medical insurance

Originanddevelopment

Medicalinsurance,inthetraditionalsense,referstotheprovisionofmedicalinsurancebyaspecificorganizationorinstitution,throughmandatorypoliciesandregulationsorvoluntarycontracts,inacertainareaRaisemedicalinsurancefundsfromtheinsuredpopulation.

MedicalinsuranceoriginatedinWesternEuropeandcanbetracedbacktotheMiddleAges.Withthesuccessofthebourgeoisrevolution,familyworkshopswerereplacedbylarge-scaleindustries,andmodernindustrialteamsemerged.Duetotheharshworkingenvironment,epidemicdiseasesandwork-relatedaccidents,workersrequirecorrespondingmedicalcare.However,theirwagesarelow,anditisdifficultforthemtopayformedicalexpenses.Asaresult,workersinmanyplacesorganizedspontaneouslytoraiseaportionofthefundsforexpenseswhentheyfellill.Butthisformisnotverystable,anditissmall-scale,andtheabilitytoresistrisksisverylow.Attheendofthe18thcenturyandthebeginningofthe19thcentury,privateinsurancedevelopedinWesternEuropeandbecameanimportantwayforthecountrytoraisemedicalfunds.

Medicalinsurancehasthebasiccharacteristicsofsocialinsurancesuchascompulsory,mutualaidandsociality.Therefore,themedicalinsurancesystemisusuallyenactedbynationallegislation,compulsoryimplementation,andtheestablishmentofafundsystem.Theexpensesarepaidbytheemployerandtheindividual,andthemedicalinsurancefundsarepaidbythemedicalinsuranceinstitutiontosolvethemedicalriskscausedbytheillnessorinjuryoftheworkers..

Classification

Medicalinsurance,likeothertypesofinsurance,alsocollectsmedicalinsurancepremiumsfrompersonsthreatenedbydiseasesinadvancebymeansofcontractstoestablishamedicalinsurancefund;Ifyougetsickandgotoamedicalinstitutionformedicaltreatmentandincurmedicalexpenses,themedicalinsuranceinstitutionwillgiveyouacertainamountoffinancialcompensation.Therefore,medicalinsurancealsohastwomajorfunctionsofinsurance:risktransferandcompensationtransfer.Thatis,theeconomiclosscausedbythediseaseriskontheindividualisallocatedtoallmembersthreatenedbythesamerisk,andthecentralizedmedicalinsurancefundisusedtocompensatetheeconomiclosscausedbythedisease.

Commercialmedicalinsurance

Itcanbedividedintoreimbursementmedicalinsuranceandcompensationmedicalinsurance.

Reimbursementtypemedicalinsurancemeansthatthemedicalexpensesspentbypatientsinthehospitalarereimbursedbyinsurancecompanies,generallydividedintooutpatientmedicalinsuranceandhospitalizationmedicalinsurance.

IndemnityMedicalinsurancemeansthatthepatientisclearlydiagnosedbythehospitalassufferingfromacertaindiseaselistedinthecontract,andtheinsurancecompanypaysthepatientfortreatmentaccordingtotheamountagreedinthecontractAndcare.Generally,itisdividedintosingleitemsicknessinsuranceandcriticalillnessinsurance.

Theabovetwotypesofmedicalinsurancehavethesamepointsbutdifferentpoints.Thesamepointisthatyoucangetinsurancebenefitsonlywhenyougetsick.Themaindifferenceis:generalmedicalinsurancebelongstoalltypes,thatis,allkindsofdiseasescanbecovered.Pay.Specialmedicalinsurancebelongstothespecialcategory,thatis,onlyacertaindiseaseoroperationspecifiedintheinsurancecontractcanreceiveinsurancebenefits.Medicalinsurancelaunchedbyinsurancecompaniesisoftencombinedwithpartsoftheabovetwotypesofinsurance.

Subsidypaymenttype

Inshort,thesubsidypaymenttypemedicalinsuranceisthattheinsurancecompanypaystheinsuredpersonaccordingtothesubsidystandardstipulatedinthecontractonaper-time,dailyorproject-basedbasisMedicalinsuranceforpremiums.Thesettlementofclaimshasnothingtodowiththeactualmedicalexpensesincurred,andnoinvoiceisrequired.

Itisrecommendedtopurchasemedicalinsurancetofirstconsidertheissueofreimbursementofmedicalexpenses,andsecondly,toconsidertheissueofcompensationforlossescausedbyhospitalization.Onlybyconsolidatingthebasicprotection,wecandoitonthisbasis.Supplementcanbetheicingonthecake.Thosewhohavesufficientsocialinsuranceprotectioncanchoosesubsidy-basedmedicalinsurancefirstwhenchoosingmedicalinsurance.

Ininsurancetheory,thereisaquestionaboutwhetherthecompensationprincipleisapplicabletohealthinsurance.Thisquestioncannotbegeneralized.Theprincipleofcompensationmeansthat"thecompensationreceivedbytheinsuredshallnotbehigherthantheactualloss."Subsidypaymentmedicalinsuranceisnotapplicable,andthepaymentofinsurancemoneyhasnothingtodowithactuallosses.Thedesignprincipleisactuallytoconsidertheinsured’ssalarylossduetosickleaveduringthehospitalizationperiod.Therefore,thecontractstipulatesthatthesubsidywillbepaidaccordingtothenumberofdaysofhospitalization.Itdoesnotconsidertheactualhospitalizationcostsandhasnothingtodowithactualeconomiclosses.Itbelongsto“fixedvalueinsurance”."

Expensetype

Expensetypemedicalinsuranceisbasedontheactualmedicalexpensesincurredbythecustomertopaytheinsurancemoneyaccordingtotheinsuranceamountagreedinthepolicy.Thepurposeistocompensatecustomersformedicalexpenses.Customersarerequiredtoissueoutpatientorinpatientinvoiceswhenmakingclaims,andthescopeofclaimsisbasicallythesameas"socialsecurity".

Inaddition,socialmedicalinsurancehasstrictrestrictions.Newdrugs,importeddrugs,andexpensivedrugsarenotcoveredbysocialmedicalinsurancereimbursement.Medicalexpensescausedbytrafficaccidentsarenotreimbursedbysocialmedicalinsurance.Inaddition,expensesfrequentlyincurredduringtheillness,suchasnutritionexpenses,nursingworkexpenses,andlostworkexpenses,arenotinthescopeofreimbursement.

Therefore,forthosewithmedicalinsurancetoinsurehospitalizationmedicalinsurance,theymayconsiderpurchasingexpense-typeandsubsidy-typecomplementation.Choosingexpense-typehospitalizationmedicalinsuranceisalsoausefulsupplement.

Role

First,itisconducivetoimprovinglaborproductivityandpromotingthedevelopmentofproduction.

Medicalinsuranceistheinevitableresultofsocialprogressandproductiondevelopment.Inturn,theestablishmentandimprovementofthemedicalinsurancesystemwillfurtherpromotetheprogressofsocietyandthedevelopmentofproduction.Ontheonehand,medicalinsurancerelievesworkers'worriesandmakesthemworkatease,therebyincreasinglaborproductivityandpromotingthedevelopmentofproduction;ontheotherhand,italsoguaranteesthephysicalandmentalhealthofworkersandensuresthenormalreproductionoflabor.

Second,adjustincomedifferencesandreflectsocialequity.

Medicalinsuranceadjustsincomedifferencesbycollectingmedicalinsurancepremiumsandreimbursingmedicalinsuranceservices,whichisanimportantmeansofincomeredistributionforthegovernment.

Three,animportantguaranteeformaintainingsocialstability.

Medicalinsuranceprovidesfinancialassistancetosickworkers,helpstoeliminatesocialinstabilitycausedbyillness,andisanimportantsocialmechanismforadjustingsocialrelationsandsocialconflicts..

Four,animportantmeanstopromotesocialcivilizationandprogress.

Thesocialsystemofmedicalinsuranceandsocialmutualaidandmutualassistance,throughsharingtheriskofillnesscostsamongtheinsuredpersons,reflectsthenewsocialrelationshipof"onepartyisintrouble,eightpartiessupport".Conducivetopromotingsocialcivilizationandprogress.

