How to calculate the payment period of the Detailed Rules for the Implementation of the Basic Medical Insurance for Urban Residents in daye city? Do I have to pay in the street?

Detailed Rules for the Implementation of Basic Medical Insurance for Urban Residents in daye city

Chapter I General Principles

Article 1 In order to establish a multi-level medical security system, effectively improve the basic medical security level of urban residents in our city, and realize the goal of universal medical security, according to the Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No.20), Opinions of the Provincial People's Government on Establishing the Basic Medical Insurance System for Urban Residents (E [2008] No.25) and Basic Medical Insurance for Urban Residents in Huangshi City,

Second, the basic medical insurance for urban residents should start at a low level, so that the financing standard and security level can adapt to the level of economic and social development and the affordability of all parties, focusing on ensuring the serious medical needs of non-employed urban residents and gradually improving the security level; Adhere to voluntary insurance and fully respect the wishes of the masses; Adhere to the fixed expenditure by income, balance income and expenditure, and make a slight savings; Adhere to the basic medical insurance for urban workers, the new rural cooperative medical system and social medical assistance, and coordinate development.

Article 3 In 2008, the basic medical insurance system for urban residents will be established in the whole city, and it will be implemented before the end of June. By the end of the year, the participation rate of urban residents will strive to reach about 50%. Gradually form a reasonable financing mechanism, a sound management system and a standardized operating mechanism, gradually cover all urban non-employed residents, and gradually establish a relatively complete basic medical insurance system for urban residents' serious illness.

Article 4 The basic medical insurance for urban residents in this Municipality shall implement a unified policy and territorial management.

Chapter II Responsibilities of Management Institutions

Fifth municipal labor and social security department is responsible for the unified organization and guidance of the city's urban residents medical insurance management, its main responsibilities are:

(a) to formulate the general rules for the trial implementation of medical insurance for urban residents;

(2) Formulating policies and regulations on medical insurance for urban residents;

(three) responsible for the implementation of the medical insurance policy for urban residents;

(four) to supervise and guide the implementation process of medical insurance for urban residents;

(five) responsible for the qualification examination and annual assessment of designated medical institutions.

Article 6 The Medical Insurance Bureau is the agency of medical insurance for urban residents in our city, and its main responsibilities are:

(a) seriously implement the policies and regulations of medical insurance for urban residents;

(two) the preparation of urban residents medical insurance fund budget;

(three) responsible for the collection, payment and management of medical insurance funds for urban residents;

(four) responsible for the qualification examination, registration confirmation and medical registration management of urban residents' medical insurance participants;

(five) to check the implementation of the medical insurance policy for urban residents by designated medical institutions, community labor and social security service stations, school students and individual medical insurance agencies;

(six) to be responsible for the summary and reporting of various financial, accounting and statistical statements of medical insurance for urban residents;

(seven) responsible for the publicity and training of urban residents' medical insurance policy, accept the policy consultation and daily business inquiry of the insured, and do the corresponding supporting services.

Article 7 The labor security service station set up by the municipal labor security department in the community is responsible for the medical insurance services of residents within its jurisdiction, and its duties are:

(a) seriously implement the policies and regulations of medical insurance for urban residents, and do a good job in publicity;

(two) responsible for the household survey of urban residents' medical insurance, the preliminary examination of insurance qualifications, the registration of insurance, and the establishment and uploading of payment declaration procedures and computer information;

(three) responsible for the preparation and declaration of medical insurance for urban residents;

(four) responsible for the issuance of medical insurance cards (certificates) for urban residents;

(five) responsible for the reimbursement of medical expenses for urban residents;

(six) regularly report to the medical insurance bureau on medical insurance for urban residents;

(seven) to undertake other matters related to medical insurance for urban residents.

Article 8 Departments such as finance, health, education, civil affairs, disabled persons' federations, local taxes, public security, auditing, supervision, price and drug supervision, and towns (fields), subdistrict offices and economic development zones shall, according to their respective functions and duties, work together to do a good job in medical insurance for urban residents.

