceeds 1 year, it is calculated as 1 year; if it is less than 1 year, it is not calculated, and the actual converted payment period is up to 8 years;
(2) After the insured person reaches the statutory retirement age and has paid basic medical insurance premiums for 30 years (including the actual payment period and the deemed payment period, of which the actual payment period must be 20 years or more), he or she can apply with his or her retirement certificate or identity certificate. After the procedures for changing the category of insured persons, they will no longer pay basic medical insurance premiums and enjoy the corresponding basic medical insurance benefits for retirees;
(3) The insured persons have reached the legal retirement age and have one of the following circumstances: , according to the payment base and payment proportion of the year, it is paid by the unit and paid by the individual, and enjoys the corresponding basic medical insurance benefits for retirees in accordance with regulations.
1. The actual payment period has reached 20 years, but the cumulative payment period for basic medical insurance premiums is less than 30 years;
2. The cumulative payment period has reached 30 years, but the actual payment period has been Less than 20 years old.
(4) Insured retirees who have gone through retirement procedures before the implementation of these measures and have not reached the prescribed payment period can pay basic medical insurance premiums in one go, or continue to pay monthly until they reach the prescribed payment period. years. For one-time payment or monthly payment, in principle, the payment base and payment rate will remain unchanged and will not change in the future, except for unified adjustment policies. According to the unified accounting method, the payment rate is 6.8; according to the individual construction plan, the payment rate is 4.8.
Article 12 Before the implementation of these Measures, if retirees from bankrupt or restructured enterprises approved by the municipal government have retained and paid basic medical insurance premiums in accordance with regulations, their basic medical insurance will continue to be implemented in accordance with the original regulations.
Article 13 Persons who reach the legal retirement age and participate in insurance after the implementation of these Measures shall pay basic medical insurance premiums in one lump sum according to the payment period specified in these Measures. For those who participate in the insurance in the employer, the pension or retirement pension of the previous year will be used as the payment base (if the payment base is lower than the average social salary of 60 in the previous year, 60 will be used as the payment base), and the unit payment rate is 6.8. For those who participate in the insurance as an individual, the payment base shall not be less than 60% of the average social salary in the region in the previous year, and the payment rate shall be 8.8%. The above-mentioned persons can enjoy the benefits of basic medical insurance for retirees only after paying the prescribed payment period.
Article 14 Flexibly employed persons and individual industrial and commercial households can participate in basic medical insurance according to the combination of unified accounts or individual construction and overall planning, with a payment base of no less than 60% of the average social wage in the region in the previous year. , individuals pay basic medical insurance premiums. Specific measures will be formulated separately.
Article 15 If an insured unit or individual fails to pay basic medical insurance premiums in full and on time, they will stop enjoying basic medical insurance benefits from the next month. After paying the arrears and late fees, you will continue to enjoy basic medical insurance benefits.
Article 16 When an insured unit merges, splits, transfers, terminates, or goes bankrupt, it must first pay off the basic medical insurance premiums in arrears, and at the same time, it must pay off the basic medical insurance premiums for retired and post-retired personnel in one lump sum according to regulations. Medical insurance premiums.
Article 17 In order to meet the medical needs of different levels, enterprises can establish supplementary medical insurance for employees. If the supplementary medical insurance premium is less than 4% of the total salary, the enterprise can directly deduct it from the cost.
Article 18 Basic medical insurance premiums paid by insured units: Government agencies and institutions that mainly rely on financial supply shall be arranged by the fiscal budget to the unit and shall be disbursed from the unit budget; other public institutions shall pay from business The expenses shall be listed in the funds; the enterprise shall pay from the employee welfare fund; the funds of social organizations shall be paid from the funds of the association; the private non-enterprise units shall be paid from the funds of the private non-enterprise units.
Article 19 The total salary of on-the-job employees shall be determined strictly in accordance with the statistical standards prescribed by the state.