Fifth,topromoteeconomicsystemreform,especiallyanimportantguaranteeforthereformofstate-ownedenterprises.

Reimbursementconditions

AccordingtoArticle28ofthe"SocialInsuranceLaw",itmeetsthebasicmedicalinsurancedrugcatalog,diagnosisandtreatmentitems,medicalservicefacilitystandards,andemergencyandrescueMedicalexpensesshallbepaidfromthebasicmedicalinsurancefundinaccordancewithnationalregulations.

Accordingtothebasicrequirementsforthepaymentofbasicmedicalinsurancebenefitsinourcountry,theinsuredpersonwhogoestothemedicalinsuranceinstitutiontoreimbursethemedicalexpensesincurredbyhimselforherselfshouldgenerallymeetthefollowingconditions:

(1)Participantsmustgotothedesignatedmedicalinstitutionofthebasicmedicalinsurancetopurchasemedicines,orpurchasemedicinesfromthedesignatedretailpharmaciesdeterminedbythesocialinsuranceinstitutionwithamedicalprescriptionissuedbythedoctorofthedesignatedhospital.

(2)Themedicalexpensesincurredbytheinsuredpersonintheprocessofseeingadoctormustmeetthescopeandpaymentstandardsofthebasicmedicalinsuranceinsurancedrugcatalog,diagnosisandtreatmentitems,andmedicalservicefacilitystandardsinordertobecoveredbythebasicmedicalinsuranceThefundpaysaccordingtoregulations.

(3)Amongthemedicalexpensescoveredbythebasicmedicalinsurancefortheinsuredpersons,theexpensesabovethethresholdofthesocialmedicalpoolingfundandbelowthemaximumpaymentlimitwillbepaidbythesocialmedicalpoolingfundinauniformproportion.

Reimbursementratio

1.Outpatientandemergencymedicalexpenses:Thetotalmedicalexpensesthatmeetthescopeofthebasicmedicalinsuranceduringtheworkingyear(January1sttoDecember31st)exceed2000Yuanabovepart.

2.Settlementratio:50%ofthereimbursementfordispatchedpersonnelover2,000yuanduringthecontractperiod,andtheindividualpays50%;themaximumamountofoutpatientandemergencyreimbursementpaidfordispatchedpersonnelinayearis20,000yuan.

3.Participantsshouldproperlykeeptheoutpatientmedicalreceipts(includingreceiptsbelowlargesums,prescriptionbases,etc.)usedindesignatedhospitalsasmedicalexpensesreimbursementcertificates.

4.Threetypesofoutpatientvisitsforspecialdiseases:theinsuredpersonwhosuffersfrommalignanttumorradiotherapyandchemotherapy,kidneydialysis,andanti-rejectiondrugsafterkidneytransplantationneedstogototheoutpatientclinicformedicaltreatment.Thesecondandthird-leveldesignatedhospitalsformedicaltreatmentshallissuea"diseasediagnosiscertificate"andfillinthe"MedicalInsuranceSpecialDiseaseDeclarationandApprovalForm",andreporttothedistrictmedicalinsurancecenterforapprovalandfiling.Outpatientvisitsandmedicinesforthesethreespecialdiseasesarelimitedtodesignatedhospitalsapprovedformedicaltreatment,andcannotbepurchasedatdesignatedretailpharmacies.Ifthemedicalexpensesincurredarewithinthescopeoftheoutpatientspecialdiseaseregulations,thesettlementshallbemadewithreferencetohospitalization.

5.Hospitalization.

Youcanonlyenjoymedicalinsurancereimbursementafterretirementfor20yearsofmedicalinsurance.

Thescopeofthereimbursementratioofmedicalinsurancevariesfromplacetoplace.Pleaserefertolocalpoliciesandregulationsfordetails.

TheChinesesystem

Establishmentanddevelopment

Thepublicmedicalandlaborinsurancemedicalservicesestablishedintheearly1950sinChinaarecollectivelyreferredtoasthesocialmedicalinsuranceforemployees.Itisanimportantpartofthenationalsocialsecuritysystemandoneoftheimportantitemsofsocialinsurance.

TheimplementationofChina'smedicalinsuranceformorethan40yearshasplayedanactiveroleinprotectingthehealthofemployeesandmaintainingsocialstability.However,withtheestablishmentofthesocialistmarketeconomicsystemandthecontinuousdeepeningofthereformofstate-ownedenterprises,thissystemhasbeendifficulttosolvetheproblemofbasicmedicalsecurityforemployeesundertheconditionsofamarketeconomy.

In1988,theChinesegovernmentbegantoreformthepubliclyfundedmedicalsystemofgovernmentagenciesandinstitutionsandthelaborinsurancemedicalsystemofstate-ownedenterprises.In1998,theChinesegovernmentpromulgatedthe"DecisiononEstablishingaBasicMedicalInsuranceSystemforUrbanEmployees"andbegantoestablishabasicmedicalinsurancesystemforurbanemployeesthroughoutthecountry.

Thebasicmedicalinsurancesystemimplementstheprincipleofcombiningsocialpoolingwithindividualaccounts,andorganicallycombinesthetwomodesofsocialinsuranceandsavingsinsurance,realizing"horizontal"socialmutualaidand"vertical"individualTheorganiccombinationofself-protectionisnotonlyconducivetogivingplaytotheadvantagesofsocialcoordinationandmutualaid,butalsoconducivetogivingplaytotheadvantagesofpersonalaccountsthathaveanincentiveandrestrictiverole.Itismoreinlinewithmycountry'snationalconditionsandiseasilyacceptedbythemajorityofemployees.ThismedicalinsurancemodelconformstoChina'snationalconditionsandisasocialmedicalinsurancesystemwithChinesecharacteristics.

Inprinciple,thebasicmedicalinsurancefundiscoordinatedattheprefectureandcitylevel.Basicmedicalinsurancecoversallemployersandtheiremployeesincitiesandtowns;allenterprises,stateadministrativeagencies,institutionsandotherunitsandtheiremployeesmustperformtheobligationtopaybasicmedicalinsurancepremiums.Theemployer’scontributionrateisabout6%ofthetotalsalary,andtheindividual’scontributionrateis2%oftheindividual’ssalary.Partofthebasicmedicalinsurancepremiumpaidbytheunitisusedtoestablishtheoverallfund,andpartofitiscreditedtothepersonalaccount;thebasicmedicalinsurancepremiumpaidbytheindividualiscreditedtothepersonalaccount.Theoverallfundandindividualaccountsbeardifferentmedicalexpensespaymentresponsibilities.Theoverallplanningfundismainlyusedtopayforhospitalizationandoutpatienttreatmentofsomechronicdiseases.Theoverallplanningfundhasaminimumpaymentstandardandamaximumpaymentlimit;personalaccountsaremainlyusedtopayforgeneraloutpatientexpenses.

Inordertoensurethattheinsuredemployeesenjoybasicmedicalservicesandeffectivelycontroltheexcessivegrowthofmedicalexpenses,theChinesegovernmenthasstrengthenedthemanagementofmedicalservicesandformulatedthebasicmedicalinsurancedrugcatalog,diagnosisandtreatmentitemsandmedicalservicesFacilitystandards,qualificationofmedicalinstitutionsandpharmaciesthatprovidebasicmedicalinsuranceservices,andallowinsuredemployeestochoose.Inordertocooperatewiththereformofthebasicmedicalinsurancesystem,thestatehasalsopromotedthereformofmedicalinstitutionsandthepharmaceuticalproductionanddistributionsystem.Throughtheestablishmentofacompetitionmechanismamongmedicalinstitutionsandamarketoperationmechanismfortheproductionandcirculationofmedicines,effortsaremadetoachievethegoalof"providingrelativelylow-costmedicalservices".

Inadditiontobasicmedicalinsurance,large-amountmedicalexpensesmutualassistancesystemshavegenerallybeenestablishedinvariousplacestosolvemedicalexpensesabovethemaximumpaymentlimitofthesocialpoolingfund.Thestatehasestablishedamedicalsubsidysystemforcivilservants.Enterpriseswithconditionscanestablishenterprisesupplementarymedicalinsurancefortheiremployees.Thestatewillalsograduallyestablishasocialmedicalassistancesystemtoprovidebasicmedicalsecurityforthepoor.

