Article 1 In order to further improve and perfect the employee medical insurance (hereinafter referred to as employee medical insurance) system, according to the Social Insurance Law of People's Republic of China (PRC), the Opinions of the Central Committee of the State Council on Deepening the Reform of the Medical Security System (Zhong Fa [2020] No.5), the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44) and the General Office of the Provincial Government on
Second employee medical insurance must adhere to the basic medical security level and the city's economic development level and all aspects of affordability; Adhere to full coverage, basic protection, multi-level and sustainable; Hospitalization and outpatient service insist on serious illness; Adhere to the employer and employees to pay medical insurance premiums, and the fund will be raised and supported by the whole city; Adhere to the combination of social pooling and personal accounts; Adhere to the fixed income and expenditure, and realize the basic balance of the fund's income and expenditure, with a slight balance.
Article 3 The medical insurance for employees shall be coordinated at the municipal level, and the basic policies, treatment standards, fund management, handling management, fixed-point management and information system shall be unified throughout the city.
Article 4 Medical insurance for employees consists of basic medical insurance for employees, subsidies for large medical expenses for employees, serious illness insurance for employees and supplementary medical insurance.
The fifth municipal medical security department is responsible for the formulation, organization, implementation, supervision and fund management of the medical insurance policy for employees in the city. The medical security departments of the people's governments of counties (including Ganyu District, the same below) are responsible for the management of medical insurance for employees within their respective administrative areas.
The financial department is responsible for the management of the financial accounts of the employee medical insurance fund and supervising the income and expenditure of the fund; The audit department shall supervise the employee medical insurance fund through auditing according to law.
Health, market supervision, taxation, human resources and social security, public security and other departments shall, in accordance with their respective responsibilities, coordinate in the management of employee medical insurance.
Chapter II Insurance Scope and Object
Article 6 State organs, institutions, enterprises, social organizations, individual economic organizations, private non-enterprise units and other employers (hereinafter referred to as insured units) and their employees within the administrative area of this Municipality shall participate in the medical insurance for employees in this Municipality according to law.
Unemployed persons who receive unemployment insurance benefits, go through retirement formalities at the statutory retirement age, enjoy pension insurance benefits and meet the payment period stipulated in employee medical insurance (hereinafter referred to as retirees), shall participate in employee medical insurance in this Municipality according to regulations.
Article 7 Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees of the employing unit and other flexible employees (hereinafter referred to as flexible employees) within the administrative area of this Municipality may participate in the medical insurance for employees.
Article 8 Employers, employees and employees with flexible employment status who participate in the basic medical insurance for employees shall participate in large medical expenses subsidies for employees (large medical assistance for former employees) and serious illness insurance for employees. Those who have not participated in the basic medical insurance for employees shall not participate in large medical expenses subsidies for employees and serious illness insurance for employees.
Article 9 Medical insurance for employees is divided into five insurance handling areas (referred to as the insured places): city level, Donghai County, Guanyun County, guannan county and Ganyu District.
Medical insurance agencies and social insurance agencies in the insured areas are responsible for the specific handling of employee medical insurance fund revenue and expenditure and the use of related services.
Chapter III Insurance Registration and Fund Raising
Article 10 Employers and individuals shall, in accordance with the provisions of the Social Insurance Law of People's Republic of China (PRC) and the Regulations on the Collection and Payment of Social Insurance Fees in Jiangsu Province, go through the registration procedures for medical insurance for employees and pay the insurance fees according to the provisions.
Eleventh basic medical insurance fund raising methods:
(a) the basic medical insurance premium for employees shall be paid in full and on time by both the employer and the employee, and the basic medical insurance premium payable by the insured shall be withheld and remitted by the insured unit from its wage income.
(two) the employer shall pay the basic medical insurance premium (including maternity insurance premium) for employees according to 8% of the total wages of employees in the previous year, and the employees shall pay the basic medical insurance premium according to 2% of the salary income in the previous year. Medical insurance premiums paid by individual employees shall be withheld and remitted by the employer.
The insured flexible employees can choose to pay the employee's basic medical insurance premium at the rate of 9%, enjoy the employee's medical insurance benefits according to the regulations, and refer to the funds allocated to the individual account by the on-the-job employees; You can also choose the rate of 5.5% to pay the employee's basic medical insurance premium, and only enjoy the treatment paid by the employee's medical insurance pooling fund, which is not included in the personal account funds.