(a) the municipal finance department is responsible for the arrangement, disbursement and supervision of financial subsidy funds;

(two) the municipal audit department is responsible for regularly auditing the income and expenditure and management of the medical insurance fund for urban residents;

(three) the municipal health department is responsible for the supervision and management of medical insurance for urban residents;

(IV) The municipal education department shall be responsible for the publicity and organization of students' enrollment, do a good job in enrollment registration and the collection of medical insurance premiums, and go through the registration and payment procedures with the local tax authorities where the insured person is located;

(five) the municipal civil affairs department is responsible for doing a good job in the list of poor groups, qualification and medical assistance, and directly giving assistance to the settlement of hospitalization medical expenses for urban residents who meet the scope of assistance (the specific assistance measures shall be formulated separately by the municipal civil affairs department);

(six) the municipal drug supervision department is responsible for the quality management of drugs and medical devices in community medical institutions and designated hospitals;

(seven) the Municipal Disabled Persons' Federation is responsible for the identification of severely disabled persons and provides their basic information to the medical insurance bureau;

(eight) the municipal public security department is responsible for the investigation of urban residents and household registration;

(nine) the municipal supervision department is responsible for the supervision of the operation of medical insurance for urban residents;

(ten) the municipal price department is responsible for the supervision of the prices of drugs and medical services in designated medical service institutions;

(eleven) the municipal local tax department is responsible for the collection of medical insurance premiums for urban residents, confirming and summarizing the payment of medical insurance premiums for urban residents and timely feeding back to the Medical Insurance Bureau.

(12) Each township (field), sub-district office and Economic Development Zone is responsible for organizing and coordinating the registration of residents in various communities within its jurisdiction, and is responsible for issuing family information certification materials such as low-income elderly people, zero-employment families, low-income people, "three noes" personnel (those who have no economic resources, no ability to work, and can't decide their dependents or dependents).

Chapter III Subject matter of Insurance

Article 9 Primary and secondary school students (including students from vocational high schools, technical secondary schools, technical schools and special schools), children and other non-employed urban residents, rural household registration students studying in urban schools, land-lost farmers in urban planning areas and non-employed accompanying families of long-term migrant workers within their jurisdiction may voluntarily participate in the basic medical insurance for urban residents. The above-mentioned rural household registration personnel will no longer participate in the new rural cooperative medical system after participating in the basic medical insurance for urban residents. College students participate in medical insurance according to relevant national and provincial regulations.

Chapter IV Fund Raising

Tenth basic medical insurance fund for urban residents consists of the following items:

(1) Medical insurance premiums paid by individuals;

(2) government subsidy funds;

(3) Fund interest income;

(4) Funds raised from other channels according to law.

Eleventh in 2008, the basic medical insurance for urban residents to raise according to the following standards:

(1)1students and non-residents in primary and secondary schools (including vocational high schools, secondary schools, technical schools and special schools) under the age of 8 per person per year 120 yuan, of which individuals pay 30 yuan and financial subsidies to 90 yuan;

(2) 18 years old and above non-employed residents 280 yuan per person per year. Among them, individuals pay 190 yuan, giving financial subsidies to 90 yuan;

(3) Older people over 60 who do not enjoy the pension or endowment insurance benefits on a monthly basis (hereinafter referred to as low-income elderly people) pay 280 yuan every year, including individual contributions 130 yuan and financial subsidies 150 yuan.

The minimum living security personnel among the above-mentioned personnel do not pay fees, and the Civil Affairs Bureau subsidizes 10 yuan per person per year from the medical assistance funds, and the difference is fully subsidized by the municipal finance; Severely disabled (refers to the physical disability assessed as Grade I or Grade II; I, II and III intellectual and mental disabilities; First-degree blindness and second-degree blindness with visual disability; First-class speech disability, hearing disability and first-class low vision disability, who hold the Disabled Persons' Card of People's Republic of China (PRC) and China issued by the Municipal Disabled Persons' Federation, do not pay fees, and are fully subsidized by the municipal finance.

Article 12 The municipal labor and social security department and the financial department may, according to the changes in the level of social and economic development and the level of medical consumption of urban residents, put forward opinions on the adjustment of financing standards, government subsidy standards and medical treatment levels, which shall be examined and approved by the municipal government and implemented after being reported to the Huangshi Municipal Government for approval.