Article 20 The insured unit must submit the annual salary report to the Medical Insurance Management Office for review before April each year. After review by the Medical Insurance Management Office, the payment base will be adjusted on July 1 every year. Article 21 Insurance procedures shall be handled according to the following procedures:
(1) The employer fills out the "Wuzhou City Employees' Basic Medical Insurance Registration Form" and the "Wuzhou City Employees' Basic Medical Insurance Registration Form" and submits them to the medical The Insurance Management Office shall submit a copy of the industrial and commercial business license or corporate legal person certificate.
(2) With the approval of the Medical Insurance Management Office, the "Wuzhou City Employee Basic Medical Insurance Certificate" (hereinafter referred to as the "Medical Certificate") and the "Wuzhou City Basic Medical Insurance Settlement Card" (hereinafter referred to as the "Wuzhou City Basic Medical Insurance Settlement Card" (hereinafter referred to as the " "Settlement Card") and medical records are kept by the insured, who purchases medical treatment. The production fees for medical certificates, settlement cards, and medical records are charged at cost and borne by the insured unit or individual.
Article 22: Basic medical insurance premiums shall be entrusted to banks for collection. The insured unit shall withhold and pay the portion payable by the unit and the portion payable by the insured individual before the 20th of each month.
Chapter 4 Allocation and Management of Basic Medical Insurance Funds
Article 23 Basic medical insurance funds shall be combined with social pooling and personal accounts. That is, the basic medical insurance fund consists of social pooling funds and personal accounts. Individuals insured by a single construction company do not have personal accounts.
(1) Configuration of personal account.
1. All basic medical insurance premiums paid by active employees are credited to personal accounts;
2. Basic medical insurance premiums paid by employers for insured persons are credited to personal accounts. The payment base is calculated into the individual account based on the age of the insured person. Employees under 35 years old are included in 1.8, those between 36 and 50 years old are included in 2, and 51 are included in 2.5. Retirees count 6.5. Retirees whose one-time payment reaches the specified payment period will be counted according to 6.5 of the actual payment base of the one-time payment at that time, and the base will no longer be adjusted with the increase in retirement fees or pensions;
3. In-service The full-time age of employees is determined based on the calculated age on February 31 of the previous year 65438, and is determined at the beginning of the year.
The proportion of personal accounts remains unchanged for the current year and will be adjusted uniformly during the next year's review;
4. Retirees approved by the labor, organization, and personnel departments in the current year will reach the level of When the payment period is specified, units and individuals will no longer pay basic medical insurance premiums, and will enjoy the benefits of basic medical insurance for retirees accordingly;
5. According to the insurance method that combines unified accounts, the personal account fund is covered by medical insurance The management department will pay the money on a monthly basis;
6. The principal and interest of the insured person’s personal account belong to the individual and can be carried forward and inherited in accordance with the law. They can only be used for basic medical treatment and no cash withdrawal is allowed. When the insured person transfers, his personal account balance can be transferred with him.
(2) The composition of the overall planning fund.
Basic medical insurance premiums paid by the employer shall be included in the individual accounts of the insured persons in accordance with the above provisions, and the rest shall be entered into the basic medical insurance pooling fund. Enter the basic medical insurance pooling fund and set aside 5 as a risk fund.
Article 24: The basic medical insurance fund shall be managed through a special fiscal account, and shall be used exclusively for special purposes and may not be misappropriated or used to balance the fiscal budget. Medical insurance management departments should establish and improve fund budget and final accounting systems, financial accounting systems and internal audit systems.
Article 25 Basic medical insurance fund interest shall be implemented in accordance with relevant national regulations.
Article 26 establishes a basic medical insurance fund supervision mechanism. The revenue and expenditure of the basic medical insurance fund shall be subject to the supervision of the financial and auditing departments at the same level. Establish a basic medical insurance fund supervision organization with the participation of relevant municipal government departments, representatives of medical institutions, trade union representatives and relevant experts, regularly listen to reports on the operation and management of basic medical insurance funds, and strengthen the supervision and management of basic medical insurance funds.