(three) the upper and lower limits of the payment base are determined according to the standards issued by Jiangsu Province.
Twelfth workers large medical expenses subsidies and employee serious illness insurance fund raising standards by the municipal medical security department in conjunction with the relevant departments to study and determine. To participate in the insurance as a flexible employee, the insured expenses of large medical expenses subsidies for employees and the expenses borne by employees' serious illness insurance should be paid in full.
The part that needs to be paid by individuals in the large medical expenses subsidy for employees and the serious illness insurance for employees shall be paid from the personal account. The insured person who has not established a personal account shall pay the large medical expenses subsidy and serious illness insurance expenses together with the basic medical insurance expenses.
Thirteenth in the administrative area of this Municipality, all employees' medical insurance participating units except the national civil service medical subsidy can participate in supplementary medical insurance. Supplementary medical insurance premiums shall be paid by the employer on a monthly basis according to 4% of the sum of the total wages of employees and pensions of retirees, and individual employees shall not pay supplementary medical insurance premiums.
Article 14 When the employing unit is divided, merged, reorganized, merged, transferred, leased or contracted, etc. , receiving or continuing the operator shall pay the employee medical insurance premium according to the regulations. Where an employer terminates due to bankruptcy, cancellation, dissolution or other reasons, it shall give priority to repaying the medical insurance premiums owed to its employees in accordance with the relevant provisions of the state, provinces and municipalities, and pay the medical insurance premiums for its retirees for a specified number of years at a time.
If the employer violates the relevant provisions of the state, province and city on the collection and payment of medical insurance premiums, it shall be handled in accordance with the relevant provisions.
Fifteenth employees' medical insurance premiums shall not be deferred or reduced except for legal reasons. If the employer fails to pay the employee medical insurance premium in full and on time, the employee medical insurance premium collection agency shall order it to pay it within a time limit or make up for it, and from the date of default, an overdue fine of five ten thousandths shall be charged on a daily basis; Fails to pay, shall be dealt with by the relevant administrative departments according to law.
Article 16 The municipal medical security department will decompose the employee medical insurance coverage plan into counties at the beginning of each year according to the task of expanding the employee medical insurance coverage assigned by the province.
Chapter IV Coordinating Funds and Individual Accounts
Seventeenth employee medical insurance funds are divided into overall funds and individual accounts. Among them, the overall fund consists of the basic medical insurance overall fund for employees, the large medical expenses subsidy fund for employees and the serious illness insurance fund for employees.
Eighteenth personal accounts are part of the basic medical insurance fund for employees, and personal accounts and the basic medical insurance fund for employees together constitute the basic medical insurance fund for employees.
Nineteenth employees' basic medical insurance premium paid by the employer, part of which is included in the personal account, and the rest is used to establish the overall fund; All the basic medical insurance premiums paid by on-the-job employees are included in personal accounts.
The large medical expenses subsidies paid by employers and individuals and the participation expenses of employees' serious illness insurance are all used to establish the overall fund.
Twentieth individual accounts are included in a certain proportion of the individual payment base (retirees use their own pensions) on a monthly basis, and the specific inclusion criteria are determined by the municipal medical security department in conjunction with relevant municipal departments according to the requirements of national and provincial documents.
Article 21 Personal account funds are mainly used to pay out-of-pocket expenses of insured persons within the scope of medical insurance policies of designated medical institutions, to pay large medical expenses subsidies for their employees, to participate in serious illness insurance for employees and to pay other compliance fees stipulated by the state, provinces and municipalities.
When the insured person purchases medicine for medical treatment and settles with a credit card, the personal out-of-pocket expenses incurred shall be paid with the funds in the personal account first.
Article 22 The principal and interest of an individual account belong to the insured, which can be carried forward and inherited according to law, and may not be used for other purposes. When the insured person's medical insurance relationship is transferred, the balance of his personal account is transferred to the medical insurance agency for newly insured employees.
Chapter v conditions for enjoying treatment
Twenty-third employees' medical insurance shall be paid first, and they shall enjoy treatment after paying first. Employers and individuals shall pay the fees in a timely, full and continuous manner in accordance with regulations.
