Policy document: Measures for the implementation of maternity insurance for employees in Guangzhou
DocumentNo.: Sui Fu Ban [20 15] 4 1
Execution time: 20 1 510 June1.
Validity: 5 years
Article 1 These Measures are formulated in accordance with the Social Insurance Law of People's Republic of China (PRC), the Special Provisions on Labor Protection for Female Workers, the Provisions on Maternity Insurance for Guangdong Workers and other laws, regulations and rules, and in combination with the actual situation of this Municipality.
Article 2 State organs, enterprises and institutions, social organizations, private non-enterprise units, foundations, law firms, accounting firms and other organizations and individual industrial and commercial households with employees (hereinafter referred to as employers) within the administrative area of this Municipality shall participate in maternity insurance for all employees of their own units (including employees, hereinafter referred to as employees) and pay maternity insurance premiums in accordance with regulations.
Article 3 An employer and its employees shall participate in maternity insurance at the place where the employer is registered. If the employing unit is a state organ or a people's organization, it shall participate in maternity insurance in the district where the unit is located.
Central units stationed in Guangdong, provincial units and their employees, employers belonging to non-military employees, armed police forces and their non-military employees who participate in social medical insurance in this city also participate in maternity insurance in this city.
Article 4 The municipal social insurance administrative department shall be responsible for the organization and implementation of these Measures and the management of maternity insurance in this Municipality. The social insurance administrative departments of each district shall be responsible for the management of maternity insurance within their respective administrative areas.
The social insurance premium collection agency is responsible for the collection of maternity insurance premiums.
City (District) social insurance agencies specifically undertake maternity insurance registration, maternity insurance premium verification, personal rights records, maternity insurance benefits payment and other matters, and are responsible for providing maternity insurance business consulting, information inquiry and other services.
City (District) development and reform, finance, health and family planning, auditing, industry and commerce, food and drug supervision, local tax, trade unions, women's federations and other relevant departments, in accordance with their respective responsibilities, coordinate the implementation of these measures.
Article 5 The maternity insurance fund shall be raised and used according to the principle of fixed income and expenditure and balance of payments. Maternity insurance premiums are paid by the employer, and individual employees do not pay.
When the maternity insurance fund fails to meet its expenses, it shall be supplemented by the finance at all levels.
Article 6 The maternity insurance fund consists of the following funds:
(1) Maternity insurance premium;
(two) the interest of maternity insurance fund;
(3) late fees;
(4) financial subsidies;
(five) other funds incorporated into the maternity insurance fund according to law.
Article 7 The employing unit shall pay the maternity insurance premium on a monthly basis according to 0.85% of the total wages of all employees of the unit last month.
If the total wages of employees of the employing unit last month exceeded 3 times the average monthly wages of employees in the previous year of this Municipality multiplied by the product of the number of employees in this unit, the excess part will not be used as the payment base.
If the employer does not have the total wages of employees in a month, the total wages of employees in that month shall be the payment base.
Article 8 The maternity insurance fund of this Municipality shall be co-ordinated at the municipal level, raised and managed in a unified way.
Maternity insurance fund into the financial accounts of social security funds, the implementation of two lines of revenue and expenditure management, separate accounts, earmarking. No unit or individual may misappropriate it.
Article 9 Where an employing unit participates in maternity insurance in this Municipality for all its employees and pays maternity insurance premiums in full and on time, its employees (hereinafter referred to as the insured) shall enjoy corresponding maternity insurance benefits in accordance with regulations.
Maternity insurance benefits in this Municipality include maternity medical expenses (including maternity medical expenses and family planning operation medical expenses, the same below) and maternity allowance.
Tenth maternity insurance fund to pay the insured maternity medical expenses shall comply with the provisions of the national and provincial maternity insurance drug list and basic medical insurance diagnosis and treatment items, medical service facilities standards (hereinafter referred to as the "three directories").
