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深圳市城镇职工社会医疗保险办法 Measures on Medical Insurance of Employees of Cities and Towns in the Shenzhen Municipality

2006-05-13 01:23   我要纠错 | 打印 | 收藏 | | |

(Adopted at the 84th permanent meeting of the third municipal government, promulgated and goes into effect on July 1, 2003)

颁布日期:20030527  实施日期:20030701  颁布单位:深圳市人民政府

  Chapter one General Principles

  Article 1 In order to establish and strengthen the medical protection system of the Shenzhen municipality, and protect the basic medial rights and interests of employees, these measures are formulated according to relevant national laws and regulations and combining with the actual situations of the city.

  Article 2 The social medical insurance system of employees of cities and towns is carried out in the city.

  The government establishes medical insurance system, such as basic medical insurance, local supplementary medial insurance and birth medial insurance.

  The government provides medical subsidies for civil servants, encourages and supports enterprises to establish supplementary medical insurance system.

  Article 3 All employing units and employees in the city shall participate in the basic medical insurance, local supplementary medical insurance and birth medical insurance according to the provisions of these measures.

  Employing units mentioned in these measures refer to all organs, public institutions, societies, enterprises, non-enterprise unit established by civilians and intermediary organs in the administrative area of the city.

  Employees mentioned in these measures refer to person in-service affiliated with the employing unit, retiree described in these measures, and unemployed person with residence registration of the municipality and is in the period of receiving unemployment pension.

  Insured unit mentioned in these measures refers to the employing unit having participated in social medical insurance.

  Insured person mentioned in these measures refers to employee having participated in social medical insurance.

  Article 4 The system of social medical insurance shall comply with the principles of combing fairness and efficiency, adjusting rights with obligations, and adjusting the level of protection with the level of the development of productivity.

  Article 5 The basic medical insurance shall carry out the fund management mode of combing overall social planning with personal account.

  The local supplementary medical insurance and birth medical insurance shall be planned by overall society.

  The fund of basic medical insurance, local supplementary medical insurance and birth medical insurance shall be contained in special financial account for social protection. Their income and outlay shall be administered by two separate ways. The fund shall be used exclusively for medical insurance and shall not be seized or embezzled.

  When the fund of basic medical insurance, local supplementary medical insurance and birth medical insurance are not sufficient because of particular situations, such as illness explosion and prevail, and serious natural disaster, the municipal finance shall subsidize.

  Article 6 The basic medical insurance has two kinds of forms: comprehensive medical insurance and in-hospital medical insurance.

  The following people shall participate in the comprehensive medical insurance:

  1. person in-service with residence registration of the municipality (including blue-stamped residence registration, the same hereinafter);

  2. retiree, which has residence registration of the municipality before retirement, and enjoys old-age insurance paid monthly by the municipal organization of social insurance;

  3. retiree, which has residence registration of the municipality before retirement, participates the original trade overall plan of old-age insurance and enjoys old-age pension paid monthly by the social insurance organization of the Guangdong Province;

  4. other person in-service described by the municipal government.

  The following people shall participate in the in-hospital medical insurance:

  1. person in-service without residence registration of the municipality;

  2. retiree, which has no residence registration of the municipality and enjoys old-age pension paid monthly by the municipal organization of social insurance;

  3. unemployed person, which has residence registration of the municipality and in the period of receiving unemployment pension.

  The person in-service without residence registration of the municipality may participate in the comprehensive medical insurance after the employing unit applies.

  Article 7 Anyone, who participates in the comprehensive medical insurance or in-hospital medical insurance, shall participate in the local supplementary medical insurance at the same time.

  The person in-service with residence registration shall participate in the birth medical insurance at the same time.

  Article 8 The municipal administrative organization of social insurance (hereinafter referred to as the municipal organization of social insurance), established by the people‘s government of the Shenzhen municipality (hereinafter referred to as the municipal government), takes the expense of medical insurance work of the municipality.

  The relevant departments of sanitation, medicine, price, planning and finance shall assist the municipal organization of social insurance to accomplish the work of medical insurance.

  Chapter 2 Collection of Medical Insurance Premium

  Article 9 The fund of basic medical insurance comes from the basic medical insurance premium and its interests, financial subsidies and other revenues.

  The fund of local supplementary medical insurance comes from the local supplementary medical insurance premium and its interests and other revenues.