Thirteenth to encourage qualified employers to give subsidies to employees' families, employers enjoy relevant preferential tax policies in accordance with state regulations.

Chapter V Insurance Registration and Payment

Fourteenth urban residents in principle to the family as a unit of insurance. The specific way to participate in insurance is:

(a) the municipal education department is responsible for the enrollment of students in school, and the school uniformly declares, registers, pays fees and changes information.

(two) the "three noes" personnel and severely disabled persons who belong to the minimum living standard are insured by the municipal civil affairs department, and the Municipal Minimum Living Standard Bureau is responsible for reporting, registration and information change. The minimum target is based on the annual 1 1 registration list of the municipal civil affairs department at the end of the year.

(three) the elderly residents, children and other insured residents shall be uniformly declared and registered by the labor and social security service institutions where the household registration is located.

Fifteenth urban residents to apply for insurance and change procedures, individual residents need to provide residence booklet, identity card, recent 1 inch color registration photos 1 piece, and fill out the "daye city urban residents basic medical insurance registration application form". The following categories of personnel also need to provide relevant certification materials when participating in the insurance:

(a) the minimum target must carry the "daye city social assistance certificate" and a copy of the original;

(2) severely disabled people carry the original People's Republic of China (PRC) Disabled Persons' Card and provide a copy;

(three) "three noes" personnel need to carry the relevant certificates provided by the municipal civil affairs department;

(4) The families and minor children of migrant workers need to bring the original "Temporary Residence Permit" of their place of residence and provide a copy and proof that the work unit has participated in social insurance;

(five) low-income elderly people need to provide proof issued by local government agencies that they do not enjoy pension or pension benefits on a monthly basis.

Article 16 Towns (fields), sub-district offices, economic development zones and community labor and social security service institutions should correctly enter the personal information of insured residents after carefully verifying the relevant identity documents and relevant certificates of urban residents, and issue the "daye city Urban Residents' Basic Medical Insurance Payment Declaration and Verification Form" according to the payment standard in Article 8 of these Rules, and urge the insured residents to pay at the designated agent bank. The agencies shall timely transmit the payment information of the insured residents to the Municipal Local Taxation Bureau and the Medical Insurance Bureau, and the Medical Insurance Bureau shall timely review and confirm according to the information transmitted and submitted, and compile the collection statistics and social security cards of the basic medical insurance fund for urban residents in daye city respectively according to the confirmation information and the payment vouchers of the insured residents, and hand them over to the community labor security service institutions in towns (fields), sub-district offices and economic development zones for distribution.

Seventeenth insured residents due to employment, household registration change or death. , the need to terminate the medical insurance relationship for urban residents and cancel the "social security card" procedures. When going through the alteration formalities, I or my family members shall submit a written application to the local labor and social security service institution and fill in the Information Change Form of daye city Urban Residents' Basic Medical Insurance Personnel.

(a) the applicant from unemployment to employment, it shall submit the employment contract and social security card and other supporting materials;

(two) the applicant to move out of the city, it shall submit the household registration certificate and a copy of the household registration certificate;

(3) When a resident dies, the medical insurance relationship will automatically terminate, and the immediate family members shall submit the death certificate within 30 days.

When the medical insurance personnel for urban residents increase or decrease, they should fill in the "Table of Increase or decrease of basic medical insurance personnel for urban residents in daye city". All townships (fields), sub-district offices, economic development zones and community labor and social security service institutions shall strictly examine the relevant information submitted by the applicant, and those who meet the requirements shall go through the formalities at the Medical Insurance Bureau before the 25th of each month.

Eighteenth urban residents insurance registration and payment from June 26, 2008, the medical insurance payment year for the natural year. In the start-up stage (the start-up stage of urban residents' medical insurance is from the date of implementation of these Rules to February 3, 20081day, that is, the transition period of residents' insurance payment), individual urban residents will pay according to the payment standard of 6 months, and after the start-up stage, urban residents will pay medical insurance premiums according to the remaining months when they join the insurance.