The following medical expenses incurred by the insured for medical treatment are paid by the maternity insurance fund if they conform to the norms of diagnosis and treatment and the scope of the "three catalogues":
(1) Maternity medical expenses: refers to the medical expenses incurred by female workers during pregnancy and childbirth, including prenatal examination expenses, termination of pregnancy expenses, delivery expenses, operation expenses, hospitalization expenses, medicine expenses and pregnancy complications and complications diagnosis and treatment expenses. Prenatal check-up items shall be implemented in accordance with the Notice of guangdong provincial department of human resources and social security on the Prenatal Check-up Items of Maternity Insurance for Employees (Guangdong Social Regulation [2014] No.6). Prenatal check-up items are divided into routine items and reference items, and designated medical institutions can determine the check-up items and check-up times according to obstetric industry norms and the actual needs of the insured during pregnancy.
(2) Medical expenses for family planning operation: including medical expenses incurred by workers in placing or taking out intrauterine devices, tubal ligation or recanalization, induced abortion, induced labor, etc.
(three) other project expenses as stipulated by laws, regulations and rules.
The medical expenses incurred by the insured during the maternity period that are not covered by the maternity insurance fund shall be included in the social medical insurance fund according to the regulations.
Eleventh the following expenses shall not be paid by the maternity insurance fund:
(1) Maternity medical expenses that should be borne by the party responsible for the accident according to law due to medical accidents;
(two) the expenses that should be borne by the public health or family planning technical service projects;
(three) the expenses that should be paid by the social medical insurance fund or the industrial injury insurance fund;
(4) Maternity medical expenses incurred abroad or in Hong Kong, Macao and Taiwan;
(five) the insured or their relatives choose special medical services or medical expenses and service facilities beyond the prescribed scope;
(six) other expenses stipulated by laws, regulations and rules that should not be paid by the maternity insurance fund.
Twelfth maternity allowance shall be paid by the maternity insurance fund according to the average monthly salary of the employees of the employer in the previous year when the insured person gives birth or carries out family planning surgery, divided by 30, and then multiplied by the prescribed number of vacation days.
The average monthly salary of employees in the previous year of the employing unit shall be determined according to the sum of the total monthly wages of employees insured in the previous natural year of the unit approved by the social insurance agency divided by the sum of the number of employees insured in each month. If the employer does not have the average monthly salary of employees in the previous year, the maternity allowance shall be calculated according to the average monthly salary of employees in this year.
Thirteenth insured persons enjoy maternity allowance holiday days, calculated in accordance with the following provisions:
(1) Maternity leave of the insured: 98 days for natural delivery; Dystocia (caesarean section, third degree perineal rupture) plus 30 days; Suction delivery, forceps delivery and breech traction delivery plus 15 days; Multiple births, multiple births 1 baby, increase 15 days. 15 days of pregnancy less than 2 months; Pregnant for more than 2 months but less than 4 months, 30 days; Pregnant for more than 4 months (including 4 months) to less than 7 months, 45 days; If stillbirth and premature birth do not survive after more than 7 months of pregnancy, it is 75 days. If the insured dies due to childbirth, the leave for enjoying maternity allowance shall be calculated according to the actual days from prenatal 15 and postpartum to death.
(two) the insured family planning operation holiday: take out the intrauterine device for 2 days; Placed intrauterine device for 3 days; Tubal ligation for 30 days; Vasectomy, 10 days; Tubal or vas deferens recanalization 14 days. At the same time, the above two kinds of birth control operations are carried out, and the holidays are calculated together.
(3) If it belongs to family planning incentive leave or late marriage, late childbearing incentive leave or breastfeeding leave, the insured person does not enjoy maternity allowance, and the employer shall pay maternity leave wages in accordance with relevant regulations.
If the state, province and city have new regulations on maternity leave or family planning operation leave, those regulations shall prevail.
Fourteenth insured persons enjoy maternity leave or family planning operation leave in accordance with the relevant provisions, maternity insurance fund in accordance with the following provisions:
(a) the insured to participate in the city's maternity insurance payment over 1 year, should enjoy the maternity allowance by the social insurance agencies to the employer on a monthly basis.
(II) During the period of enjoying maternity insurance benefits, if the employer stops paying maternity insurance premiums for the insured, the maternity insurance fund will stop paying maternity allowance to the employer from the month when the payment is stopped, and the maternity leave salary during the period when the insured stops paying will be paid by the employer.