  The fund of birth medical insurance comes from the birth medical insurance premium and its interests and other revenues.

  Article 10 The paying base of the basic medical insurance premium, local supplementary medical insurance premium and birth medical insurance premium shall be established according to the following provisions:

  1. person in-service participating the comprehensive medical insurance shall use the total amount of his monthly wage as the paying base. If the total amount of his monthly wage exceeds 300% of the monthly average wage of the employees of cities and towns in the last year, the 300% of the monthly average wage of the employees of cities and towns in the last year shall be used as the paying base; if the total amount of his monthly wage is below 60% of the monthly average wage of the employees of cities and towns in the last year, the 60% of the monthly average wage of the employees of cities and towns in the last year shall be used as the paying base;

  2. anyone, who participates the in-hospital medical insurance, shall use the monthly average wage of the employees of cities and towns in the last year as the paying base;

  3. retiree described in item 2, paragraph 2 of article 6 shall use his monthly basic retirement pension as the paying base;

  4. retiree described in item 3, paragraph 2 of article 6 shall use the monthly average wage of the employees of cities and towns in the last year before his retirement as the paying base;

  5. the paying base of local supplementary medical insurance premium and birth medical insurance premium shall be established according to the paying base of basic medical insurance premium.

  Article 11 The employing unit and employee shall pay the basic medical insurance premium, local supplementary medical insurance premium and birth medical insurance premium according to the following standards:

  1. As to the comprehensive medical insurance premium, employee in-service shall pay 2% of the paying base, the employing unit shall pay 6%; in regard to the retiree, described in item 2, paragraph 2 of article 6, the municipal organization of social insurance shall pay 11.5% of the paying base, which shall be paid out from the common fund of the basic old-age insurance; in regard to the retiree, described in item 3, paragraph 2 of article 6, the original employing unit shall pay off for only one time, according to the amount of 11.5% (of the paying base)*12(month)*18(year)。

  2. As to the in-hospital medical insurance premium, in regard to employee in-service described in item 1, paragraph 3 of article 6, the employing unit shall pay according to 0.8% of the paying base; in regard to person described in item 2 or 3, paragraph 3 of article 6, the municipal organization of social insurance shall pay according to 0.8% of the paying base, which shall be paid out from the common fund of the basic old-age insurance and the fund of unemployment insurance;

  3. As to the local supplementary medical insurance premium, in regard to those who participate the comprehensive medical insurance, they shall pay according to 0.5% of the paying base; in regard to those who participate the in-hospital medical insurance, they shall pay according to 0.2% of the paying base. Except that the employing unit shall pay for person in-service, the paying channel and manner of others shall be carried out according to the provisions of the two preceding items;

  4. The birth medical insurance premium shall be paid by the employing unit according to 0.5% of the paying base.

  Article 12 The basic medical insurance premium, local supplementary medical insurance premium and birth medical insurance premium, shall be transferred into the account of the fund of social insurance, which is opened by the municipal organization of social insurance in the bank, after being collected by the deposit bank.

  Article 13 The social medical insurance premium paid by the insured unit and person shall be managed uniformly by the municipal organization of social insurance through establishing overall fund of medical insurance and individual account separately. The specific measures are:

  1. As to the comprehensive medical insurance premium, the part paid by individual shall all be counted into individual accounts; as regard to the part paid by the employing unit or by the municipal organization of social insurance, if the insured person in-service is younger than 35 (not including as old as 35), 30% of the amount shall be counted into individual account; if he is younger than 45 but older than 35 (not including as old as 45), 40% of the amount shall be counted into individual accounts; if he is older than 45, 50% of the amount shall be counted into individual accounts.

  As regard to retiree described in item 2, paragraph 2 of article 6, 60% of the amount shall be counted into individual account; as to retiree described in item 3, paragraph 2 of article 6, the amount that shall be counted into individual account is 11.5% * 60% * the monthly average salary of employees of cities and towns in the last year; the other part shall be counted into the overall fund of basic medical insurance;

  2. The in-hospital medical insurance premium shall all be counted in the overall fund of basic medical insurance; the individual account shall not be established.