China'sbasicmedicalinsurancesystemreformissteadilyadvancing,andthecoverageofbasicmedicalinsurancecontinuestoexpand.Bytheendof2001,97%oftheprefecturesandcitiesacrossthecountryhadinitiatedthebasicmedicalinsurancereform,andthenumberofemployeesparticipatinginthebasicmedicalinsurancereached76.29million.Inaddition,publicmedicalcareandotherformsofmedicalsecuritysystemsalsocovermorethan100millionurbanpopulations,andtheChinesegovernmentisgraduallyincorporatingthesepopulationsintothebasicmedicalinsurancesystem.

AccordingtotheMinistryofHumanResourcesandSocialSecurity,the``GuidingOpinionsonImprovingtheManagementofAgreementsforDesignatedMedicalInstitutionsforBasicMedicalInsurance''hasbeenannouncedrecently,clearlyrequiringallcoordinatedareasacrossthecountrytocompletelyabolishsocialinsuranceadministrationbytheendof2015.Thedepartmentimplementedthe"two-design"qualificationreviewof"basicmedicalinsurancedesignatedmedicalinstitutionqualificationreview"and"basicmedicalinsurancedesignatedretailpharmacyqualificationreview"tosimultaneouslyimprovethemanagementofagreementsbetweensocialinsuranceagenciesandmedicalinstitutions,andimprovemanagementservicelevelsAndtheefficiencyoffunduse.

The"Opinions"putforwardclearrequirementsonhowtoimprovethemanagementoftheagreementafterthecancellationofthequalificationreviewofthe"two-determination"implementedbythesocialsecurityadministrativedepartment.Alltypesofmedicalinstitutionsestablishedinaccordancewiththelaw,regardlessoftheirlevel,category,andnatureofownership,canvoluntarilyapplytothesocialsecurityagencytobecomeadesignatedmedicalinsuranceagencybasedonconditions,andthesocialsecurityadministrativedepartmentwillnolongerconductpre-approval.Atthesametime,theagencymustestablishanopenandtransparentevaluationmechanism,explorewaystoconductevaluationthroughthird-partyevaluation,andselectmedicalinstitutionswithgoodservicequality,reasonableprices,andstandardizedmanagementtonegotiateandsignserviceagreements.

Legalregulations

ChapterThreeBasicMedicalInsurance

Article23Employeesshallparticipateinthebasicmedicalinsuranceforemployees.Employersandemployeesshalljointlypaybasicmedicalinsurancepremiumsinaccordancewithstateregulations.

Individualindustrialandcommercialhouseholdswithoutemployees,part-timeemployeeswhoarenotintheemployer’sbasicmedicalinsuranceforemployees,andotherflexibleemployeescanparticipateinthebasicmedicalinsuranceforemployees,andtheindividualshallpaythebasicmedicalinsuranceinaccordancewithnationalregulations.fee.

Article24Thestateestablishesandimprovesanewruralcooperativemedicalsystem.

ThemanagementmeasuresforthenewruralcooperativemedicalsystemshallbestipulatedbytheStateCouncil.

Article25Thestateestablishesandimprovesthebasicmedicalinsurancesystemforurbanresidents.

Urbanresidents’basicmedicalinsuranceimplementsacombinationofpersonalpaymentandgovernmentsubsidies.

Personswhoenjoytheminimumlivingguarantee,thedisabledwhoareincapacitated,theelderlyandminorsfromlow-incomefamilieswhoareover60yearsold,etc.,willbesubsidizedbythegovernment.

Article26Thetreatmentstandardsofbasicmedicalinsuranceforemployees,newruralcooperativemedicalcareandbasicmedicalinsuranceforurbanresidentsshallbeimplementedinaccordancewithnationalregulations.

Article27Individualswhoparticipateinthebasicmedicalinsuranceforemployees,whentheyreachthestatutoryretirementage,thecumulativepaymentforthenumberofyearsprescribedbythestatewillnolongerpaythebasicmedicalinsurancepremiumsafterretirement.Enjoybasicmedicalinsurancebenefitsinaccordancewithnationalregulations;ifthenumberofyearsspecifiedbythecountryhasnotbeenreached,thepaymentcanbemadeuptothenumberofyearsspecifiedbythecountry.

Article28Medicinesthatmeetthebasicmedicalinsurancecatalogue,diagnosisandtreatmentitems,medicalservicefacilitystandards,andemergencyandrescuemedicalexpensesshallbecollectedfromthebasicmedicalinsurancefundinaccordancewithnationalregulationsPaid.

Article29Thepartofthemedicalexpensesoftheinsuredpersonsthatshouldbepaidbythebasicmedicalinsurancefundshallbedirectlysettledbythesocialinsuranceagency,themedicalinstitution,andthepharmaceuticalbusinessunit.

Theadministrativedepartmentofsocialinsuranceandtheadministrativedepartmentofhealthshallestablishasettlementsystemformedicalexpensesformedicaltreatmentindifferentplacestofacilitatetheinsuredpersonstoenjoythebasicmedicalinsurancebenefits.

Article30Thefollowingmedicalexpensesarenotincludedinthepaymentscopeofthebasicmedicalinsurancefund:

(1)Thosethatshouldbepaidfromthework-relatedinjuryinsurancefund;

(2)Shouldbebornebyathirdperson;

(3)Shouldbebornebypublichealth;

(4)Seekmedicaltreatmentabroad.

Medicalexpensesshallbebornebyathirdpersoninaccordancewiththelaw.Ifthethirdpersondoesnotpayorthethirdpersoncannotbeidentified,thebasicmedicalinsurancefundshallpayfirst.Afterthebasicmedicalinsurancefundhaspaidinadvance,ithastherighttoclaimcompensationfromathirdparty.

Article31Accordingtotheneedsofmanagementservices,socialinsuranceagenciesmaysignserviceagreementswithmedicalinstitutionsandpharmaceuticalbusinessunitstoregulatemedicalservicebehaviors.

Medicalinstitutionsshallprovidereasonableandnecessarymedicalservicestotheinsuredpersons.

Article32Ifanindividualisemployedacrossacoordinatedarea,hisbasicmedicalinsurancerelationshipwillbetransferredwiththeindividual,andthepaymentperiodwillbecalculatedcumulatively.

ReformTrends

AccordingtothewebsiteoftheMinistryofHumanResourcesandSocialSecurity,theMinistryofHumanResourcesandSocialSecurityandtheMinistryofFinanceissuedthe"NoticeonthePhasedReductionofSocialInsuranceRates".The"Notice"statedthatThecombinedimplementationofmaternityinsuranceandbasicmedicalinsurancewillbeorganizedandimplementeduniformlyaftertheStateCouncilformulatesandissuesrelevantregulations.

Introductiontooperations

Accountmanagement

(1)Personalaccountestablishment

SocialmedicalinsuranceagenciesprovideforeachinsuredpersonCreateapersonalaccountforbasicmedicalinsuranceanduseyourIDnumberasyourlifelongmedicalinsurancenumber.Thefundsinthepersonalaccountofthebasicmedicalinsuranceforemployeesareownedbytheindividualandusedformedicalconsumption.Whentheemployeedies,hispersonalaccountshallbecancelled,andthebalanceshallbeinheritedaccordingtoregulations.

(2)Issuanceofpersonalaccountcard

Theemployershallapplyforthepersonalmedicalaccountsettlementcardfortheemployeewhileparticipatinginthebasicmedicalinsurance.Foremployeeswhonewlyparticipateinmedicalinsurance,within30daysfromthedateofenrollment,theemployershallapplytothesocialmedicalinsuranceagencyandproviderelevantmaterials.Afterthesocialmedicalinsuranceagencyreceivestheemployer’sapplicationfortheestablishmentofanemployee’shousehold,itshallcarefullyreviewtherelevantmaterials,establishanindividualaccountfortheemployeewithin15days,andissueapersonalaccountsettlementcard.Injectfundsintoemployees’personalmedicalaccountsinatimelymanner,andaccrueinterestinaccordancewithrelevantregulations.Retireeswhoareresettledindifferentplacesmaynotbeissuedcardsforthetimebeing.