Twenty-fourth people who participate in employee medical insurance for the first time shall enjoy the waiting period of treatment within 3 months from the date of paying the basic medical insurance premium for employees, and enjoy the treatment paid by the employee medical insurance pooling fund after 3 months. Personal accounts can be used normally during the waiting period of treatment.
Twenty-fifth employees who participate in medical insurance will enjoy medical insurance benefits for employees from the day after the payment is suspended for 3 months; If the payment is interrupted for more than 3 months, you will enjoy the payment treatment of the overall fund after 3 months from the next day of payment.
Twenty-sixth basic medical insurance for employees to implement the payment period system, including the deemed payment period and the actual payment period. Before the start of the medical insurance system in each insured place, the insured workers meet the length of service or working years stipulated by the state and the province, which is regarded as the payment period of medical insurance; The actual payment period of medical insurance only refers to the actual payment period of employee medical insurance premium after the medical insurance system is started.
Reach the legal retirement age, go through the retirement formalities, enjoy the old-age insurance benefits, and be in a state of continuous insurance payment before retirement. The minimum payment period is 25 years for men and 20 years for women, and the actual payment period exceeds 10 year. After retirement, employees will no longer pay the basic medical insurance premium and enjoy the medical insurance benefits for retirees.
Insured persons who have reached the statutory retirement age, if the payment period does not reach the provisions of the preceding paragraph, can pay in one lump sum according to the prescribed payment base and proportion or continue to pay after exceeding the prescribed period, and enjoy the medical insurance benefits for retirees. Choose a one-time payment, only the payment period is calculated, and all the payment fees are included in the employee basic medical insurance fund, and the personal account funds are not supplemented.
Twenty-seventh insured social insurance relationship changes, the employer or I shall promptly handle the transfer procedures of medical insurance relationship. The insured person's medical insurance payment period can be calculated cumulatively.
Insured persons who have enjoyed the medical insurance benefits for retirees do not transfer the medical insurance relationship.
Twenty-eighth cross-regional mobile employment of insured persons, their participation in employee medical insurance payment period can be calculated cumulatively. For employees who should participate in medical insurance for employees and choose to participate in medical insurance for urban and rural residents, the payment period of their participation in medical insurance for urban and rural residents can be calculated by combining the payment method with the payment period of medical insurance for employees, and the specific measures shall be formulated by the municipal medical security department.
Chapter VI Medical Insurance Benefits for Employees
Twenty-ninth insured in designated medical institutions in accordance with the provisions of the expenses, medical insurance funds in accordance with the provisions of payment. The scope of non-payment by the fund shall be implemented in accordance with the provisions of relevant laws, regulations and policies.
Thirtieth employee medical insurance benefits mainly include outpatient co-ordination, outpatient chronic diseases, outpatient specific items, outpatient special drug protection (special drugs), special diseases, emergency rescue, hospitalization (family beds, day wards), serious illness insurance and other treatment categories. The medical insurance benefits shall specify the Qifubiaozhun, payment proportion and maximum payment limit of the medical insurance pooling fund.
The specific standard of medical insurance benefits for employees shall be determined by the municipal medical security department in conjunction with relevant departments.
Thirty-first large medical expenses subsidy fund is used to pay the insured medical expenses that exceed the annual payment limit of the basic medical insurance pooling fund within the policy scope. The large medical expenses subsidy and the basic medical insurance benefits are enjoyed at the same time and suspended at the same time.
Article 32 After the medical expenses incurred by the employees' medical insurance participants in a medical insurance year are paid in accordance with the regulations through the employees' basic medical insurance and large medical expenses subsidies, the part of the compliance medical expenses borne by individuals that exceeds the threshold of critical illness insurance shall be paid by the employees' critical illness insurance fund in accordance with the regulations. There is no annual maximum compensation limit for employee critical illness insurance.
Thirty-third establish and improve the differential payment mechanism of employee medical insurance fund, promote the construction of graded diagnosis and treatment system and family doctor contract service system, and guide the formation of a reasonable medical order. According to the insured population, the type of medical institutions, diseases and different medical expenses, we can scientifically and reasonably set the threshold, payment ratio and maximum payment limit of differentiated pooling funds.
