Sources Of Temporary Medical Insurance For Urban Employees In Shanghai: Legal Express Labor Law

Medical care

The insurance system reform plan is formulated.

Article second (definition of hospitalization insurance)

The medical insurance for employees of urban enterprises, as referred to in these measures, refers to the social security system that the enterprises pay the hospitalization insurance premium according to the regulations, and the medical insurance fund pays part of the hospitalization medical expenses when the workers are hospitalized.

Third article (scope of application)

These Measures shall apply to enterprises and their employees in towns and cities within the limits of this Municipality.

These Measures shall not apply to foreign nationals of foreign-funded enterprises and foreign invested institutions in Shanghai, as well as enterprises and personnel provided by the state.

The employees mentioned in these measures include in-service personnel and retirees.

Fourth (Principles of hospitalization insurance)

The principles of hospitalization, medical insurance, social co ordination, mutual aid and mutual assistance, ensuring basic medical needs and avoiding waste.

Fifth article (rights and obligations)

The enterprise has the obligation to pay the hospitalization insurance premium for the employees, and the workers have the right to enjoy the hospitalization medical insurance benefits according to the regulations.

Sixth (management and settlement institutions)

The city medical insurance bureau is the competent authority of the city's medical insurance, which is responsible for the unified management of medical insurance in this Municipality.

The medical insurance offices of the district and county health bureaus (hereinafter referred to as the district and county medical insurance management institutions) accept the business leaders of the municipal medical insurance bureau, and are responsible for the management of inpatient medical insurance in this area.

The municipal social insurance fund settlement management center and the district and county social insurance business management center (hereinafter referred to as the clearing house) are responsible for the collection of hospitalization medical insurance premium and the allocation of hospitalization medical expenses.

The second chapter is the registration and payment of inpatient medical insurance.

Seventh (registration of hospitalization insurance)

Any enterprise that is within the scope of the third provision of the present Measures shall go through the registration procedures for inpatient medical insurance to the designated district or county medical insurance management institutions, and the newly established enterprises shall handle the registration procedures for inpatient medical insurance within 30 days from the date of establishment.

When an enterprise is divided, merged or terminated, it shall, within 15 days from the date of approval or the date of the occurrence of the relevant circumstances, go through the procedures of registration of change or cancellation of registration with the original medical insurance administrative institution of the district or county.

Eighth (approved procedures for hospitalization insurance premiums)

After going through the registration procedures for inpatient medical insurance, the enterprise shall settle the hospitalization medical insurance fee verification procedures to the designated clearing houses monthly.

An enterprise that has registered the formalities for old-age insurance in accordance with the provisions of the "Shanghai urban endowment insurance system", may go through the approved procedures of the inpatient medical insurance premium to the designated settlement institution before going through the registration procedure for hospitalization insurance.

Ninth (ratio of hospitalization insurance premiums)

The enterprise shall pay the hospitalization insurance premium on the basis of the proportion of 4.5% of its total in-service personnel in the previous month.

Medical insurance premiums paid by enterprises are at the forefront of taxation.

Tenth (adjustment of proportion of hospitalization insurance premiums)

The adjustment of the proportion of inpatient medical insurance premiums shall be put forward by the municipal medical insurance bureau together with the relevant departments and submitted to the Municipal People's government for approval.

Eleventh (payment of hospitalization insurance premiums)

The enterprise shall pay the hospitalization insurance premium to the designated clearing house in accordance with the prescribed time limit.

If an enterprise delays in paying the hospitalization insurance premium, the settlement institution shall increase the amount of late fee payable by 2 days per day.

Article twelfth (hospitalization insurance certificate)

After the medical insurance registration procedures are processed and the medical insurance premiums for the first month are paid in time and in full, the district and county medical insurance regulatory agencies shall issue to the enterprises medical insurance vouchers for their employees.

The certificate of hospitalization insurance is a proof that the workers enjoy the benefits of hospitalization insurance.

The certificate of inpatient medical insurance is uniformly printed by the municipal medical insurance bureau, and no unit or individual shall forge, lend, use or alter it.