  3. The local supplementary medical insurance premium shall all be counted in the fund of local supplementary medical insurance; the individual account shall not be established, and shall only be used to pay the treatment of local supplementary medical insurance;

  4. The birth medical insurance premium shall all be counted in the fund of birth medical insurance; the individual account shall not be established, and shall only be used to pay the medical expense of birth medical insurance.

  Article 14 The employing unit shall register and participate insurance within 30 days after the establishment or receiving the business license.

  Article 15 The medical insurance premium may be paid consecutively by the insured person with the residence registration of the municipality, if he participates in the basic medical insurance for more than 1 consecutive year, and there is no employing unit to pay the medical insurance premium for him because he changes his job. It shall be considered as consecutive paying, but the longest period of consecutive paying shall not exceed 3 months.

  Article 16 The medical insurance premium paid by enterprise shall be listed in cost, the premium paid by organs, public institution and unit shall be expended from the fund of administrative affairs; the premium ought to be paid by individual shall be paid before tax.

  Article 17 The interests of the fund of social medical insurance and individual account of the insured person shall be calculated according to relevant national provisions.

  Article 18 The municipal government may adjust the standard of the basic medical insurance premium, local supplementary insurance premium and birth medical insurance premium, which shall be paid by employing unit and individual, according to the specific situation of the economic development, the growing of employee‘s salary, the level of price and the expenditure of medical premium.

  Chapter 3

  Treatment of Medical Insurance

  Article 19 The insured person begins to enjoy the treatment of medical insurance stipulated in these measures from the first day of the next month upon transacting the formalities of participating insurance.

  If the insured person or his unit stops to pay the medical insurance premium, he stops to enjoy the treatment of medical insurance from the first day of the next month upon stopping payment, with the exception of individual account.

  Article 20 The insured person of basic medical insurance enjoys the medical treatment in the range of medicine catalog of basic medical insurance, items of diagnosis and treat, and standards for facilities of medical service, and other medical treatment stipulated.

  The insured person of local supplementary insurance enjoys the treatment of local supplementary medical insurance stipulated in these measures.

  The insured person of birth medical insurance enjoys the treatment of birth medical insurance stipulated by these measures.

  Article 21 The medicine catalog and items of diagnosis and treat of medical insurance shall comply with the system of access.

  The medicine catalog of basic medical insurance shall accord with the catalog promulgated by the administrative department of social insurance of the Guangdong Province and of the country; the items of diagnosis and treat of basic medical insurance, the standards for facilities of basic medical service and the medicine catalog of local supplementary medical insurance and the range of items of diagnosis and treat shall be laid down by the municipal organization of social insurance and be promulgated.

  Article 22 As to person in-service participating the comprehensive medical insurance, 90% of his basic medical expense in hospital shall be paid from the overall fund of basic medical insurance, the other 10% shall be paid by themselves; as to retiree participating the comprehensive medical insurance, 95% of his basic medical expense in hospital shall be paid from the overall fund of basic medical insurance, the other 5% shall be paid by himself, except that these measures stipulated otherwise.

  Article 23 The basic medical expense of outpatient service, the expense of the items of diagnosis and treat, the medicine in medicine catalog of the local supplementary medical insurance used in outpatient service of insured person of the comprehensive medical insurance, shall be paid from the individual account; if the individual account can not pay it off, 70% of the basic medical expense of outpatient service, which exceeds 10% of the yearly average salary of municipal employees of cities and towns last year, in the year of medical insurance, shall be paid from the overall fund of basic medical insurance, the other 30% shall be paid by himself.

  Article 24 As to the basic medical expense of insured person of in-hospital medical insurance in hospital, 90% shall be paid from the overall fund of basic medical insurance, 10% shall be paid by himself. If the insured person is a retiree, 95% of his basic medical expense in hospital shall be paid from the overall fund of basic medical insurance, 5% shall be paid by himself, with the exception that these measures stipulated otherwise.

  Other medical expense of outpatient service, which is not stipulated in article 27 of insured person of in-hospital medical insurance, shall be paid by himself.

  Article 25 When the insured person of the comprehensive medical insurance goes to outpatient service, 80% of the expense occurred in the check by large medical equipment and curing because of the situation of his illness shall be paid from the overall fund of basic medical insurance, the other 20% shall be paid by himself, after being examined and approved by the municipal organization of social insurance or medical organization authorized by it.

  The check item by large medical equipment and curing item shall be established by the municipal organization of social insurance.