Chapter 5 Basic Medical Insurance Benefits
Article 27 The overall fund and personal accounts shall be calculated and managed separately and shall not crowd out each other. The scope of payment is: the personal account is used to pay the out-patient expenses and inpatient medical expenses that are compliant with the basic medical insurance regulations. The overall fund is used to pay the hospitalization expenses that are compliant with the basic medical insurance regulations.
Article 28 Payment of outpatient fees. Outpatient medical expenses and drug expenses incurred by insured persons at designated medical institutions and retail pharmacies that comply with the basic medical insurance regulations are paid from their personal accounts, and any excess expenses are borne by themselves. For those who are identified by the Municipal Basic Medical Insurance Expert Committee as suffering from special chronic diseases that require long-term outpatient treatment, the required medical expenses shall be paid from the personal account first, and the individual shall pay 10 yuan first, and the excess medical expenses shall be paid according to Article 29 of these Measures. Standard settlement listed in items (2) and (3). According to the construction plan, insured persons with special chronic diseases can refer to the implementation.
Article 29 Payment of hospitalization medical expenses. For hospitalization expenses incurred by the insured in designated medical institutions that comply with the provisions of basic medical insurance, such as the use of Class B drugs, special examinations, special treatments and special materials, the insured will first pay RMB 10 to RMB 50 out of pocket, and the rest will be borne by the insured. Bear a certain amount of hospitalization deductible. The portion exceeding the deductible standard will be paid by the overall fund and the insured in accordance with the method of "segment calculation and cumulative payment":
(1) The setting of hospitalization deductible standard for insured persons: the first payment within one year For the first hospitalization, the fee is 600 yuan for a third-level hospital and 500 yuan for a second-level hospital; for the second hospitalization, it is 480 yuan for a third-level hospital and 380 yuan for a second-level hospital; for the third and above hospitalization, it is 360 yuan for a third-level hospital and 360 yuan for a second-level hospital and below. 260 yuan for the hospital; (2) The portion of the insured person’s hospitalization medical expenses that exceeds the minimum payment standard will be paid by the overall fund and the insured person in accordance with the method of “segment calculation and cumulative payment”. The insured person’s out-of-pocket proportion is:
1. The minimum payment standard is 10,000 yuan (including 10,000 yuan), the personal self-pay ratio for active employees is 20, and the ratio for retirees is 16;
2. 10,000 to 20,000 yuan (including 20,000 yuan) , active employees pay 15, retirees pay 12;
32,000 to 24,000 yuan, employees pay 10 out-of-pocket ratio, retirees pay 8.
(3) The annual cumulative maximum payment limit of the overall planning fund is 24,000 yuan.
Medical expenses above the maximum payment limit will not be paid by the basic medical insurance pooling fund, and can be resolved through large-amount medical insurance, supplementary medical insurance, commercial insurance, social assistance, etc.
Article 30: Retired insured personnel who are resettled in other places must apply in person, and their units or individuals must go to the Medical Insurance Management Office to register for the off-site resettlement between June and October of each year. Outpatient medical expenses that comply with the provisions of the basic medical insurance shall be paid from the individual's personal account; if hospitalization is required, the patient shall seek medical treatment at a local medical institution designated by the basic medical insurance and report to the medical insurance management office in a timely manner. After discharge, submit medical expenses to the Medical Insurance Management Office according to regulations with relevant information. Specific measures will be formulated separately. Medical expenses incurred by retirees in other places shall be handled in accordance with the above provisions.
Article 31 If an insured person needs to be transferred to a hospital for treatment due to illness, the principle of step-by-step transfer shall be followed. The conditions for transfer of treatment outside the city are: critical and difficult diseases that cannot be treated in this city due to technical and equipment conditions and other reasons; and difficult diseases that are still not identified by municipal medical institutions or specialist medical institutions and experts.