Where an enterprise is divided, merged or terminated, and if the enterprise or employee loses the certificate of hospitalization insurance, the enterprise shall go through the cancellation procedures for the medical insurance certificate of the hospital in the district or county medical insurance management institution that originally issued the certificate.

The third chapter deals with medical institutions and workers seeking medical treatment.

Thirteenth (definition of medical institution)

The term "medical institutions" as mentioned in these Measures refers to the medical institutions that are allowed to provide medical services within the scope of medical insurance after being examined by the Municipal Health Bureau and the municipal medical insurance bureau.

The fourteenth rule (the principle of providing services for medical institutions)

The appointed medical institutions shall provide corresponding medical services according to the medical insurance situation of the medical workers according to the scope and items of medical insurance stipulated by the municipal medical insurance bureau.

Fifteenth (allocation of inpatient medical cost revolving fund)

The medical insurance bureau of the city shall allocate the turnover charge for hospitalization expenses to the appointed medical institutions in accordance with the prescribed proportion.

Sixteenth (employees hospitalized)

If a worker needs to be hospitalized for illness, he may be hospitalized in an agreed medical institution selected by the enterprise.

The scope of an enterprise's choice of a medical institution shall be stipulated by the municipal medical insurance bureau.

Where the employee's employment place or residence is not located in the urban area, he may be hospitalized in the local medical institution accredited by the municipal medical insurance bureau.

When an employee is suffering from an acute disease, he may be hospitalized in other medical institutions other than those specified in the first and second paragraphs of this article.

The specific measures for the hospitalization of staff and workers shall be formulated by the Municipal Health Bureau and the municipal medical insurance bureau.

Seventeenth (verification of medical insurance vouchers)

When a worker goes through the formalities for hospitalization, he shall issue a certificate of inpatient medical insurance to the appointed medical institution, and the medical institution shall make an inspection of the medical insurance certificate.

If a medical institution finds that the certificate of hospitalization insurance is forged, fraudulent or altered, it should detain or copy its voucher number and report it to the district and county medical insurance management institutions in a timely manner.

Eighteenth (approval of special medical items)

During the period of hospitalization, employees who use expensive examinations or treatment methods or use expensive imported materials or medicines shall go through the examination and approval procedures according to the provisions of the municipal medical insurance bureau.

The fourth chapter is the payment and settlement of hospitalization expenses.

Nineteenth (payment for hospitalization expenses)

If the medical expenses incurred by the workers in the agreed medical institutions exceed the following standards, the cost of the excess part shall be 85% of the medical insurance fund.

(1) hospitalization in three level medical institutions and medical expenses exceeding 2500 yuan;

(two) hospitalization in two level medical institutions and medical expenses exceeding 2000 yuan;

(three) hospitalization in a primary medical institution with a medical cost exceeding 1500 yuan.

The medical expenses incurred by the workers in the appointment of medical institutions for hospitalization shall be reasonably shared by the enterprises and medical workers, except those paid by the medical insurance fund.

The adjustment of the standards and the proportion of payment stipulated in the first paragraph of this article shall be put forward by the municipal medical insurance bureau together with the relevant departments and submitted to the Municipal People's government for approval.

Twentieth (payment for hospitalization expenses for occupational injuries and occupational diseases)

If the medical expenses incurred by a worker for hospitalization due to work-related injuries or occupational diseases exceed nineteenth of the standard prescribed in the first paragraph, the cost of the excess part shall be paid by the medical insurance fund 50%, and the rest shall be borne by the enterprise according to the state regulations.

Twenty-first (payment for special medical items)

The medical insurance bureau of the city can formulate corresponding medical insurance payment rates and methods for higher cost inspection, treatment or expensive import materials and drugs.

Twenty-second (except for medical insurance fund payment)

The medical expenses incurred by the staff for hospitalization due to the following circumstances can not be paid by the medical insurance fund.

(1) suicide and self mutilation (except mental patients);

(two) fight and drug abuse;

(three) medical accidents;

(four) traffic accident;

(five) in violation of the sixteenth provision of these measures, hospitalization is required;

(six) other non payment cases stipulated by the municipal medical insurance bureau.