Insuredpersonscanpurchasemedicinesatanydesignatedmedicalinstitutionordesignatedpharmacyinthiscoordinatingareawithapersonalmedicalaccountcard.Whenthefundsinthepersonalmedicalaccountareinsufficient,thepaymentshallbemadeincash.

(3)Transferandinheritanceofpersonalaccount

Theinsuredpersonistransferredfromthelocalarea,andthefundsofthepersonalmedicalaccountwillbetransferredalongwithit.Ifthetransferisnotpossible,thebalanceofthepersonalaccountcanberefundedtome,andatthesametimeLogoffyourpersonalaccount.

Iftheinsuredpersondies,thebalanceofhispersonalaccountcanbeinheritedbyhislegalheir.

(4)Lossreportingandreissuanceofpersonalaccountcard

Theinsuredpersonshallproperlykeepthepersonalaccountcard.Ifitisdamagedandneedstobereplacedwithanewcard,thecostshallbebornebytheindividual.Ifthepersonalaccountcardislost,therelevantcertificateshallbereportedtothemedicalinsuranceagencyordesignatedunitintimetoreporttheloss,andthemedicalinsuranceagencyshallimmediatelysealuptheaccount.Ifyoucannotfinditwithin30days,youshouldapplyforanewcardatyourownexpense.Forthemedicalexpensesincurredduringthereportingoftheloss,thepersonalaccountwillbepaidincashbytheemployee.Ifthepersonalaccountcardisfraudulentlyusedbeforegoingthroughtheproceduresforreportingtheloss,theinsuredpersonshallberesponsiblefortheloss.

Whentheinsuredpersonusesthecardtopurchasemedicinesandsettlethemedicalexpenses,thedesignatedmedicalinstitutionandpharmacyservicepersonnelshouldcarefullycheck.Ifthecardisfoundtobeforgedorfraudulentlyused,thecardshouldbeimmediatelydetained,andthesocialmedicalinsuranceagencyshouldbenotified.Officeinstitutions.Designatedmedicalinstitutionsandpharmaciesshallnotrefusetoacceptcardfunds,andshallnotexchangecashforcardholders.

InJanuary2010,theMinistryofHumanResourcesandSocialSecurityannouncedthe"InterimMeasuresfortheTransferandContinuationoftheBasicMedicalSecurityRelationsofMigrantWorkers".This"Measures"stipulatesthatstartingfromJuly1,2010,Migrantscantransfertheirmedicalinsurancerelationshipwhentheyareemployedacrossprovinces,andtheirpersonalaccountsarealsotransferredwiththetransfer.Inadditiontothemedicalinsurancerelationshipthatcanbetransferredacrossprovinces,asthestatusoftheinsuredpersonchanges,threedifferenttypesofmedicalinsurancerelationships,namely,employeemedicalinsurance,residentmedicalinsurance,andnewruralcooperativemedicalcare,canalsobetransferredtoeachother.Migrantworkersenteringthecitycanparticipateinthelocalbasicmedicalinsuranceforemployeesattheplaceofemployment,andcanbetakenbackwhentheyreturntothecountrysidetobeconvertedtoanewtypeofruralcooperativemedicalinsurancewithoutinterruption.

Collectionofinsurancepremiums

(1)Thecollectiondepartmentofthemedicalinsuranceinstitutionacceptsthe"MedicalInsurancePaymentBaseChangeReport"filledoutbytheinsuredunit,andrequiresthefollowinginformation:

1.Salarypaymentschedule;

2."DetailedListofIncreaseandDecreaseofPersonsParticipatinginMedicalInsurance"

3.Otherinformationrequiredbythemedicalinsuranceagency.

(2)PaymentApproval

1.Thecollectiondepartmentofthemedicalinsuranceinstitutionshallreviewthepaymentdeclarationverificationformandrelatedmaterialssubmittedbytheinsuredunit.Afterpassingthereview,gothroughtheproceduresforverificationoradditionorreductionoftheinsuredpersonnel.

2.Thecollectiondepartmentofthemedicalinsuranceinstitutionshall,basedonthepaymentdeclarationandverificationstatus,promptlyrecordinformationsuchasthetimeofenrollmentandthecurrentpaymentsalaryforthenewlyinsuredpersons.Thecollectiondepartmentofthemedicalinsuranceinstitutionshallverifythecurrentpaymentbasebasedonthereportingstatusoftheinsuredunit.

3.Thecollectiondepartmentofthemedicalinsuranceinstitutioncalculatestheamounttobepaidbasedonthecurrentpaymentbaseandpaymentrateoftheapprovedparticipatingunit,andprintsoutthe"MedicalInsurancePaymentNotice"tofeedbackthereportingunit,andcollectitbasedonthis.

(3)Collectionoffees

1.Themedicalinsuranceinstitutionchargesthebankthatopenstheaccountthroughthe"incomeaccountdeposit",andcanalsochargebycheque,cash,wiretransfer,promissorynote,etc.,andissueaspecialreceiptvoucher.Thefinancialmanagementdepartmentofthemedicalinsuranceinstitutionchecksandsettlesaccountswiththebankeverymonth,andfeedsbackthestatusoftheaccounttothecollectiondepartment.

2.Thecollectiondepartmentofthemedicalinsuranceinstitutionshall,basedonthemedicalinsurancepremiumpaymentstatusreportedbythefinancialmanagementdepartment,issuea"SocialInsurancePaymentNotice"totheinsuredunitthathasnotpaidthemedicalinsurancepremiuminfullorintimeafterthedeclaration.Ifitfailstoexecutewithinthetimelimit,therelevantinformationandmaterialsshallbeprovidedtothelaborsecurityadministrativedepartment,andthelaborsecurityadministrativedepartmentshallmakecorrectionswithinatimelimit.

3.Beforethe25thofeachmonth,iftheinsuredunitdelayspayment,alatepaymentfeeof2‰willbeimposedonadailybasisfromthedayofdefault.Itcanbepaidinalumpsumforonemonth,onequarter,sixmonthsoroneyear.Ifyoupayquarterlyorannually,youshouldpayfromthebeginningofthequarterorthebeginningoftheyear.Thosewhoaretemporarilyunabletopayshallapplyforpostponementofpayment,andtheperiodofpostponementshallnotexceed2months.

(4)Makeuppaymentofarrears

1.Thecollectiondepartmentofthemedicalinsuranceinstitutionshall,basedonthearrearsofthemedicalinsurancepremiums,establishthearrearsdatainformation,fillinthe"SocialInsurancePremiumPaymentNotice",andnotifytheinsuredunitstopaythearrears.

2.Forinsuredunitsthatareunabletopayoffthearrearsinfullduetofinancingdifficulties,thecollectiondepartmentofthemedicalinsuranceinstitutionsignsasocialinsurancesupplementarypaymentagreementwiththem.Intheeventofmergers,divisions,bankruptcies,etc.,theunitsinarrearsshallsignasupplementarypaymentagreementaccordingtothefollowingmethods.

⑴Ifthearrearsunitismerged,asupplementarypaymentagreementshallbesignedwiththemergingparty.

⑵Ifthearrearsunitisseparated,asupplementarypaymentagreementshallbesignedwitheachdivision.

(3)Ifthearrearsunitentersthebankruptcyproceedings,itshallsignasettlementagreementwiththeliquidationteam.

⑷Iftheunitissoldorleasedbyauction,asupplementarypaymentagreementshallbesignedwiththecompetentauthority.

3.Theinsuredunithandlesthesupplementarypaymentinaccordancewiththe"SocialInsurancePremiumPaymentNotice"orthesupplementarypaymentagreement,andthemedicalinsuranceinstitution'scollectiondepartmentwillacceptitandnotifythemedicalinsuranceinstitution'sfinancialmanagementdepartmenttocollectthepayment.

