Tianjin Basic Medical Insurance Regulations shall come into force on March 1

Chapter 1 General Provisions

Article 1

Article 2 This regulation applies to the activities of basic medical insurance in the administrative area of the city, such as enrollment, payment, treatment protection, management services and supervision and management.

The basic medical insurance referred to in these regulations includes employees' basic medical insurance and urban and rural residents' basic medical insurance.

Article 3 of the city's basic medical insurance adhere to the full coverage, basic, multi-level, sustainable policy, follow the level of protection and economic and social development level, the rights and obligations correspond to the principle of fairness and efficiency.

Article 4 of the municipal and district people's governments shall strengthen the organization and leadership of the basic medical insurance work, the basic medical insurance business into the national economy and social development planning, to ensure the necessary financial investment, strengthen the supervision and management of the basic medical insurance fund, to ensure that the fund is safe and effective operation.

The township people's governments and street offices do a good job in basic medical insurance related work in accordance with the prescribed duties.

Article 5 of the city and district medical insurance administrative department is responsible for the administration of basic medical insurance in the administrative region.

Departments of development and reform, finance, human resources and social security, health, market supervision, education, audit, civil affairs, public security, and veterans' affairs are responsible for the relevant basic medical insurance work within their respective areas of responsibility.

Medical insurance fee collection organizations are responsible for the collection of basic medical insurance fees.

Medical insurance management organizations are responsible for providing basic medical insurance management services.

Article 6 The city has established a multi-level medical insurance system with basic medical insurance as the main body, supplemented by supplementary medical insurance, medical assistance and commercial health insurance.

Article 7 The people's governments of the city and districts shall strengthen the publicity of basic medical insurance laws, regulations, rules and policies, and encourage and guide all people to participate in basic medical insurance.

Article 8 The city and Beijing Municipality and Hebei Province shall establish a working mechanism for the coordinated development of basic medical insurance, and promote cooperation in policy formulation, management services, supervision and management, direct settlement of medical treatment in other places, mutual recognition of qualifications for fixed-point treatment, procurement of medicinal products, and informationization, so as to do a good job of coordinating the work of basic medical insurance in the region.

The city has strengthened basic medical insurance cooperation with other provinces, autonomous regions and municipalities directly under the central government, and has done a good job of transferring basic medical insurance relations and direct settlement for medical treatment in other places in accordance with national regulations.

Chapter II Participation and Contributions

Article 9 State organs, enterprises, institutions, social organizations, private non-enterprise units, individual households with employees and other employers and their employees shall participate in the basic medical insurance for employees.

Individual entrepreneurs without employees, part-time workers who do not participate in the basic medical insurance for employees at their employers, and other flexibly employed persons (hereinafter collectively referred to as flexibly employed persons) may participate in the basic medical insurance for employees or the basic medical insurance for urban and rural residents.

Students, children and other unemployed urban and rural residents may participate in urban and rural residents' basic medical insurance.

Article 10 Employers shall, in accordance with the law, apply for basic medical insurance registration for their employees. Enterprises, when registering for registration, simultaneous registration for basic medical insurance. Other employers shall apply for basic medical insurance registration within thirty days from the date of establishment.

Flexibly employed persons who participate in the basic medical insurance for employees shall apply for basic medical insurance registration on their own.

The basic medical insurance for urban and rural residents shall be categorized and registered, and the specific measures shall be formulated by the municipal administrative department of medical insurance in conjunction with the relevant departments.

Article 11 of the basic medical insurance premiums by the employer and the employee **** the same payment. Flexible employment personnel to participate in the basic medical insurance, by the individual in accordance with the provisions of the basic medical insurance premiums. Receiving unemployment insurance benefits to participate in employees' basic medical insurance, should pay the basic medical insurance premiums from the unemployment insurance fund, the individual does not contribute.

The basic medical insurance premiums for urban and rural residents are a combination of individual contributions and government subsidies. The government subsidizes the individual contributions required for participation in basic medical insurance for urban and rural residents by members of the minimum subsistence guarantee family, special hardship dependents, low-income family members, and persons with severe disabilities.

Article 12 of the employer shall, in accordance with the law, self-declaration, pay the basic medical insurance premiums in full and on time, not due to force majeure and other legal reasons shall not be deferred, reduced or waived. Employees shall pay the basic medical insurance premiums shall be withheld by the employer on behalf of the payment. Flexibly employed persons who participate in the basic medical insurance for employees shall declare their own contributions to the medical insurance premium collection organization.