Article 15 If the insured participates in the cumulative payment of maternity insurance in this Municipality 1 year, the employer shall apply to the social insurance agency for the payment of maternity allowance from 1 year after the insured gives birth or implements family planning operation, and provide the following information:
(1) An application form for enjoying maternity insurance benefits;
(2) The valid identity certificate of the insured (the original copy shall be kept after verification);
(3) A medical certificate of the birth or death of the baby;
(four) proof materials that meet the conditions of family planning (a copy of the original shall be retained after verification);
(5) In case of dystocia, multiple births, termination of pregnancy or family planning operation, a diagnosis certificate from a medical institution shall also be provided.
Article 16 If the insured person has participated in the maternity insurance in this Municipality for less than 1 year, the employer shall apply to the social insurance agency for the payment of maternity allowance within 1 year after the accumulated payment of 12 months. When applying for maternity allowance for such insured persons, the employer shall provide information in accordance with the provisions of Article 15 of these Measures, and shall also supplement the following information:
(a) the labor contract or the employer's recruitment certificate. If it is a labor dispatch, a labor dispatch agreement is also required;
(two) the employee's salary payment voucher during the on-the-job period;
(3) The business license, registration certificate or organization code certificate of the employing unit.
Seventeenth employers did not provide information to apply for maternity allowance, social insurance agencies will no longer pay maternity allowance for the insured.
The social insurance agency shall pay the maternity allowance within 30 days from the date of receiving the application from the employer, and it meets the payment conditions upon examination; Do not meet the payment conditions, it shall make a written decision not to pay within 30 days, and explain the reasons and basis.
Eighteenth municipal social insurance administrative department is responsible for determining the designated medical institutions of maternity insurance in this Municipality (hereinafter referred to as designated medical institutions). The social insurance agency shall sign a service agreement with the designated medical institutions, clarify the service items, the rights, obligations and responsibilities of both parties, and the relevant expense settlement standards, and announce the list of designated medical institutions to the public.
Nineteenth insured persons to participate in the city's maternity insurance payment period of 1 year, should be in 12 weeks after pregnancy, according to the following methods for medical confirmation procedures:
(a) the insured shall independently choose a designated medical institution in this Municipality to handle the medical confirmation procedures, and provide relevant information as required.
(2) The designated medical institution that has gone through the procedures for confirming the insured person's medical treatment shall immediately transmit the relevant information of the insured person to the social insurance agency.
(3) If the social insurance agency meets the conditions for enjoying maternity insurance benefits, it shall be marked in the maternity insurance information system and transmitted to the designated medical institution that has gone through the medical confirmation procedures, which will become the "selected medical institution" of the insured.
(4) When the insured who has gone through the medical treatment confirmation formalities goes through the check-in formalities at the selected medical institution for the first time, the selected medical institution will print the confirmation receipt as the medical treatment certificate of the insured.
(five) the insured person shall not change the selected medical institution in principle during the period of enjoying the treatment of maternity medical expenses. If it is really necessary to change the selected medical institution due to special reasons such as medical condition restriction and change of residence, it shall apply to the social insurance agency for the change formalities with the original medical confirmation certificate and relevant certificates of the reasons for the change.
(six) for medical confirmation procedures should provide the following information:
1. application form for medical confirmation of maternity insurance;
2. Guangzhou Maternal Health Care System Management Manual;
3. Proof of compliance with family planning regulations (a copy shall be kept after verification of the original);
4. A valid identity document (a copy shall be kept after the original is verified);
5. Photos of recent certificates.
Twentieth insured persons enjoy maternity insurance benefits in this Municipality, and shall implement the following medical management regulations:
(1) The insured shall go through the formalities of prenatal examination and medical confirmation of delivery at the selected medical institution. The medical institutions selected by the insured, as well as other designated medical institutions at the same level in this Municipality managed by the same legal person institution, can be regarded as the medical institutions selected by the insured (hereinafter collectively referred to as the selected medical institutions). The insured person can seek medical treatment in non-selected medical institutions due to emergency delivery, and should be transferred to selected medical institutions in time after his condition is stable.
(2) If the insured person needs abortion, induced labor or family planning operation, he/she does not need to go through the medical confirmation procedures, and he/she can choose the designated medical institutions in this Municipality for medical treatment with the supporting materials that meet the family planning regulations.
(3) If the insured person needs to be transferred to a higher-level designated medical institution or a specialized designated medical institution for diagnosis and treatment due to illness, an application shall be made by the designated medical institution department and reported to the medical department of the institution for approval. When being transferred to a hospital, the transfer registration form of Guangzhou maternity insurance insured person (hereinafter referred to as the transfer registration form) should be filled out for the transfer and transfer to designated medical institutions.