(1) If it is necessary to go through transfer procedures, the patient or his family members shall submit an application, and the designated medical institution where the original diagnosis and treatment was made shall make recommendations and submit them to the Medical Insurance Management Office for approval before the transfer can be made;
(2) If the transfer procedures cannot be completed in time and in accordance with regulations due to critical illness, the procedures must be completed within 5 working days after the transfer to the hospital for medical treatment;
(3) The medical expenses incurred in the transfer shall be paid in advance by the individual. After discharge, you can go to the medical insurance management office for reimbursement according to regulations with the discharge summary, disease certificate, relevant inspection reports, detailed list of medical expenses and invoices issued by the medical institution. For medical expenses above the deductible and below the maximum payment limit, the personal out-of-pocket ratio will be increased by 10% within the transfer area and 15% outside the transfer area, based on the provisions of Article 29 of these Measures.
Article 32 If the patient or his family members request to be transferred to a hospital outside the city for treatment, the medical expenses within the scope of the basic medical insurance shall be paid according to the personal expenses stipulated in Item 3 of Article 31 of these Measures. The payment ratio is calculated, but the maximum payment limit is the amount of medical expenses within the scope of the insured's hospitalization in the previous year.
Article 33 Designated medical institutions, retail pharmacies and insured persons shall strictly abide by the basic medical insurance diagnosis and treatment catalog, basic medical insurance drug catalog, and basic medical insurance medical service facilities formulated by relevant departments of the State Council and autonomous regions. standards and corresponding management regulations. The basic medical insurance fund will not cover expenses for diagnosis, treatment, services and medicines that exceed the prescribed limits.
Article 34 Principles for payment of special medical expenses for insured persons:
(1) Personal responsibility medical treatment for illegal crimes, alcoholism, drug abuse, self-mutilation, suicide (except for mental illness), etc. Expenses will not be paid by the basic medical insurance fund;
(2) Medical accidents, work-related injuries, maternity and other medical expenses shall be implemented in accordance with relevant regulations; (3) Traffic accidents, other injuries, and other deaths for which others are responsible If the medical expenses incurred cannot be concluded within one year from the date of investigation by the judicial department, they may be paid in advance from the basic medical insurance coordinating fund in accordance with regulations. After the judicial department concludes the case, if it is determined that another person is responsible, the responsible person shall return the medical expenses paid by the basic medical insurance pooling fund. If the judicial department determines that the responsible person has no financial ability to pay the victim's medical expenses, the medical expenses can be reimbursed by the basic medical insurance fund in accordance with regulations.
Article 35 Medical expenses incurred by the insured in emergency hospitalization in other places during a business trip or visiting relatives on statutory holidays shall be paid with valid medical expense receipts, discharge summaries and employer certificates from medical institutions at or above the township level. (A copy of the travel expense reimbursement voucher is attached), and reimbursement will be made in accordance with Article 29 of these Measures. If the employer needs to go abroad for a long period of time for work, the employer shall submit the list of persons going abroad to the Medical Insurance Management Office for filing procedures. If the registration formalities are not completed, medical expenses incurred in other places will not be paid.
Chapter 6 Basic Medical Insurance Expense Settlement and Medical Service Management
Article 36 Insured persons shall go to designated medical institutions for outpatient treatment or to designated retail pharmacies according to the unified accounting method To purchase medicines, you must have a "Medical Certificate" and a "Settlement Card". The attending physician (pharmacist) will verify the case before processing.
Medical expenses that meet the regulations will be settled from the personal account balance of the "Settlement Card".
Article 37 If the insured person is ill and needs hospitalization, he must pay a certain amount of hospitalization advance expenses to the designated medical institution with the diagnostic opinion, medical certificate, and settlement card of the designated medical institution. Designated medical institutions should go to the medical insurance management office to complete the filing procedures within 3 days after accepting the hospitalization of the insured person.
Article 38 The settlement methods for outpatient and inpatient medical expenses that comply with the provisions of basic medical insurance shall be jointly formulated by the labor and social security administrative departments in conjunction with the health and financial departments in accordance with relevant national regulations.