Participants in the basic medical insurance for urban and rural residents shall pay the basic medical insurance premiums for the following year in a lump sum during the centralized enrollment and payment period from September to December each year; those who fail to pay in time may make up for the payment in accordance with the regulations.

Article XIII of the basic medical insurance premiums for the implementation of the city's unified collection. Medical insurance premium collection agencies shall, in accordance with the law, the full amount of basic medical insurance premiums collected in a timely manner to the medical insurance agencies to provide payment, and regularly inform employers and individuals.

Medical insurance premium collection organizations shall strengthen their inspection of the payment of basic medical insurance premiums by employers.

Article 14 The standard of basic medical insurance contributions for employees shall be determined in accordance with the city's contribution rates and the individual contribution base.

The basic medical insurance for urban and rural residents is subject to a differential contribution system. Students, children in accordance with the prescribed standards for urban and rural residents to pay the basic medical insurance premiums; other unemployed urban and rural residents to set different levels of contribution standards, by their own voluntary choice to pay. The government subsidizes individual contributions in accordance with the prescribed standards.

Article 15 of the city employees basic medical insurance premium rates, urban and rural residents of basic medical insurance contribution standards and government subsidies, according to the level of economic and social development, basic medical insurance fund operation and other circumstances to determine and make appropriate adjustments in due course.

The municipal medical insurance administrative department shall, in conjunction with the municipal finance and other relevant departments, put forward in a timely manner the basic medical insurance premium rates for employees, urban and rural residents of the basic medical insurance contribution standards and government subsidy standards of the specific program and adjustment program, reported to the municipal people's government for approval and implementation.

Chapter III treatment and payment

Article 16 of the basic medical insurance for employees to participate in the basic medical insurance of the employer from the month of payment, participate in the basic medical insurance for employees to participate in the basic medical insurance of the flexibly employed since the continuous payment of six months from enjoying the basic medical insurance treatment of employees. If the payment of contributions is interrupted, the enjoyment of the basic medical insurance treatment for employees shall be suspended, and the basic medical insurance premiums during the interruption period can be paid up. The specific measures for the reimbursement of medical expenses incurred during the period of retroactive payment and interruption shall be formulated by the municipal medical insurance administrative department in conjunction with the relevant municipal departments.

If a person who has participated in the basic medical insurance for employees reaches the legal retirement age with an accumulated contribution period of not less than twenty-five years for men and twenty years for women, and with an actual contribution period of not less than five years, he shall not pay the basic medical insurance premiums for employees after his retirement and shall continue to enjoy the basic medical insurance benefits for employees. If the number of years is less than the above, you can enjoy the basic medical insurance treatment after making up the basic medical insurance premiums in a lump sum in accordance with the provisions of the difference in the number of years.

If an employee is employed in a different coordinating area, his/her basic medical insurance relationship shall be transferred with him/her, and his/her contribution period shall be cumulative.

Article 17: If a person who participates in the basic medical insurance for urban and rural residents pays contributions during the period of centralized participation and payment of contributions, the period of entitlement shall be from January to December of the year following the year of payment of contributions. If the city has other regulations on the entitlement period for newborn babies, etc., such regulations shall apply.

Article 18 Participants shall be entitled to reimbursement of medical expenses for hospitalization, outpatient (emergency) consultation for common diseases and outpatient consultation for specific diseases in accordance with the provisions of the State and the city.

Medical expenses within the scope of reimbursement in accordance with the basic medical insurance drug list, diagnostic and treatment items, medical service facility standards, as well as emergency treatment, rescue, etc., shall be paid out of the basic medical insurance fund in accordance with the regulations, except for one of the following cases:

(1) those that should be paid out of the workers' compensation insurance fund;

(2) those that should be borne by a third party;

(iii) should be borne by the public ****health;

(iv) medical treatment outside the country.

Article 19 of the basic medical insurance fund to pay for medical expenses set the starting standard, the maximum payment limit, the payment ratio. Those exceeding the starting standard and below the maximum payment limit shall be shared by the basic medical insurance fund and individuals in accordance with the prescribed payment ratio.

The municipal medical insurance administrative department shall, in conjunction with the municipal finance and other relevant departments, in accordance with the provisions of the basic medical insurance fund to pay for medical expenses in due course to put forward the starting standard, the maximum payment limit and the payment ratio of the specific program and adjust the program for the approval of the Municipal People's Government to implement.