Twenty-third (accounting for hospitalization expenses)

The medical expenses incurred by the medical institutions for the hospitalization of the staff shall be accounted for according to the prescribed scope of medical insurance, items and cost standards.

An agreed medical institution shall charge an enterprise or a medical worker for hospitalization expenses that cannot be paid by the medical insurance fund.

Twenty-fourth (settlement audit of hospitalization expenses)

Where a medical institution is required to pay the medical insurance fund for its hospitalization expenses, it may apply to the designated district or county medical insurance management agency for settlement on a monthly basis.

The district and county medical insurance management institutions shall conduct preliminary examination within 10 days and submit the preliminary examination opinions to the municipal medical insurance bureau.

The municipal medical insurance bureau shall make an audit decision within 10 days from the date of receiving the opinions of the first instance.

Those authorized by the clearing house shall be allocated and approved by the clearing house.

The appointed medical institution shall not apply false accounts or materials for settlement of hospitalization expenses.

The settlement and examination of hospitalization expenses shall be formulated by the municipal medical insurance bureau.

Twenty-fifth (appropriation for hospitalization expenses)

After the municipal medical insurance bureau approves the payment of hospitalization expenses, it shall issue a notice of payment to the clearing house and notify the relevant medical treatment ditch.

The clearing house shall, within 7 days from the date of receiving the notice of disbursement, allocate the hospitalization expenses to the appointed medical institution.

Twenty-sixth (settlement of hospitalization expenses under special circumstances)

Where the medical expenses incurred by the workers in the sixteenth, second, and third paragraphs of the present Measures are to be paid by the medical insurance fund, the enterprise shall apply to the designated district and county medical insurance management institutions for detailed calculation according to the relevant provisions.

Twenty-seventh (illegal access to medical insurance fund)

If the units, individuals, and other medical institutions of the appointed medical institutions fail to pay the medical insurance funds in violation of the provisions of these measures, the medical insurance bureau of the city shall have the right to recover them.

It can cancel the qualification of the appointed medical institution.

The fifth chapter is the management of medical insurance fund.

Twenty-eighth article (source of funds)

The sources of medical insurance funds include:

(1) medical insurance premiums paid by enterprises;

(two) interest income from medical insurance funds;

(three) the increment operation income of the medical insurance fund;

(four) in accordance with the provisions of the first paragraph of article eleventh of these measures, the late fee shall be charged.

Article twenty-ninth (use and adjustment of funds)

Medical insurance funds shall be used for payment of medical expenses prescribed by these measures, and special funds shall be used for any purpose. No unit or individual shall be allowed to divert him to other medical expenses.

If the medical insurance fund is not paid enough due to special circumstances, the municipal medical insurance bureau shall, in conjunction with the relevant departments, report to the Municipal People's government for approval, and make overall adjustment from the social security fund.

Article thirtieth (fund management report)

The clearing house shall provide the municipal medical insurance bureau with the collection and allocation of the medical insurance fund monthly.

The municipal medical insurance bureau shall regularly inspect and verify the utilization and management of the medical insurance fund, and report to the municipal social insurance committee.

Thirty-first (preparation of fund budget and final accounts)

The municipal medical insurance bureau shall compile budgets and final accounts annually for the collection and payment of medical insurance funds.

Thirty-second (supervision of funds)

The collection and payment of medical insurance funds shall be subject to the supervision of the financial departments and auditing departments.

Thirty-third (extraction of management fees)

The proportion and scope of management expenses for inpatient medical insurance shall be put forward by the relevant departments of the municipal medical insurance bureau and submitted to the Municipal People's government for approval.

Sixth chapter supplementary provisions

Article thirty-fourth (implementation of foreign investment enterprises)

The specific implementation of medical insurance for employees of foreign-invested enterprises shall be formulated by the Municipal Medical Insurance Bureau in conjunction with relevant departments.

Article thirty-fifth (application interpretation Department)

The municipal medical insurance bureau shall be responsible for the specific application of these measures.

Thirty-sixth article (implementation date)

These Measures shall come into force on May 1, 1996.