Chapter VII Management of Medical Treatment Article 34 Insured persons seek medical treatment and purchase medicines at designated medical institutions with social security cards and other medical certificates, and the part of medical expenses paid by the medical insurance fund shall be settled by the agency and the designated medical institutions according to regulations.
Thirty-fifth medical insurance for employees shall implement the catalogue of medical insurance drugs, diagnosis and treatment items, special medical materials and medical service facilities determined by the state and the province. The medical expenses incurred by the insured using Class B drugs, medical service items, special medical materials and medical service facilities in the catalogue shall be paid by the individual in advance according to the regulations, and then enjoy the treatment according to the prescribed reimbursement ratio.
In addition to emergency rescue, designated medical institutions shall fulfill the obligation to inform when using drugs, medical materials, diagnosis and treatment projects and medical service facilities with higher prices outside the scope of medical insurance payment; Not informed, the expenses incurred shall be borne by the designated medical institutions. The scope and procedures of prior notification shall conform to the relevant provisions and agreements of the national, provincial and municipal basic medical insurance designated medical institutions for medical services.
Thirty-sixth resettlement, long-term residence, permanent residents (hereinafter referred to as foreign personnel) and referral personnel from different places shall go through the filing procedures in accordance with the provisions and enjoy the prescribed medical insurance benefits.
Thirty-seventh patients with trauma and poisoning need to be audited first, and those who meet the conditions of medical insurance payment can enjoy the treatment paid by medical insurance fund.
Thirty-eighth except for emergency rescue, the medical insurance fund will not pay the medical expenses incurred by the insured in non-designated medical institutions.
Thirty-ninth insured persons in different regions or different medical insurance coverage between repeated insurance, not repeated treatment.
Article 40 The settlement year of employee medical insurance is 10 month/kloc-0 day to February/kloc-0 day.
Chapter VIII Supervision and Management of Funds
Forty-first employee medical insurance fund into the municipal social insurance fund financial accounts management, separate accounting, earmarking, shall not be misappropriated. Audit, finance and other departments should strengthen the supervision and management of the fund. The municipal medical security department shall regularly announce the balance of the employee medical insurance fund to the public and take the initiative to accept social supervision. According to the principle of "fixed income and expenditure, balance of payments and slight savings", the settlement shall be made in accordance with the requirements of "total control, monthly settlement, year-end final accounts, quality assessment and cost overruns sharing", and the specific settlement measures shall be formulated by the municipal medical security department jointly with relevant municipal departments.
Article 42 The expenses incurred by the insured in outpatient service, hospitalization, family sickbed treatment and drug purchase in designated medical institutions belong to the part paid by the medical insurance fund, which shall be accounted for by the designated medical institutions, and the medical insurance agency shall settle with the designated medical institutions every month; Medical expenses paid by individuals shall be collected from the insured by designated medical institutions.
Forty-third full implementation of multiple compound medical insurance payment methods under the total control, strengthen fund management, control the unreasonable increase of medical expenses, ensure the basic medical care of the insured, and ensure the safe operation of the fund.
Forty-fourth designated medical institutions for medical insurance for employees shall implement agreement management, and the rights and obligations of both parties shall be clarified by signing a medical insurance service agreement.
Designated medical institutions shall strictly implement the employee medical insurance policies and medical insurance service agreements, consciously accept the supervision of the medical security department, and strive to provide high-quality and efficient medical services for the insured.
Forty-fifth relevant units and their staff, the insured in violation of the relevant provisions, according to the law and regulations; Suspected of a crime, transferred to judicial organs for criminal responsibility.
Chapter IX Medical Care of Relevant Personnel
Forty-sixth retired personnel, one to six disabled soldiers to implement medical expenses as a whole, the specific medical treatment in accordance with the relevant provisions.
Article 47 On the basis of participating in basic medical insurance, national civil servants shall implement the medical subsidy system for civil servants.
Chapter X Supplementary Provisions Article 48 The municipal medical security department may, in accordance with the changes of laws, regulations, rules and policy documents, and in combination with the economic and social development level of this Municipality and the operation of the medical insurance fund, timely adjust and improve the policies of employee medical insurance financing standard, treatment level and service management in conjunction with relevant departments. Involving major changes, it shall be submitted to the municipal government for approval according to law.
Article 49 These Measures shall come into force as of the date of 20211.