4.Ifthebankruptcyunitcannotfullypayoffthearrears,thecollectiondepartmentofthemedicalinsuranceinstitutionacceptstheapplicationsubmittedbythebankruptcyliquidationteamoftheunit,andsendsittotheauditandsupervisiondepartmentforprocessingafterreview.

5.Thecollectiondepartmentofthemedicalinsuranceinstitutionadjuststhearrearsinformationoftheinsuredunitbasedontheinformationonthepaymentofarrearsreceivedfromthefinancialmanagementdepartmentandtheverificationinformationfromtheauditsupervisiondepartment.

Settlementprocedures

  1. Settlingproceduresforhospitalizationandoutpatienttreatmentofspecialdiseasesmedical insurance

DesignatedmedicalinstitutionsBeforethe10thofeachmonth,submittheexpensestatement,hospitalizationstatementandrelatedinformationofthepatientsdischargedfromthehospitallastmonthtothemedicalinsuranceagency.Afterthemedicalinsuranceagencyreviews,itwillbeusedasthebasisformonthlyadvancesandyear-endfinalaccounts.Themedicalinsuranceagencypre-appropriatestheoverallplanningexpensesforhospitalizationandoutpatienttreatmentofspecialdiseasesinthepreviousmonth.

Insuredpersonswhohavebeenidentifiedassufferingfromspecialdiseasesshouldgotoadesignatedmedicalinstitutiondesignatedbythelaborandsocialsecuritydepartmentformedicaltreatmentandpurchasedrugs.Themedicalexpensesincurredaredirectlyaccountedforandsettledimmediately.

(2)Emergencysettlementprocedures

Insuredpersonsarehospitalizedinnon-designatedmedicalinstitutionsinthecityandremotemedicalinstitutionsduetoemergencytreatment,andthemedicalexpensesincurredshallfirstbepaidbytheindividualorTheunitpaysinadvance.Aftertheemergencytreatmentiscompleted,thehospitalemergencymedicalrecords,examinations,laboratorytestreports,invoices,detailedmedicalbills,etc.gotothemedicalinsuranceagencytogothroughthereimbursementproceduresinaccordancewiththeregulations.

(3)Settlementproceduresforpeopleresettledindifferentplaces

1.Fortheworkerswhoareresettledindifferentplaces,theirunitsshalldesignate1-2designatedmedicalinstitutionsintheirplacesofresidenceandreporttomedicalinsurance.Thehandlingagencyfortherecord.

2.Themedicalexpensesincurredintheclinicofthedesignatedmedicalinstitutionintheplaceofresidenceoftheworkerswhoareresettledindifferentplacesshallbepaidinadvancebythepersonortheunit.Afterthetreatmentiscompleted,theunitshallholdthemedicalcertificateoftheinsuredpersonandMedicalrecords,validexpensereceipts,compoundprescriptions,hospitalizationexpenseslist,etc.shallbesettledatthesocialmedicalinsuranceagencyonthespecifieddate.

(4)Referralandtransfersettlement

1.Iftheinsuredpersonistransferredtoothermedicalinstitutionsfordiagnosisandtreatmentduetotheconditionsofdesignatedmedicalinstitutionsorspecialdiseases,areferralisrequiredTransferapprovalform.Thedoctorinchargeputforwardthereasonforthereferral,thedirectorofthedepartmentputforwardtheopinionofthereferral,themedicalinsuranceofficeofthemedicalinstitutionreviews,thedirectorinchargesigns,andthemunicipalmedicalinsurancecenterforapprovalcanbetransferred.

2.Inprinciple,referralisfirstinthecityandthenoutsidethecity,firstintheprovinceandthenoutsidetheprovince.Referralsinthecityarestipulatedtobecarriedoutamongdesignatedmedicalinstitutions.Referralsoutsidethecitymustbesubmittedbydesignatedmedicalinstitutionsatorabovethethirdlevelinthecity.

3.Themedicalexpensesincurredaftertheinsuredpersonistransferredshallbepaidincashbytheindividualororganizationfirst.Afterthemedicaltreatmentends,theinsuredpersonorhisagentshallholdthereferralandtransferapprovalformandmedicalrecordCertificates,prescriptionsandvaliddocumentsshallbereimbursedatthemedicalinsuranceagencyforhospitalizationexpensesthatfallwithinthescopeofpaymentbytheoverallplanningfund.

Reimbursementprocess

Fortheparticipants,thereimbursementprocessisasfollows:

(1)Participatingfarmersaretreatedindesignatedinstitutionswiththe"NewRuralCooperativeCertificate".Designatedmedicalinstitutionswilldirectlyreduceorexemptmedicalexpensesbasedonthecurrentamountinthe"NewRuralCooperativeMedicalCareCertificate"familyoutpatientclinicaccount,andtheexcesswillbepaidbytheparticipatingfarmers.Thedesignatedmedicalinstitutionshallmakesettlementswiththeagriculturalmedicalinstituteinatimelymanner.

(2)Participatingfarmerswhoarehospitalizedindesignatedmedicalinstitutionsincities,counties,andtownshipsshallbedirectlycompensatedbythedesignatedmedicalinstitutions.Thedesignatedmedicalinstitutionshallreviewthemedicalexpensesincurredbyit,andadvancethesubsidyamountaccordingtothestandardsstipulatedintheimplementationmeasures.

Participatingfarmerswhoarehospitalizedinprovincial-leveldesignatedmedicalinstitutionsandnon-designatedmedicalinstitutionsshallbecompensatedatthetownshipandruralmedicalinstitutions.Ifthehospitalizationmedicalexpensesarelessthan2,000yuan(including2,000yuan),thereimbursementwillbereviewedandreimbursedbythetownship(town)agriculturalmedicaloffice,andthosewithmorethan2,000yuanordoubtfulaboutthehospitalizationmaterialswillbereviewedandreimbursedbythetownship(town)agriculturalmedicaloffice.ReimbursementcanonlybemadeafterreviewandapprovalbytheMedicalBureau.

(1)Whenapplyingforcompensation,youneedtobringyourIDcard,householdregistrationbook,"NewRuralCooperativeMedicalCareCertificate"(theoriginalthreecertificatesarereviewedandkeptinthecopy)validhospitalizationinvoice,dischargesummary(orMedicalrecord),expenselistandreferralcertificate.

(2)Participatingfarmerswhosufferfromseriousoutpatientdiseases(chronicdiseases)mustbringtheirIDcards,householdregistrationbooks,"NewRuralCooperativeCertificate",andoutpatientinvoicesatthespecifiedtime(usuallyinJulyandDecembereachyear)Andthelist,outpatientmedicalrecord,inspectionreport,outpatientseriousillness(chronicdisease)certificateofGradeAorhigherhospitalsorspecialisthospitalsshallbehandledattheruralmedicalclinicofthetownship(town).

(3)Forparticipatingfarmerswhohaveparticipatedincommercialinsuranceandschoolstudentswhohaveparticipatedinstudentmedicalinsurance,whentheyaredischargedfromhospital,bothcommercialinsuranceandnewruralcooperativecompensationarerequired,theparticipatingfarmersshouldfirstTheoriginalhospitalizationinvoiceandacopyoftheinvoicearefirstsubmittedtotheagriculturalmedicalinstituteorcounty-leveldesignatedmedicalinstitutionforverificationandcompensation,andthentheoriginalhospitalizationinvoiceispaidtothecommercialinsurancecompany.Thecopyoftheinvoiceiskeptbytheagriculturalmedicalinstituteorthecounty-leveldesignatedmedicalinstitution,butthetraumapatientcanonlybereimbursedintheoriginal(exceptforstudents).

(4)Atime-limitedreportingsystemisimplementedforhospitalizationexpenses.Compensationandsettlementprocedurescanbeprocessedatanytimewithinthreemonthsafterdischarge.Thosewhoaremorethanthreemonthsoldwillbedeemedtohavegivenupcompensationontheirown..TheamountofcompensationthatshouldbecompensatedbytheAgriculturalMedicalInstituteinaccordancewiththestandardsstipulatedintheImplementationMeasuresshallbepaidtotheparticipatingfarmerswithin10workingdays.