Nineteenth residents who have gone through the insurance registration procedures in accordance with the provisions of these rules during the transition period and paid an annual medical insurance premium in full shall enjoy medical insurance benefits from the next month of payment; After the transition period, those who are insured or insured after the termination of insurance can enjoy medical insurance benefits after 90 days from the date of payment, and the payment period before the termination of insurance is not counted. Do not enjoy medical insurance benefits during arrears.

Newborns can apply for insurance registration after completing household registration within 60 days after birth, and if they pay an annual medical insurance premium in full, they will enjoy medical insurance benefits for residents from the day after payment. Residents who newly apply for Daye household registration can apply for insurance payment within 30 days of naturalization and enjoy medical insurance benefits from the next month.

Twentieth students and urban residents medical insurance time from September 1 day to August 3 1 day. The school will send the standard electronic documents and related forms to the Medical Insurance Bureau every June1-June 30th, and the Medical Insurance Bureau will review the qualifications of the insured students and fill in the payment declaration and approval form; Newly enrolled students who are insured for the first time shall go through the registration and payment procedures in the above manner from September/KLOC-0 to September 30 every year.

Students in school will enjoy the relevant treatment of residents' medical insurance from September 1 day after paying in full according to regulations.

Chapter VI Medical Insurance Benefits

Twenty-first urban residents' basic medical insurance fund is used to pay for hospitalization, outpatient serious illness and general outpatient subsidies (general outpatient subsidies shall be formulated separately).

Twenty-second insured residents hospitalization refers to the process of admission and discharge procedures. Emergency rescue and uninterrupted hospitalization are regarded as one hospitalization. If the diagnosis and treatment process of a hospitalization spans multiple years, the medical insurance year shall be determined according to the discharge settlement time.

Twenty-third insured residents hospitalization expenses in accordance with the provisions, borne by the individual Qifubiaozhun. The expenses above Qifubiaozhun shall be shared by the urban residents' medical insurance fund and the insured residents in proportion.

(a) Qifubiaozhun: tertiary hospitals, medical institutions outside 500 yuan; 400 yuan, a secondary hospital; First-class hospitals (including township hospitals, community health service centers and community health service stations) 100 yuan.

The insured "three noes" are hospitalized in Huimin Hospital, and there is no deductible.

(2) Fund payment ratio: 40% for tertiary hospitals and medical institutions transferred outside the city; Secondary hospitals pay 50%; A hospital (including township hospitals, community health service centers and community health service stations) pays 75%.

Twenty-fourth residents in Huimin hospital hospitalization and serious illness outpatient expenses first enjoy Huimin policy, on the basis of enjoying preferential treatment for Huimin, and then according to the provisions of Article 23 of these rules for reimbursement of the rest of the medical expenses. The sum of the reimbursement ratio of basic medical insurance for urban residents and preferential medical care for Huimin is not less than 80% of the medical expenses that meet the requirements of the medical insurance policy for urban residents in principle.

After the subsistence allowances are cancelled, the insured can still enjoy the medical insurance benefits for urban residents in the same year.

Twenty-fifth insured residents who receive radiotherapy and chemotherapy, anti-rejection, uremia dialysis, hemophilia and lupus erythematosus treatment after tissue and organ transplantation in outpatient department, and meet the medical expenses stipulated in the policy, shall be subsidized by the municipal urban residents' medical insurance fund at 55%.

Article 26 Insured residents who meet the requirements of the Catalogue of Medicines for Basic Medical Insurance and Work Injury Insurance in Hubei Province, the Catalogue of Diagnosis and Treatment Items for Basic Medical Insurance for Urban Employees in Hubei Province, and the Scope and Standard of Medical Service Facilities for Basic Medical Insurance for Urban Employees in Hubei Province (hereinafter referred to as the "three catalogues"), but do not meet the indications specified in the catalogue, shall undergo special examination and treatment, and install special materials and artificial organs (made in China). The use of special materials is limited to domestic production, and the difference between joint venture and imported materials caused by special circumstances is borne by individuals.