(4) If the insured person needs medical examination, delivery or family planning in a different place due to special circumstances, the unit shall confirm that before going to a different place for medical treatment, he/she shall fill out the Application Form for Medical Treatment in a Different Place for Maternity Insurance of Guangzhou Insured Workers (hereinafter referred to as the Application Form for Medical Treatment in a Different Place), hold relevant materials, and enjoy maternity insurance benefits in accordance with the regulations with the approval of the social insurance agency.
Article 21 The maternity medical expenses incurred by the insured for medical treatment that meet the requirements of maternity insurance shall be settled by social insurance agencies and designated medical institutions in accordance with the average quota standard of maternity medical expenses and family planning operation medical expenses (hereinafter referred to as the quota standard). Among them, the quota standard of delivery medical expenses is determined according to the quota standard of prenatal examination expenses and the quota standard of hospitalization delivery expenses.
The quota standard shall be separately determined by the municipal social insurance administrative department, and the social insurance agency shall sign a service agreement with the designated medical institution for implementation.
The scope of serious high-risk pregnancy diseases shall be implemented in accordance with the provisions of the "Guangzhou High-risk Pregnancy Management Measures" formulated by the municipal health and family planning administrative department.
If the total amount of maternity medical expenses incurred by the insured in the designated medical institutions after medical confirmation is within 6,543.8+0,000 yuan (including 6,543.8+0,000 yuan), the social insurance agency and the designated medical institutions shall settle according to the quota standard; The part exceeding RMB 6,543,800+0,000 yuan shall be settled according to the service items after being audited by the social insurance agency. The insured person independently chooses special medical services such as "painless delivery", and part of the expenses beyond the basic medical services or the standards stipulated in the "three catalogues" shall be borne by the insured person; The cost of high-tech services beyond the scope specified in the "Three Catalogs" shall be chosen by the insured and borne by the insured in full.
Twenty-second insured maternity medical expenses, according to the provisions should be paid by individuals, by designated medical institutions to individuals; The expenses that should be paid by the maternity insurance fund shall be accounted for by the designated medical institutions first, summarized monthly, provided with the "Guangzhou Maternity Insurance Medical Expenses Settlement Declaration Form" and medical records and other related materials, and reported to the social insurance agency for settlement.
Maternity medical expenses (including prenatal examination and other expenses) incurred by the insured in a number of medical institutions deemed to choose medical treatment shall be summarized by the medical institutions selected by the insured, and shall be declared and settled to the social insurance agency according to the production type (or operation type) quota standard corresponding to a number of births.
Twenty-third referral and referral to designated medical institutions respectively by the "referral registration form" to the social insurance agencies to declare the settlement fee. Social insurance agencies in accordance with the quota standards and transfer, transfer to designated medical institutions were settled. If the maternity medical expenses incurred by the insured from transferring to designated medical institutions do not reach 70% of the quota standard (excluding 70%), they shall be settled according to the actual expenses; Reach more than 70%, according to the quota standard settlement.
Article 24 In a social insurance year, if the designated medical institutions provide high-quality medical services for the insured and there is no violation of maternity insurance regulations, and the total amount of maternity medical expenses actually incurred by the insured reaches more than 90% of the total fixed payment, the social insurance agency shall pay in full according to the fixed standard; If it does not reach 90% (excluding 90%) of the total fixed payment, it shall be paid according to the actual cost.
Twenty-fifth insured persons for emergency treatment in non designated medical institutions, approved medical treatment in different places and other maternity medical expenses in line with the provisions, can apply for reimbursement to social insurance agencies with relevant information. After examination, if the expenses that meet the requirements are lower than the quota standard of designated medical institutions at the same level in this Municipality, they shall be reimbursed according to the facts; Above the quota standard, according to the quota standard reimbursement.
If the insured person has enjoyed the treatment of prenatal examination in the selected medical institutions, he will only be reimbursed for the corresponding hospital delivery expenses, which belongs to the fact that the actual hospital delivery expenses that meet the requirements are lower than the quota standard of hospital delivery expenses of the designated medical institutions at the same level in this municipality, and will be reimbursed according to the facts; Above the quota standard, according to the quota standard reimbursement.