Article 20 of the insured persons suffering from outpatient specific diseases, the outpatient specific disease identification organization to identify the condition meets the standard, enjoy the outpatient specific disease medical expenses reimbursement treatment. The types of outpatient specific diseases and identification criteria, by the municipal health insurance administrative department in conjunction with the municipal health and other relevant departments to develop.

Outpatient specific diseases are managed by fixed-point medical treatment and specific scope of medical services.

Article 21: If the conditions for the establishment of family hospital beds in the city are met, insured persons may apply for treatment in family hospital beds.

The municipal medical insurance administrative department shall, in conjunction with the relevant departments of the city to formulate the reimbursement of medical expenses for family hospital beds.

Chapter IV Fund Management

Article 22 of the basic medical insurance fund management should adhere to the principle of income to determine expenditure, balance of income and expenditure, a slight surplus, the implementation of the city's co-ordination, to ensure that the fund is stable and sustainable operation.

Article 23 of the basic medical insurance fund consists of the basic medical insurance premiums paid by employers and insured persons, government subsidies, social contributions, late payment, interest and other funds.

Article 24 of the basic medical insurance fund into the financial account management. Employee basic medical insurance fund and urban and rural residents' basic medical insurance fund separate accounts, separate accounting, the implementation of the national unified fund financial system, accounting system and fund budget management system.

Article 25: The basic medical insurance fund for employees consists of a general fund and individual accounts. The basic medical insurance premiums paid by individual employees are all credited to the individual account; unit of the basic medical insurance premiums paid in accordance with the proportion were transferred to the integrated fund and the individual account, the proportion of the individual account by the municipal medical insurance administrative department in conjunction with the municipal finance and other relevant departments to determine the municipal people's government for approval after the implementation. The principal and interest of the individual account are owned by the individual and can be carried forward for use and inheritance.

If the state and the city have other regulations on the establishment of individual accounts of the basic medical insurance fund for employees, the regulations shall apply.

The basic medical insurance fund for urban and rural residents establishes a comprehensive fund in accordance with the regulations, and does not establish individual accounts.

Article 26: The bank deposits of the basic medical insurance fund shall be subject to a uniform method of interest accrual. For deposits in the income account and expenditure account of demand deposits to implement preferential interest rates, according to the three-month whole deposit prime rate of interest accrued. For deposits in the financial account, the interest rate is managed in accordance with the interest rate of residential savings deposits for the same period.

Article 27 of the basic medical insurance fund budget, the draft final accounts of the preparation, review and approval, in accordance with the provisions of the law and the State Council.

Article 28 of the medical insurance agencies shall regularly publicize to the community to participate in basic medical insurance, as well as the basic medical insurance fund income, expenditure, balance and income.

Chapter V Services

Article 29 The medical insurance agencies shall establish and improve operational, financial, security and risk management systems.

Medical security agencies shall pay basic medical insurance benefits in full and on time.

Article 30 of the medical insurance agencies, medical insurance premium collection agencies shall, in accordance with the division of responsibilities and timely for the employer and the insured to establish files, complete and accurate records of basic medical insurance registration, contributions, benefits payment and other personal rights and interests of the relevant information, and to provide inquiries, consultations and other related services.

Article 31 of the medical insurance agencies in accordance with the needs of management services, can sign a service agreement with medical institutions and retail pharmacies, the implementation of designated medical institutions and designated retail pharmacies (hereinafter collectively referred to as designated medical institutions) management, and standardize the behavior of pharmaceutical services.

The municipal medical insurance administrative department shall, in accordance with national regulations, develop and improve the basic medical insurance designated medical institutions agreement management methods. The development of agreement management approach should fully listen to the designated medical institutions, relevant industry associations, physicians and pharmacists on behalf of the views of the reasonable views should be absorbed.

Article 32 of the designated medical institutions shall give priority to the basic medical insurance reimbursement for the insured to provide reasonable and necessary medical services. When providing medical services outside the scope of reimbursement for insured persons, they shall obtain the consent of the insured persons or their guardians or relatives in advance and provide details of the expenses.

Specified medical institutions shall strengthen the management of real-name medical treatment and purchase of medicines, and verify the validity of participants' medical insurance vouchers when providing medical services.

Specified medical institutions should be equipped with the necessary information technology equipment, and medical insurance agencies to realize network settlement of medical expenses and real-time information **** enjoy.