Article 39 Basic medical insurance implements designated medical treatment and establishes a designated qualification inspection system. The labor and social security administrative department will review and approve designated medical institutions and retail pharmacies every year. Approved designated medical institutions and retail pharmacies sign service agreements with the medical insurance management department to provide medical care and drug sales services to insured persons. Article 40 The labor and social security administrative department, together with the health department, establishes a basic medical insurance expert committee (composed of experts from the labor and social security administrative department, the health department, designated medical institutions and other departments) to be specifically responsible for the appraisal of basic medical insurance disputes.
Chapter 7 Punishments and Rewards
Article 41: The employer refuses to participate in basic medical insurance, or refuses to pay, defaults on, conceals or underpays basic medical insurance premiums, or fabricates facts If the situation arises, the labor and social security administrative department shall deal with the employer and relevant responsible persons in accordance with the provisions of the "Interim Regulations on the Collection and Payment of Social Insurance Premiums".
Article 42: Anyone who defrauds basic medical insurance benefits or basic medical insurance funds shall be ordered to return it by the labor and social security administrative department in accordance with the provisions of the "Labor and Social Security Supervision Regulations" and shall be fined more than 1 time and 3 times of the amount defrauded. The following fines shall be imposed; if the circumstances are serious, administrative sanctions shall be imposed by the employer; if a crime is constituted, criminal liability shall be pursued in accordance with the law.
Article 43: For designated medical institutions and retail pharmacies that violate the basic medical insurance management regulations, in addition to recovering or refusing to pay the medical expenses incurred, rectification shall be made within a time limit; if the circumstances are serious, basic medical insurance shall be suspended. Qualifications for medical insurance services; if it is an act of defrauding basic medical insurance funds, a fine of 1 or 3 times the amount defrauded will be imposed in accordance with the "Labor and Social Security Supervision Regulations"; if the rectification is refused or the rectification is ineffective, the designated site qualification will be cancelled.
Article 44 If a medical insurance management staff member has any of the following circumstances, the unit where he/she works shall impose administrative sanctions on the responsible person; if a crime is constituted, criminal liability shall be investigated in accordance with the law:
(1) Engaging in favoritism and malpractice for personal gain in the collection of basic medical insurance premiums and medical fees; (2) Taking advantage of one’s authority and work to solicit and accept bribes and seek personal gain;
(3) Neglect of duty causing losses to the basic medical insurance fund.
Article 45 Employers or individuals have the right to report violations of basic medical insurance policies to the labor and social security administrative departments. Once verified, the whistleblower will be rewarded, and the source of funds will be derived from fine income. If there is no penalty or confiscation of income, it will be included in the fiscal budget.
Chapter 8 Supplementary Provisions
Article 46: The municipal people's government shall settle the medical expenses for emergency, critical, and serious medical emergencies on a large scale caused by sudden epidemics and natural disasters. .
Article 47: Basic medical insurance disputes between insured units, insured persons, designated medical institutions, designated retail pharmacies, and medical insurance management departments shall be resolved through negotiation between the parties to the dispute; if the negotiation fails, , handled in accordance with relevant laws and regulations.
Article 48 The labor and social security administrative department shall, in accordance with these Measures, work with finance, health and other departments to formulate other supporting documents and implement them simultaneously.
Article 49 The municipal labor and social security administrative department is responsible for the interpretation of these Measures.
Article 50 These Measures shall come into effect on March 1, 2006. Prior to this, the "Notice of the Wuzhou Municipal People's Government on Issuing the Implementation Measures for the Basic Medical Insurance System for Urban Employees in Wuzhou City (Trial)" (Wu [2000] No. 92), and the "Notice of the Wuzhou Municipal People's Government on Issuing Supporting Documents for Urban Employees" (Wu [2000] No. 94) ceased execution. If these measures conflict with relevant documents newly issued by superiors, please follow the relevant documents of superiors.
Counties (cities) under the jurisdiction of our city can refer to these measures for implementation.