NationalPolicy

InDecember1998,theStateCouncilissuedthe"DecisionoftheStateCouncilonEstablishingaBasicMedicalInsuranceSystemforUrbanWorkers"(GuoFa[1998]No.44)todeploynationwideThereformofthemedicalinsurancesystemforemployeeswillbecomprehensivelypromotedwithinthescope,andabasicmedicalinsurancesystemforemployeeswillbebasicallyestablishedthroughoutthecountryin1999.

Themeaningofbasicmedicalinsurance:Itisasocialsecuritysysteminwhichthestateorsocietyprovidesmedicalservicesoreconomiccompensationwhenpeoplefallillorareinjured.

1.Whatistheframeworkoftheurbanemployeebasicmedicalinsurancesystem?

Accordingtothe"DecisionoftheStateCouncilonEstablishingaBasicMedicalInsuranceSystemforUrbanEmployees"(Guofa[1998]No.44),theframeworkofthebasicmedicalinsurancesystemforurbanemployeesincludessixparts:

Thefirstistoestablishajointpaymentmechanismwithreasonableburden.

Basicmedicalinsurancepremiumsarepaidjointlybyemployersandindividuals,reflectingthecompulsorycharacteristicsofnationalsocialinsuranceandtheunityofrightsandobligations.Thejointpaymentofmedicalinsurancepremiumsbyunitsandindividualscannotonlyexpandthesourceofmedicalinsurancefunds,butmoreimportantly,clarifytheresponsibilitiesofunitsandemployees,andenhanceindividualself-protectionawareness.Inthisreform,thestatehasstipulatedthecontrolstandardsfortheemployer'scontributionrateandtheindividual'scontributionrate:theemployer'scontributionrateiscontrolledatabout6%ofthetotalwagesofemployees,andthespecificratioisdeterminedbyeachregion.Theemployeecontributionrateisgenerally2%oftheirownwageincome..

Thesecondistoestablishanoverallfundandpersonalaccount.

Thebasicmedicalinsurancefundiscomposedofapooledfundusedbythesocietyasawholeandapersonalaccountfundspeciallyusedbyindividuals.Allindividualpaymentsarecreditedtoindividualaccounts,about30%ofunitpaymentsarecreditedtoindividualaccounts,andtheremainingpartissetupasacollectivefund.Thepersonalaccountisusedexclusivelyformedicalexpensesandcanbecarriedforwardandinherited.Theprincipalandinterestofthepersonalaccountbelongtotheindividual.

Thethirdistoestablishapaymentmechanismwithseparateaccountingandclearscope.

Theoverallplanningfundandpersonalaccountdeterminetheirrespectivepaymentranges.Theoverallplanningfundmainlypaysforlargeandinpatientmedicalexpenses,andthepersonalaccountmainlypaysforsmallandoutpatientmedicalexpenses.Theoverallfundmustbebasedontheprincipleof"financingexpendituresbyrevenueandbalancingrevenuesandexpenditures",anddeterminetheminimumpaymentstandardandmaximumpaymentlimitbasedontheactualconditionsofeachregionandthefund'saffordability.

Fourthistoestablishaneffectivecontrolmechanismformedicalservicemanagement.

Thescopeofbasicmedicalinsurancepaymentislimitedtothemedicalexpenseswithintheprescribedbasicmedicalinsurancedrugcatalog,diagnosisandtreatmentitemsandmedicalservicefacilitystandards;fixed-pointmanagementisimplementedformedicalinstitutionsandpharmaciesthatprovidebasicmedicalinsuranceservices;societyInsuranceagenciesandbasicmedicalinsuranceserviceagencies(designatedmedicalinstitutionsanddesignatedretailpharmacies)shallsettletheirexpensesinaccordancewiththesettlementmethodstipulatedintheagreement.

Fifth,establishaunifiedsocialmanagementsystem.

Basicmedicalinsuranceimplementsacertainlevelofsocialmanagement.Inprinciple,administrativeregions(includingprefectures,cities,states,andleagues)abovetheprefecturelevelareusedasthecoordinatingunit,andthecountycanalsobethecoordinatingunit.Thesocialinsuranceagencyresponsiblefortheunifiedcollection,useandmanagementofthefundensuresthefullcollection,reasonableuseandtimelypaymentofthefund.

Thesixthistoestablishasoundandeffectivesupervisionmechanism.

Thebasicmedicalinsurancefundshallbemanagedbyaspecialfinancialaccount;thesocialinsuranceagencyshallestablishandimproverulesandregulations;theoverallplanningareashallestablishabasicmedicalinsurancesocialsupervisionorganizationtostrengthensocialsupervision.Itisnecessarytofurtherestablishandimprovefundbudgetandfinalaccountssystem,financialaccountingsystemandinternalauditsystemofsocialinsuranceagencies.

Thesecontentsbasicallydeterminethegeneralframeworkofthenewbasicmedicalinsurancesystemforurbanemployees,andlaythefoundationfortheunificationoftheChinesesysteminthefuture,whichisconvenientforlocalitiestofollowwhenformulatingreformplans,andatthesametime,theyarereservedforlocalities.Thereisroomformakingspecificregulationsbasedonlocalconditions.

2.Whichunitsandemployeesmustparticipateinbasicmedicalinsurance?

Accordingtothe"DecisionoftheStateCouncilonEstablishingaBasicMedicalInsuranceSystemforUrbanEmployees"(GuoFa[1998]No.44),allemployersincitiesandtowns,includingenterprises(state-ownedenterprises,collectiveenterprises,andforeign-investedenterprises),Privateenterprises,etc.),governmentagencies,publicinstitutions,socialorganizations,privatenon-enterpriseunitsandtheiremployeesmustparticipateinbasicmedicalinsurance.Thatistosay,theunitsandemployeesthatmustparticipateinthebasicmedicalinsuranceforurbanemployeesincludebothgovernmentagenciesandvarioustypesofurbanenterprises,includingbothstate-ownedandnon-state-ownedeconomicentities,andbothenterpriseswithgoodreturnsandenterprisesindifficulties.ThisisoneofthemostextensiveinsurancetypesinChina'ssocialinsurancesystem.

However,thestateclearlydetermineswhethertownshipenterprisesandtheiremployees,ownersofindividualurbaneconomicorganizationsandtheiremployeesparticipateinbasicmedicalinsurance.Thisismainlyduetothemanagementofthispartofthepopulationandtheparticularityofthemedicalinsuranceitself.Ifthebasicmedicalinsuranceisrigidlyincluded,andthemanagementabilitycannotkeepup,itmayleadtouncontrollablemedicalexpensesandincreasetheriskoffundoverspending.

3.Howdoindividualspaybasicmedicalinsurancepremiums?

Firstofall,eachcoordinatingareamustdetermineapersonalbasicmedicalinsurancepaymentratethatissuitableforthelocalemployees'burdenlevel,whichisgenerally2%ofsalaryincome.Secondly,theindividualpaysthebasicmedicalinsurancepremiumsattheprescribedlocalpersonalpaymentratebasedonhissalaryincome.ThebaseofpersonalpaymentshouldbebasedonthesalaryincomestatisticalcalibersetbytheNationalBureauofStatistics,thatis,allsalaryincome,includingallkindsofbonuses,laborincome,andincomeinkind,asthebase,multipliedbytheprescribedpersonalpaymentrate,ThatisthebasicmedicalinsurancepremiumsthatIshouldpay.Third,individualpaymentgenerallydoesnotrequireindividualstopayatthesocialinsuranceagency,buttheunitwithholdsandpaysfromthesalary.

4.Howtoestablishabasicmedicalinsurancepoolingfundandpersonalaccount?

Injectfundsintopersonalaccountscomefromtwoparts:personalpaymentandunitpayment:allpersonalpaymentsarecreditedtothepersonalaccount,andpartoftheunitpaymentiscreditedtothepersonalaccount.Theunitpaymentisgenerallycreditedtopersonalaccountsatabout30%.However,duetothelargedifferencesinthelevelofmedicalconsumptionexpendituresofemployeesofeachagegroup,whendeterminingtheunit'spaymentintheoverallplanningareatorecordtheproportionofeachemployee'saccount,theagefactorshouldbeconsideredtodeterminethedifferentproportionofdifferentageclasses.Todeterminethespecificproportionoftheunit'spaymenttothepersonalaccount,theoverallplanningareashallbedeterminedbasedonfactorssuchasthepaymentrangeofthepersonalaccountandtheageoftheemployees.