Twenty-seventh insured residents within a year of hospitalization and serious illness outpatient medical expenses, the highest payment standard of urban residents' medical insurance fund (that is, the top line) is 30 thousand yuan.

The number of insured residents who have paid for 3 years or 6 years (inclusive) continuously has increased to 40,000 yuan and 50,000 yuan respectively. Medical expenses exceeding the maximum payment limit shall be settled through social medical assistance or commercial insurance, and the urban residents' medical insurance fund will no longer pay.

Chapter VII Medical Management

Twenty-eighth basic medical insurance for urban residents is managed by designated medical institutions. Medical insurance for urban workers designated medical institutions for urban residents medical insurance designated medical institutions, insured residents can choose their own medical treatment.

Twenty-ninth municipal labor and social security departments should strengthen the management of medical services in designated medical institutions. The Medical Insurance Bureau and the designated medical institutions shall sign a medical service agreement on the service scope, items, quality and settlement methods, clarify the rights and obligations of both parties, and effectively protect the legitimate rights and interests of insured patients.

Thirtieth insured residents must carry the "Resident Medical Insurance Card" and "Social Security Card" issued by the Medical Insurance Bureau. When providing medical services for the insured, the designated medical institutions shall carefully examine and check, and shall not resort to deceit for medical treatment. Designated medical institutions should strictly implement the provisions of the first diagnosis responsibility system and the residents' medical insurance policy, and treat diseases reasonably, check reasonably, use drugs rationally and charge reasonably.

Thirty-first insured residents hospitalized, designated medical institutions should register as required, timely and accurately input the details of residents' hospitalization medical expenses into the computer, and upload them to the medical insurance bureau through the computer network system. All medical expenses incurred by residents during hospitalization, designated medical institutions must provide the insured patients with a "daily list" of hospitalization expenses, which shall be signed by the patients themselves or their families. When patients leave the hospital, they only need to pay the medical expenses that should be paid by individuals, and the rest will be settled by the medical insurance bureau and designated medical institutions.

Article 32 The drug list, diagnosis and treatment items and service items of residents' medical insurance shall be implemented in accordance with the relevant provisions of the basic medical insurance for urban workers in Hubei Province, and the scope of drugs, diagnosis and treatment items and services suitable for children shall be appropriately increased in accordance with the relevant provisions of the state and the province.

Article 33 If the insured residents need to be transferred to Huangshi and Wuhan for treatment due to illness, the chief physician of the secondary medical institution shall consult, issue a referral certificate and a medical record summary, and report to the Municipal Medical Insurance Bureau for the record after being audited by the Hospital Medical Insurance Office.

Thirty-fourth insured residents who receive emergency assistance due to critical illness can choose the nearest medical institution for medical treatment, and are not restricted by referral procedures. However, I or my family members should go through the formalities with the medical insurance bureau with the emergency certificate and related documents within 5 working days.

Thirty-fifth insured residents in foreign countries for a long time, need to bring the residence of the "temporary residence permit" to the Municipal Medical Insurance Bureau for medical treatment in different places, and restrict the choice of a local medical insurance designated medical institution. Foreign residents who have been hospitalized in designated medical institutions in other places for a long time should be reported to the Medical Insurance Bureau for the record within 5 working days after admission.

Article 36 The medical expenses incurred by insured residents due to emergency hospitalization, temporary hospitalization due to illness, transfer to other hospitals, and long-term hospitalization due to illness in different places shall be reimbursed by themselves or their agents on the basis of the residents' medical insurance and social security card, ID card, discharge summary, detailed list of medical expenses and original hospitalization invoice, and the medical expenses that meet the requirements shall be reimbursed according to the proportion stipulated by residents' medical insurance transfer treatment.

Thirty-seventh insured residents suffering from five kinds of serious diseases stipulated in Article 25 may apply for serious illness outpatient service. By the insured patients or their families to the "daye city urban residents serious illness outpatient application form", the original medical history data (subject to the diagnosis of two or more designated hospitals) to declare to the Municipal Medical Insurance Bureau. Outpatient serious illness from the approval of the next month to enjoy treatment.