Article 33 of the medical insurance agency shall strengthen the management of the agreement, the fixed-point medical institutions in violation of the service agreement upon examination and verification, according to the service agreement to give the appropriate treatment.

Specialized medical institutions in violation of the declared costs are reviewed and verified, the medical insurance agency shall not pay. The designated medical institution shall not transfer the rejected expenses to the insured person.

Article 34 of the city to improve the basic medical insurance services physicians, pharmacists management system, the implementation of directory management.

Article 35 of the participants enjoy basic medical insurance treatment for medical treatment or purchase of medicines, should hold their own valid vouchers for medical insurance, and to comply with the relevant provisions of the basic medical insurance.

If a participant is unable to go to a designated medical institution to purchase medicines due to special circumstances such as mobility problems, he or she may entrust another person to purchase medicines on his or her behalf with the participant's valid medical insurance vouchers, and the person entrusted with such vouchers shall present his or her own valid proof of identity.

Participants are not allowed to lend or rent their valid medical insurance certificates.

Article 36 of the city to provide participants with convenient and fast settlement services. Participants shall be given priority in the implementation of network direct settlement of medical expenses incurred in designated medical institutions in the city.

The medical expenses incurred by the insured persons for medical treatment in other places shall be prioritized for direct settlement through networking if the conditions for direct settlement through networking are met.

Article 37 of the municipal medical insurance administrative department in accordance with national regulations on drugs, diagnostic and treatment items, medical materials, diagnostic codes and surgical operation codes and other basic codes to implement standardized management.

Medical security agencies shall collect information on the service capacity of designated medical institutions, strengthen the standardization of medical insurance database, standardize basic management.

Article 38 of the municipal medical insurance administrative department to establish and improve the basic medical insurance fund total budget management under the composite medical insurance payment method, to guide the designated medical institutions to rationally control the medical costs, and to improve the efficiency of the use of the basic medical insurance fund.

Article 39 of the municipal medical insurance administrative department shall establish and improve the basic medical insurance information system.

Medical insurance administrative departments, medical insurance agencies, designated medical institutions, information technology service providers and other relevant departments and units and their staff shall strengthen information security management, shall not disclose or unlawfully provide others with the employer and personal information known in the course of work.

Article 40: Medical insurance agencies, medical insurance fee collection agencies, designated medical institutions and other relevant departments and units shall properly keep files and vouchers related to the income and expenditure of the basic medical insurance fund, such as registration, declaration, payment and settlement.

Chapter VI Supervision and Inspection

Article 41 The administrative department of medical insurance shall strengthen the supervision and inspection of the income and expenditure of the basic medical insurance fund and its management, as well as the compliance of relevant units and individuals with the laws, rules and regulations on medical insurance, and where problems are found to exist, it shall put forward suggestions for rectification, make decisions on handling in accordance with the law, or put forward suggestions for handling to the relevant administrative departments. The Basic medical insurance fund inspection results shall be regularly announced to the community.

The municipal medical insurance administrative department can be entrusted to the municipal medical insurance administrative law enforcement agencies, the specific implementation of basic medical insurance supervision and inspection and other administrative law enforcement work.

Article 42 of the financial and auditing departments in accordance with their respective duties, according to law on the basic medical insurance fund income and expenditure, management and other supervision.

Article 43 of the medical insurance administrative departments, medical insurance premium collection agencies, in conjunction with public security, health, market supervision and other departments to establish and improve the basic medical insurance violations of the investigation and handling of communication and coordination and information *** enjoyment mechanism, according to the needs of the work can be carried out joint inspections.

Medical security administrative departments in the supervision and inspection process, suspected of cheating the basic medical insurance fund units and personnel refused to investigate, fleeing, or transfer, concealment, destruction of evidence, etc., the need to take urgent measures, shall promptly notify the public security organs, the public security organs shall be promptly disposed of in accordance with the law.

Article 44 The administrative department of medical insurance or other relevant administrative departments may take the following measures to supervise and inspect the use of the basic medical insurance fund in accordance with the law:

(1) Entering the relevant premises of the unit being supervised and inspected to carry out investigations and inspections;

(2) Utilizing modern information technology, such as big data and cloud computing, to carry out real-time monitoring;

(c) Collecting relevant evidential materials through inspection, recording, copying and other forms, and sealing information that may be transferred, concealed or lost;

(d) questioning units and individuals related to the matters under investigation, and requesting them to give explanations and provide relevant materials on issues related to the matters under investigation;

(e) stopping and ordering the concealment, transfer, embezzlement and misappropriation of the basic medical insurance fund. The act of hiding, transferring, misappropriating or misappropriating the basic medical insurance fund shall be stopped and ordered to be corrected;

(f) other investigation and inspection measures that can be taken according to the law.