  Article 26 In case that the insured person use special material for medical use or use material for medical use only one time with a unit price of above 1000, or install or replace man-made apparatus during the treatment in the items of diagnosis and treat of basic medical insurance, after being examined and approved by the municipal organization of social insurance, the overall fund of basic medical insurance shall pay 90% of the expense occurred according to the price of home-made style of widespread; or pay 50% of the expense occurred according to the price of import style of widespread if there is no comparable price of home-made style.

  The range of special material for medical use and man-made apparatus shall be established by the municipal organization of social insurance.

  Article 27 In case that the insured person use dialysis of chronic prostration of nephric function for out-patient, anti-rejection medicine for out-patient after organ transplantation, malignancy chemotherapy for out-patient, intervention therapy, radiotherapy therapy or nuclide therapy, after being examined and approved by the municipal organization of social insurance, 90% of his basic medical expense occurred shall be paid from the overall fund of basic medical insurance, the other 10% shall be paid by himself.

  The range of organ transplantation shall be established by the municipal social insurance.

  Article 28 The highest amount of money, paid from the overall fund of basic medical insurance by insured person in every medical insurance year, shall not exceed 4 times of yearly average salary of the city-and-town employees in last year, and shall be linked up with his time of participating insurance consecutively. The specific standards are:

  1. if the time of participating insurance consecutively is shorter than half a year, the highest amount of money paid from the overall fund of basic medical insurance is 0.5 times of yearly average salary of the city-and-town employees in last year;

  2. if the time of participating insurance consecutively is shorter than a year, the highest amount of money paid from the overall fund of basic medical insurance is 1 times of yearly average salary of the city-and-town employees in last year;

  3. if the time of participating insurance consecutively is longer than a year but shorter than two years, the highest amount of money, paid from the overall fund of basic medical insurance is 2 times of yearly average salary of the city-and-town employees in last year;

  4. if the time of participating insurance consecutively is longer than two years but shorter than three years, the highest amount of money paid from the overall fund of basic medical insurance is 3 times of yearly average salary of the city-and-town employees in last year;

  5. if the time of participating insurance consecutively is longer than three years, the highest amount of money paid from the overall fund of basic medical insurance is 4 times of yearly average salary of the city-and-town employees in last year;

  Article 29 As to the insured person of the local supplementary medical insurance, 85% of the following expenses shall be paid from the fund of the local supplementary medical insurance, the other 15% shall be paid by himself:

  1. the basic medical expense exceeding the highest amount of money paid from the overall fund of basic medical insurance;

  2. the expense occurred in hospital of medicine described in the medicine catalog of local supplementary medical insurance, or items for diagnosis and treat of local supplementary medical insurance.

  Article 30 The highest quota of medical expense, paid from the fund of the local supplementary medical insurance in each medical insurance year of the insured person of the local supplementary medical insurance, shall be linked with the time of participating basic medical insurance consecutively. The specific standards are:

  1. If the time of participating insurance consecutively is longer than half a year but shorter than 1 year, the highest quota of medical expense paid from the fund of local supplementary medical insurance is 50,000 yuan;

  2. If the time of participating insurance consecutively is longer than a year but shorter than 2 years, the highest quota of medical expense paid from the fund of local supplementary medical insurance is 100,000 yuan;

  3. If the time of participating insurance consecutively is longer than 2 years but shorter than 3 years, the highest quota of medical expense paid from the fund of local supplementary medical insurance is 150,000 yuan;

  4. If the time of participating insurance consecutively is longer than 3 years, the highest quota of medical expense paid from the fund of local supplementary medical insurance is 200,000 yuan;

  Article 31 The basic medical expense of perinatal check, parturition hospitalization, visit and check after parturition and operation of family planning of the insured person of birth medical insurance shall be paid from the fund of birth medical insurance.

  Article 32

  In case that the insured person refuses to leave hospital although meeting the requirement to leave, and being affirmed by the fixed medical organization, his medical expense occurred after the day on which he is affirmed to leave hospital shall all be paid all by himself.

  The insured person may apply to the municipal organization of social insurance for appraisal within 3 working days upon the day he is affirmed by the fixed medical organization to leave hospital, if he has dispute with the fixed medical organization about leaving hospital.