Thecapitalinjectedintotheoverallplanningfundmainlycomesfromunitpayment.Theremainingpartofthefeepaidbytheunitafteritistransferredtothepersonalaccountisthecapitaloftheoverallplanningfund.

5.Howtodealwiththepersonalaccountoftheemployeewhoparticipatedinthebasicmedicalinsuranceafterthedeath?

Theprincipalandinterestoftheemployee'spersonalmedicalinsuranceaccountbelongtotheemployee,andcanbecarriedforwardandinherited.Therefore,afterthedeathofanemployeeparticipatinginthebasicmedicalinsurance,ifhisorherpersonalmedicalaccountstillhasabalance,itcanbeusedasaninheritanceandinheritedbyhisrelativesinaccordancewiththeprovisionsoftheInheritanceLaw.Atthesametime,theirpersonalmedicalaccountaccountsandthe"EmployeeMedicalandSocialInsuranceManual"weretakenbackandcancelledbythemedicalsocialinsuranceagency.

6.Howcananinsuredemployeegetmedicaltreatmentaccordingtotheregulations?

Firstofall,theinsuredpersonsmustseekmedicaltreatmentandpurchasemedicinesatdesignatedmedicalinstitutionsunderthebasicmedicalinsurance,orpurchasemedicinesatdesignatedretailpharmaciesaccordingtoprescriptions.Medicalexpensesincurredinnon-designatedmedicalinstitutionsanddrugpurchasesinnon-designatedpharmacieswillnotbepaidbythebasicmedicalinsurancefundunlesstheymeettheprescribedconditionssuchasemergencyandreferral.

Secondly,themedicalexpensesincurredmustmeetthescopeandpaymentstandardsofthebasicmedicalinsurancedrugcatalog,diagnosisandtreatmentitems,andmedicalservicefacilitystandardsbeforetheycanbepaidbythebasicmedicalinsurancefundasrequired.Fortheexcesspart,thebasicmedicalinsurancefundwillnotbepaidaccordingtoregulations.

Thirdly,formedicalexpensesthatmeetthepaymentscopeofthebasicmedicalinsurancefund,itisnecessarytodistinguishwhetheritbelongstothepaymentscopeoftheoverallfundorthepaymentscopeofthepersonalaccount.Formedicalexpensesthatfallwithinthescopeofpaymentbytheoverallplanningfund,thosethatexceedthethresholdwillbepaidinproportiontotheoverallplanningfund,andthehighestpaymentwillbeuptothe"cappedline".Individualsalsohavetobearpartofthemedicalexpenses,andallexpensesabovethe"cappedamount"arepaidbytheindividualorsolvedbyparticipatinginsupplementarymedicalinsurance,commercialmedicalinsurance,etc.Themedicalexpensesbelowthethresholdshallbesettledbythepersonalaccountorpaidbytheindividual.Ifthereisabalanceinthepersonalaccount,partofthemedicalexpensesthatshouldbepaidbytheindividualwithinthescopeoftheoverallfundpaymentcanalsobepaid.

7.Howdoemployeesparticipatinginmedicalinsurancechoosedesignatedmedicalinstitutions?

AccordingtotheprovisionsoftheMinistryofLaborandSocialSecurityandotherdepartments"NoticeonPrintingandDistributingtheInterimMeasuresfortheManagementofUrbanWorkers’BasicMedicalInsuranceDesignatedMedicalInstitutions"(LaborandSocialAffairsDepartment[1999]No.14),participateintheinsuranceWithinthescopeofdesignatedmedicalinstitutionsthathaveobtainedthedesignatedqualifications,thepersonnelproposetheintentionofselectingdesignatedmedicalinstitutionsforpersonalmedicaltreatment,andtheunitwillcollectthemandsubmitthemtothesocialinsuranceagencyintheoverallplanningarea.Thesocialinsuranceagencyshallmakeoverallplanstodeterminethedesignatedmedicalinstitutionbasedontheinsured’sselectionintention.[Includingfirst-levelhospitalsandvarioushealthcenters,outpatientdepartments,clinics,healthclinics,infirmariesandcommunityhealthserviceinstitutions).

Insuredpersonscanmakechangestoselecteddesignatedmedicalinstitutionsafteroneyear,andthecoordinatingregionalsocialinsuranceagencieswillhandlethechangeprocedures.

8.Canemployeesofanenterprisenotbeabletoarriveatadesignatedpointduetoillnesswhenmedicalinstitutionsseekmedicaltreatment?Cantheybereimbursedmedicalexpenses?

AccordingtotheMinistryofLaborandSocialSecurityandotherdepartments’"NoticeonPrintingandDistributingtheInterimMeasuresfortheManagementofUrbanWorkers’BasicMedicalInsuranceDesignatedMedicalInstitutions"(LaborandSocialAffairsDepartment[1999]No.14),insuredpersonsYoushouldseekmedicaltreatmentatadesignateddesignatedmedicalinstitution,andyoucanindependentlydecidetopurchasedrugsatadesignatedmedicalinstitutionorpurchasedrugsatadesignatedretailpharmacywithaprescription.Exceptforemergencytreatmentandfirstaid,theexpensesincurredbytheinsuredpersonsformedicaltreatmentinnon-selecteddesignatedmedicalinstitutionsshallnotbepaidbythebasicmedicalinsurancefund.Therefore,ifanemployeedoesnothavetimetogototheselectedhospitalfortreatmentincaseofanemergency,he/shegoestoanearbyhospitalfortreatmentandholdsahospitalemergencycertificate.Themedicalexpensescanbepaidbythebasicmedicalinsurancefundaccordingtotheregulations.

9.Whatisthemedicalperiod?Whataretheregulationsforthemedicaltreatmentperiodforsickornon-work-relatedemployees?

Accordingtotheprovisionsofthe"RegulationsontheMedicalPeriodforSicknessorNon-WorkInjuryofEnterpriseEmployees"issuedbytheformerMinistryofLaborin1994,themedicalperiodreferstothestoppingofworkbyemployeesoftheemployerduetoillnessornon-work-relatedinjuries.Theemployercannotterminatethetimelimitofthelaborcontractduringtreatmentandrest.

The"RegulationsontheMedicalPeriodforSicknessorNon-WorkInjuryofEnterpriseEmployees"issuedbytheformerMinistryofLaborin1994mainlyhavethefollowingregulationsonthemedicalperiod:

(1)EnterpriseWhenanemployeeneedstostopworkingformedicaltreatmentduetoillnessornon-work-relatedinjury,themedicaltreatmentperiodisfrom3monthsto24monthsaccordingtotheactualworkingyears.Iftheactualworkinglifeislessthan10years,itis3monthsifyouhaveworkedintheunitforlessthan5years;ifyouhaveworkedformorethan5years,itis6months.Iftheactualworkinglifeismorethan10years,6monthsforthoseworkingintheunitforlessthan5years;9monthsforthoseworkingformorethan5yearsandlessthan10years;12monthsforthoseworkingformorethan10yearsandlessthan15years;andmorethan15years2018monthsunderoneyear;24monthsover20years.

(2)Themedicalperiodof3monthsiscalculatedasthecumulativesickleavetimewithin6months;the6monthsiscalculatedasthecumulativesickleavetimewithin12months;the9monthsiscalculatedasthecumulativesickleavetimewithin15monthsSickleavetimeiscalculated;12monthsiscalculatedasthecumulativesickleavetimewithin18months;18monthsiscalculatedasthecumulativesickleavetimewithin24months;24monthsiscalculatedasthecumulativesickleavetimewithin30months.

(3)Duringthemedicalperiodoftheenterpriseemployees,theirsickleavewages,sicknessrelieffeesandmedicalinsurancebenefitsshallbeimplementedinaccordancewiththeregulationsoftherelevantdepartments.