The medical insurance premium collection organization shall carry out inspections on the payment of basic medical insurance premiums by employers in accordance with the relevant laws, regulations and related provisions.

Article 45 The relevant units and individuals shall cooperate with the supervision and inspection by the administrative departments of medical insurance and the administrative law enforcement agencies of medical insurance. Those being inspected shall truthfully reflect the situation and provide the necessary information.

If a participant is suspected of fraudulently obtaining basic medical insurance benefits and refuses to cooperate in the investigation, the administrative department of medical security may temporarily adjust the method of settlement of his or her medical expenses, and during the period of adjustment of the method of settlement of medical expenses, medical expenses incurred shall be examined and reimbursed in accordance with the method of full advance payment.

Article 46 encourages the support of units and individuals to report violations of laws and regulations related to basic medical insurance, verified, in accordance with the relevant provisions of the reward. Accept the report of the department, should be confidential to the informant's relevant information.

Chapter VII Legal Liability

Article 47 of the people's governments at all levels of the city, the administrative departments of health care and other departments with supervision and management responsibilities in the management of basic medical insurance, supervision of the work of abuse of power, dereliction of duty, favoritism and malpractice, on the directly responsible persons in charge of the directly responsible personnel and other directly responsible personnel shall be given sanctions; constitutes a crime, shall be investigated for criminal responsibility.

Article 48 of the fixed-point medical institutions fraudulent basic medical insurance fund expenditure, one of the following circumstances, by the medical insurance administrative department ordered to return the fraudulent medical insurance premiums, fraudulent amount of more than three times the five times the fine; by the medical insurance agency in accordance with the agreement to pursue responsibility for the seriousness of the circumstances, can be terminated and its signed service agreement; on the practicing qualifications of the person directly responsible for the Supervisors and other directly responsible personnel, by the relevant competent authorities to grant its license to practice revoke its license to practice according to law:

(a) fictitious medical services or forged, altered records of visits, bills;

(b) for impersonation of medical treatment, false hospitalization;

(c) forged, altered the relevant certificates for the registration of outpatient specific diseases;

p>(d) Declaring expenses incurred by non-designated medical institutions or suspended service agreement medical institutions;

(e) Fraudulent use or convergence of others' valid medical insurance certificates to cheat the basic medical insurance fund, or fraudulent use of the name of the basic medical insurance service physician or pharmacist to declare the medical expenses;

(f) Violating the laws, regulations and the state's relevant provisions to cheat the basic medical insurance fund Other circumstances of the expenditure.

Article 49 If a participant or other person fraudulently obtains basic medical insurance benefits under any of the following circumstances, the administrative department of medical insurance shall order the return of the fraudulently obtained medical insurance premiums, and impose a fine of not less than three times and not more than five times the amount of the fraudulently obtained amount:

(1) using another person's valid medical insurance credentials to seek medical treatment and purchase medicines in an impostor's name, or lending or renting out his or her own valid medical insurance credentials

(ii) Falsifying or altering reimbursement bills and medical documents;

(iii) Falsifying or altering relevant certificates to obtain outpatient treatment for specific diseases;

(iv) Illegal use of valid medical insurance vouchers to obtain medicines and consumables, etc., and selling them at a profit;

(v) Violating the laws, regulations, and other relevant provisions of the State to obtain basic medical insurance treatment by fraud. Treatment of other circumstances.

Article 50 of the city of the violation of laws and regulations related to basic medical insurance units and individuals in accordance with the law to implement joint disciplinary action for breach of trust. Medical insurance and other administrative departments shall, in accordance with the provisions of the law will be investigated and dealt with information on violations of the law into the credit information **** enjoyment platform or the market entity credit information publicity system.

Article 51 violation of the provisions of this regulation, the law or administrative regulations have been administrative penalties, from its provisions; constitutes a crime, shall be investigated for criminal responsibility.

Chapter VIII Supplementary Provisions

Article 52 of these Regulations shall come into force on March 1st.