Article 26 If the insured person has participated in the cumulative payment of maternity insurance in this Municipality 1 year, and has not gone through the medical confirmation procedures or gone to the hospital according to the regulations, the employer or the insured person may apply to the social insurance agency for a one-time maternity medical expense subsidy after the birth, abortion and family planning operation 1 year. The subsidy limit standard is 60% of the corresponding quota standard of the designated medical institutions at the same level in this Municipality.
Article 27 If pregnancy or family planning operation occurs during the maternity insurance period in this Municipality, but the accumulated payment is less than 1 year, the employer may apply for reimbursement to the social insurance agency within 1 year after the accumulated payment is over 1 month, and the reimbursement limit is 80% of the corresponding quota standard of the designated medical institutions at the same level in this Municipality.
Twenty-eighth insured persons or employers to apply for reimbursement of maternity medical expenses, should provide the following information:
(1) An application form for maternity insurance benefits;
(2) Original medical bills;
(3) Detailed list of medical charges;
(4) Hospital medical records and diagnosis certificates;
(five) certification materials that meet the requirements of family planning;
(six) for medical treatment in different places, an application form for medical treatment in different places is required;
(7) If the insured applies for reimbursement of maternity medical expenses after paying maternity insurance premium 12 months, the labor contract or the employer's recruitment certificate must be supplemented. If it belongs to labor dispatch, it must also provide the labor dispatch agreement, the salary payment certificate of the laborer during the employment period, the business license, registration certificate or organization code certificate of the employing unit.
Twenty-ninth unemployed spouses of male workers who participate in maternity insurance in this Municipality (hereinafter referred to as unemployed spouses) can enjoy maternity insurance benefits in this Municipality in accordance with the provisions if they meet the following conditions:
(1) The unemployed spouse holds a valid unemployment registration certificate in this Municipality;
(two) the unemployed spouse did not enjoy the basic medical insurance for urban and rural residents in the city or where the household registration is located (including the basic medical insurance for urban residents or the new rural cooperative medical system).
Thirtieth unemployed spouses can only enjoy maternity medical expenses in this city, and do not enjoy maternity allowance. The treatment standard for unemployed spouses to enjoy maternity medical expenses shall be implemented with reference to the basic medical insurance for urban and rural residents in this Municipality. The specific criteria are as follows:
(a) in accordance with the provisions of the prenatal medical expenses, paid by the maternity insurance fund according to the standard limit of 300 yuan per person per pregnancy.
(two) the termination of pregnancy or the implementation of family planning surgery in accordance with the provisions of the outpatient medical expenses, paid by the maternity insurance fund according to the standard of 50%.
(three) maternity medical expenses that meet the requirements during hospitalization shall be paid by the maternity insurance fund according to the proportion of 85% of the first-class medical institutions, 70% of the second-class medical institutions and 55% of the third-class medical institutions.
(four) the payment limit of maternity insurance fund for outpatient and inpatient maternity medical expenses of unemployed spouses shall be implemented with reference to the corresponding quota standards of designated medical institutions at the same level in this Municipality.
Thirty-first unemployed spouse maternity medical expenses of medical management and sporadic reimbursement standards with reference to the relevant provisions of the insured.
Thirty-second unemployed spouses enjoy the treatment of maternity medical expenses, and the employer of the insured male workers shall go through the application procedures. To apply for the spouse treatment of unemployed persons, in addition to the information requirements of the insured, the following information shall be provided:
(1) The unemployment registration certificate of this Municipality;
(two) proof of the relationship with the spouse of the insured male employee;
(3) Proof materials issued by social insurance agencies or health departments at or above the county level where the household registration is located that they have not participated in the basic medical insurance for urban and rural residents (including the basic medical insurance for urban residents or the new rural cooperative medical system).
Thirty-third foreigners who are legally employed by employers in this Municipality and participate in maternity insurance according to regulations shall enjoy maternity insurance benefits according to the following provisions:
(a) both husband and wife are foreign nationals, not affected by the adjustment of China's family planning policy, and the number of times they enjoy maternity insurance benefits in this city (excluding termination of pregnancy and family planning surgery) is no more than two.