(4)Employeesofanenterprisearenotdisabledduetoworkandhaveadifficult-to-treatdiseaserecognizedbyadoctorormedicalinstitution,andthemedicaltreatmentendsduringthemedicaltreatmentperiod,andcannotperformtheoriginaljoborengageinotherarrangementsbytheemployerThelaborappraisalcommitteeshallcarryouttheappraisalofworkingabilityaccordingtotheappraisalstandardsforthedegreeofdisabilityduetowork-relatedinjuriesandoccupationaldiseases.(Trial)"(issuedbytheMinistryofLaborandSocialAffairs[2002]No.8)implementation).ThosewhoareappraisedasGrade1to4shallquittheirjobs,suspendthelaborrelationship,gothroughtheproceduresforretirementandresignation,andenjoyretirementandresignationbenefits;thelaborcontractshallnotbeterminatedduringthemedicaltreatmentperiodwhenappraisedasGrade5to10.

(5)Forthosewhohavenotrecoveredafterthemedicaltreatmentperiodexpires,theeconomiccompensationoftheterminatedlaborcontractshallbeimplementedinaccordancewithrelevantregulations.

10.Domigrantworkersparticipateinbasicmedicalinsurance?

TheMinistryofLaborandSocialSecurity"NoticeonImplementingTwoRegulations,ExpandingtheCoverageofSocialSecurityandStrengtheningtheCollectionofFunds"(MinistryofLaborandSocialSecurity[1999]No.10)stipulatesthatfarmers’contractsystememployeesparticipateinunitsThelocalsocialinsuranceandsocialinsuranceagenciesestablishindividualaccountsforbasicmedicalinsuranceforemployees.Aftertheterminationorcancellationofthelaborcontractofthepeasantcontractemployee,thesocialinsuranceagencymaysendthedepositofthebasicmedicalinsurancepersonalaccounttothepersoninalumpsum.

11,thescopeandstandardofruralmedicalinsurancecompensation?

Compensationforseriousillness:

(1)Townshipriskfundcompensation:Allinpatientsparticipatingincooperativemedicalcareshallbecompensatedinstagesforaone-timeorannualaccumulativereportablemedicalexpensesexceedingRMB5,000.Thatis,thecompensationof5001-10000yuanis65%,andthecompensationof10001-18000yuanis70%.

(2)Town-levelcooperativemedicalhospitalizationandoutpatienturemiaoutpatienthemodialysis,tumoroutpatientradiotherapyandchemotherapycompensationhaveanannuallimitof11,000yuan.

HospitalizationCompensation:

(1)Reimbursementratio:60%reimbursementfortownshiphospitals;40%reimbursementforsecondaryhospitals;30%reimbursementfortertiaryhospitals.

(2)Scopeofreimbursement:

A.Medicineexpenses:auxiliaryexamination:ECG,X-rayfluoroscopy,filming,laboratorytests,physicaltherapy,acupuncture,CT,MRI,etc.Eachinspectionfeeislimitedto200yuan;surgeryfee(refertonationalstandards,1,000yuanwillbereimbursedifitexceeds1,000yuan).

B.Elderlypersonsover60yearsoldarehospitalizedintownshiphealthcenters,andthetreatmentandnursingexpensesarecompensatedat10yuanperday,withalimitof200yuan.

Compensationforoutpatientclinics:

(1)60%reimbursementforclinicvisitsinvillageclinicsandvillagecenterclinics,prescriptiondrugfeelimitforeachvisitis10yuan,hospitaldoctors’temporaryrehydrationprescriptiondrugfeelimit50RMB.

(2)40%reimbursementformedicalvisitsinthetownshiphospital,eachexaminationfeeandsurgeryfeelimitis50yuan,prescriptiondruglimitis100yuan;secondaryhospitalvisits30%reimbursement,prescriptiondruglimitis200Yuan;20%reimbursementfortreatmentintertiaryhospitals,andalimitof200yuanforprescriptiondrugs.

(3)Chinesemedicineinvoicesareattachedwithaprescriptionlimitof1yuanperpost.

(4)Theannualcompensationlimitoftown-levelcooperativemedicaloutpatientclinicsis5,000yuan.

Theaboveisanintroductiontothescopeandstandardofcompensation,butcompensationisnotavailableunderallcircumstances.Thefollowingconditionsarenotcoveredbythescopeofreimbursement:self-seeking(seeingadoctorwithoutadesignatedhospitalornotapplyingforareferralform),self-purchasingMedicines,medicinesthatcannotbereimbursedunderpublicmedicalregulations,andmedicalexpensesthatdonotcomplywithfamilyplanning;outpatienttreatmentfees,outpatientfees,hospitalizationfees,meals,accompanyfees,nutritionfees,bloodtransfusionfees(exceptforthosewithfamilybloodstorage,accordingtorelevantregulationsReimbursement),heatingandcoolingexpenses,ambulanceexpenses,specialcareexpensesandotherexpenses;medicalexpensesforcaraccidents,fights,suicides,alcoholism,industrialaccidentsandmedicalaccidents;orthopedics,plasticsurgery,dentalimplants,prosthetics,organtransplants,androll-callsurgeryfees,Consultationfeesandotherreimbursementscope,thepartoutsidethelimit.

Localpolicies

InNovember2019,Anhuiissuedthe"AnhuiProvinceBasicMedicalInsuranceGroupedPaymentGuidancePlanbyTypeofDisease(Trial)"tofullyimplementbasicmedicalinsurancetogroupbytypeofdiseasePay-basedpaymentmethod.Thefirstbatchof422diseasesandpaymentmethodswereannounced.StartingfromJanuary1,2020,urbanandruralresidentsmedicalinsuranceparticipantswillhaveaunifiedpaymentstandardwhentheyseekmedicaltreatmentin18provincialhospitals.

Multi-riskhandling

Iftheinsuredconsumerpurchaseshospitalizationmedicalexpenseinsurancefromtwodifferentinsurancecompanies,thenwithintheinsuredamount,theinsurancecompanywillTheactualcostsituationiscombinedwiththeinsuredamounttocalculatetheclaim.Mostinsurancecompaniessetacertainamountofnocompensation.Ontopofthenocompensation,theinsurancecompanypaysaccordingtotheagreedratio.Afterthefirstinsurancecompanypays,thesecondinsurancecompanydeterminesreasonableexpensesbasedontheremainingamount.Makeapayment.Inshort,thetotalamountofcompensationpaidbyinsurancecompanieswillnotexceedthemedicalexpensesofinsuredconsumers.

MisunderstandingofClaims

Misunderstanding1:Thewoolisonthesheep

SomepolicyholdersbelievethattheannualamountofmedicalinsuranceclaimsissmallAsforpremiums,itisnotcost-effective,soifyouaresickandhospitalized,youhavetorelyonyourusualsavings.Infact,thekeyroleofmedicalinsuranceliesinthepreventionandtransferofdiseaserisks.Onceasuddenmajordiseaseoccurs,theindividual'sabilitytoresistislimited.Therefore,youshouldtransferyourownrisksthroughcommercialmedicalinsurance.

Misunderstanding2:Medicalinsuranceonlyworkswhenyouhaveaseriousillness

Actually,medicalinsurancedoesnotonlystartwhentheinsuredpersonhasaseriousillnesseffect.Whenadiseaseoccurs,consumersnotonlyfacetheburdenofmedicalexpenses,butalsobearexpensesotherthanmedicalexpenses.Atthistime,reimbursementmedicalinsurancespecificallyformedicalexpensescansharetheworriesofpolicyholders.Asforsubsidizedmedicalinsurance,regardlessofwhethertheinsuredishospitalizedornot,themedicalexpensescanbesubsidized.

Misunderstanding3:Whenyouareyoung,youcanbuylessclaims,andwhenyouareold,youcanbuymorepremiums.

Infact,consumerscanplanforarainydaywhentheyareyounganddoagoodjobforlife.Whenplanningmedicalinsurance,paypremiumswhenyouareyoung,andyouwillhavenoworrieswhenyouareold.

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