Thirty-eighth insured residents of the following expenses, urban residents medical insurance fund will not be reimbursed:

(a) receiving treatment abroad or in Hong Kong, Macao and Taiwan;

(2) Self-mutilation and suicide (except mental patients);

(three) fighting, drinking, drug abuse and other illegal and criminal acts lead to disability;

(four) traffic accidents, accidental injuries (except students), medical accidents and other medical expenses borne by the other party;

(five) work-related injuries, occupational diseases and family planning expenses;

(six) medical expenses paid by special financial funds for AIDS, schistosomiasis and tuberculosis;

(seven) other expenses that are not reimbursed according to relevant laws and regulations.

Thirty-ninth municipal civil affairs departments should conscientiously do a good job in medical assistance for needy groups and give assistance to insured urban residents who meet the conditions for assistance. The specific measures shall be formulated separately by the municipal civil affairs department.

Chapter VIII Fund Management and Supervision

Fortieth the basic medical insurance fund for urban residents shall be included in the management of special financial accounts, and separate accounts shall be established for special purposes and shall not be misappropriated.

Article 41 The basic medical insurance fund for urban residents shall implement a unified social insurance budget and final accounts system, financial accounting system and internal audit system. The municipal labor and social security department manages the residents' basic medical insurance fund; The municipal finance department shall supervise the use of funds; The municipal audit department regularly audits the income and expenditure and management of the basic medical insurance fund for urban residents.

Forty-second designated institutions and their staff have one of the following acts, and the municipal labor and social security department shall investigate the liability for breach of contract in accordance with the agreement. If the circumstances are serious, the qualification of the designated institution shall be cancelled, and if necessary, the relevant departments shall be submitted to give administrative sanctions to the responsible person according to law. If a crime is constituted, criminal responsibility shall be investigated according to law.

(a) do not verify whether the patient belongs to the urban residents medical insurance insured residents, resulting in an impostor for medical treatment;

(two) in the name of hospitalization, medical records are fabricated, and the medical records are inconsistent with the hospitalization expenses;

(three) prevarication or detention of patients;

(four) can not guarantee the necessary inspection, diagnosis and treatment of urban residents and medication, resulting in adverse consequences;

(5) Exchanging diagnosis and treatment items and medicines, and including the diagnosis and treatment items and medicines that do not meet the requirements into the payment scope of the urban residents' medical insurance fund;

(six) in violation of the charging standards for medical treatment projects and the provisions on drug prices;

(seven) examination, treatment and medication are inconsistent with the condition;

(eight) taking advantage of work to prescribe drugs by car;

(nine) other acts in violation of the provisions of the residents' medical insurance policy.

Residents have one of the following acts, resulting in the loss of medical insurance fund for urban residents. In addition to recovering the losses, the Medical Insurance Bureau may informed criticism and suspend its medical insurance benefits. When necessary, request the relevant departments to punish the parties according to law, and if the case constitutes a crime, criminal responsibility shall be investigated according to law.

(a) providing my medical insurance card to others, causing an impostor to seek medical treatment;

(two) false medical expenses;

(three) other acts in violation of the provisions of the residents' medical insurance policy.

Forty-third medical insurance bureau and its staff have one of the following acts, by the unit to recover illegal income, and depending on the seriousness of administrative sanctions, constitute a crime shall be investigated for criminal responsibility according to law.

(a) in the management of medical insurance, favoritism, favoritism;

(two) taking advantage of his authority and work to ask for bribes and seek personal gain;

(three) in violation of the provisions of the urban residents' medical insurance fund for other purposes;

(4) Loss of residents' medical insurance fund due to dereliction of duty.

Chapter IX Supplementary Provisions

Forty-fourth municipal labor and social security departments shall, jointly with relevant departments, formulate measures for the implementation of large medical insurance for urban residents and specific supporting measures for these rules.

Forty-fifth insured residents due to sudden, epidemic diseases and natural disasters and other force majeure factors caused by a wide range of acute, dangerous and serious patients' medical expenses, by the municipal government to comprehensively coordinate and solve.

Forty-sixth these rules shall be interpreted by the Municipal Labor and Social Security Bureau.

Article 47 These Rules shall come into force as of the date of promulgation.

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