(two) the maternity insurance fund will not pay the maternity medical expenses incurred by foreigners abroad or in Hong Kong, Macao and Taiwan.
(three) unmarried foreign nationals who give birth do not enjoy maternity insurance benefits.
Foreign (border) nationals who apply for maternity insurance benefits in this Municipality shall, in addition to providing information in accordance with the provisions of these Measures, provide legal employment certificates and valid passports of both husband and wife or passes from Hong Kong, Macao and Taiwan; If one of the husband and wife is a citizen of their own country, they shall also provide proof of compliance with family planning regulations.
Thirty-fourth employees who have participated in maternity insurance in this Municipality before unemployment can enjoy maternity medical expenses in accordance with the relevant provisions of maternity insurance in this Municipality during the period of receiving unemployment insurance benefits.
Thirty-fifth insured persons who have reached the statutory retirement age can enjoy the treatment of maternity medical expenses in this city during the period of receiving the pension benefits in this city on a monthly basis.
Article 36 During the period when the insured enjoys maternity leave or family planning operation leave in accordance with the regulations, if the employer stops paying maternity insurance premiums and fails to pay maternity leave wages due to objective reasons such as revocation of business license, closure or revocation, the insured can continue to enjoy maternity allowance in this Municipality in accordance with the regulations.
If the insured declares and pays maternity allowance in accordance with the provisions of the preceding paragraph, it shall provide the information specified in these Measures to the social insurance agency within 1 year after the end of maternity leave or family planning operation leave, and submit the relevant labor contract, labor dispatch agreement or employer's recruitment certificate and the proof that the employer has not paid maternity allowance.
Thirty-seventh social insurance agencies shall pay the relevant expenses within 30 days after receiving the information of the insured or the employer to declare the payment of maternity medical expenses and benefits, and meet the payment conditions after examination; Do not meet the payment conditions, it shall make a written decision not to pay within 30 days, and explain the reasons and basis.
Thirty-eighth municipal social insurance, finance, auditing and other administrative departments shall, in accordance with their respective duties, supervise the income and expenditure, management and investment operation of maternity insurance funds.
Social insurance agencies and social insurance premium collection agencies shall promptly check the true information of the employer's declaration and payment of maternity insurance premiums, and supervise the employer to participate in maternity insurance according to law.
The social insurance agency shall examine the relevant information of the employer's application for maternity insurance benefits according to law, and conduct on-the-spot verification of the relevant situation when necessary. If any illegal situation is found, it shall be promptly transferred to the social insurance administrative department for handling according to law.
Article 39 The employing unit shall inform the employees themselves of the payment of maternity insurance premiums and accept the supervision of the employees.
The social insurance agency shall regularly announce the income, expenditure, balance and income of the maternity insurance fund to the public and accept social supervision.
Designated medical institutions, departments or institutions responsible for family planning work that violate maternity insurance regulations shall promptly inform the social insurance agencies about the situation.
Any organization or individual has the right to report and complain to the administrative department of social insurance or other relevant departments and institutions about violations of maternity insurance policies. The administrative department of social insurance or other relevant departments and institutions shall promptly deal with it according to law.
Article 40 If an employer fails to register maternity insurance for its employees or fails to pay in full and on time, resulting in the employees being unable to enjoy maternity insurance benefits, the employer shall pay relevant expenses to the employees in accordance with the treatment items and standards stipulated in these Measures.
If the employer fails to truthfully declare the total wages of the unit and the rights and interests of maternity insurance benefits of employees are damaged, the employer shall bear corresponding responsibilities.
Article 41 Whoever defrauds maternity insurance benefits by fraudulent means, forged certification materials or other improper means shall be dealt with in accordance with Article 88 of the Social Insurance Law of People's Republic of China (PRC).
Forty-second municipal social insurance administrative departments can formulate supporting service management measures according to these measures.
Article 43 Calculation method of "number of months" of vacation: According to the concept of obstetrics, 7 days is a pregnant week and 4 weeks is a pregnant month.
Article 44 These Measures shall come into force on 20 1 51June1day. The validity period is 5 years. Upon the expiration of the validity period, or during the implementation of these measures, it may be revised according to relevant laws and regulations or changes in actual conditions. Since the date of implementation of these measures, the provisions of this Municipality on maternity insurance are inconsistent with these measures and shall be abolished at the same time.
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