  The committee of experts on medical insurance shall be consigned by the municipal organization of social insurance to appraise, and shall make appraisal conclusion within 7 working days upon reception of the application. The date to leave hospital affirmed by the appraisal decision made by the committee of experts on medical insurance is the leaving day.

  Article 33 The expense of medical service, beyond the range of basic medical insurance, local supplementary insurance and birth medical insurance, shall be paid by the insured person himself.

  If the accumulated money of the individual account reaches two times of town employee‘s average monthly income of the previous year of whole municipality, the excess part can be used to pay the basic medical expense, or local supplementary medical expense paid by the individual when seeing a doctor in the fixed medical organization, or pay non-prescription medicine in the medicine catalog of basic medical insurance and the local supplementary medical insurance.

  Article 34 If the insured person is the counterpart of health care, his medical expense in the scope of basic medical insurance and local supplementary medical insurance shall be paid as stipulated by the municipal organization of social insurance. The excessive part shall be settled by the municipal government according to relevant provisions.

  Article 35 The medical expense of insured person due to industrial injury or occupational disease shall be settled according to relevant provisions on insurance of industrial injury.

  Article 36 If the insured person leaves the municipality, the remaining sum of his individual account shall be transferred into the local organization of social insurance of his residence registration; if there is no corresponding organization, the remaining sum shall be returned to him at one time.

  If the insured person died, the remaining sum of his individual account shall be paid to his inheritor at one time; if there is no inheritor, it shall be transferred to the overall fund of basic medical insurance.

  Article 37 If the insured person goes in hospital for emergency in another domestic city (not including Hongkong, Macao and Taiwan), during a business trip or visiting relatives, or is allowed by the municipal organization of social insurance to transfer to another domestic city to be in hospital, the basic medical expense and local supplementary medical expense shall be checked and reimbursed according to relevant provisions of these measures.

  The insured person with registered permanent residence in Shenzhen, who works in other domestic city for a long time or lives in other domestic city after retirement, shall be recorded with the municipal organization of social insurance. His basic medical expense and local supplementary medical expense occurred in hospital at his working place or living place shall be examined and reimbursed according to relevant regulations.

  The outpatient basic medical expense of the insured person occurred in other domestic city may be deducted from his individual account.

  Article 38 The insured person shall enjoy medical insurance treatment according to the compensation standard of municipal hospital if he gets in hospital under emergency during a business trip, visiting relatives or in Hongkong, Macao or Taiwan.

  Article 39 The insured person can not enjoy the medical insurance treatment stipulated in these measures under any one of the following circumstances:

  1. going to hospital in other domestic city or Hongkong, Macao, Taiwan or abroad arbitrarily;

  2. going to non-pointed medical organization for treatment in the city arbitrarily, except that his life is endangered and needs to be rescued;

  3. buying medicine arbitrarily, except that the circumstances stipulated in paragraph 2 of article 33;

  4. being injured because of traffic accident, medical accident or other negligent accident;

  5. being injured because of kill, wound or injure himself, drink excessively, brawl or his own illegal behavior;

  6. being injured because of other people‘s injurious act;

  7. other circumstances stipulated by the country, province or city.

  Article 40 The insured people shall not enjoy the medical insurance treatment stipulated in these measures if he uses the following items for diagnosis and treat or material for medical use:

  1. service of registration, consultation outside hospital or special medical service;

  2. non-illness treatment of face beauty, non-functional face-lifting, physical examination, medical consultation or illness prevention;

  3. non-basic medical insurance treatment of PET or photon knife;

  4. material for medical use only one time;

  5. recovery appliance, such as glasses, artificial tooth and hearing-aid;

  6. resources of organs or tissues for transplantation;

  7. other transplantation of organs or tissues other than kidney, bone marrow and cornea;

  8. complementary treatment such as qigong and magnet therapy;

  9. treatment of various barrenness and sterility or sexual disorder;

  10. various scientific or clinical treatment;

  11. other treatment stipulated by relevant provisions of country, province or city whose expense shall not be reimbursed.

  The specific range of treatment and material for medical use listed in the preceding paragraph shall be described by the municipal organization of social insurance, and adjusted according to the needs of social medial insurance and development of medial skill.

  Chapter 4 Fixed Medical Organization and Fixed Retail Drugstore of Medical Insurance

  Article 41 The social medical insurance system shall comply with the administration of fixed medical organization and fixed retail drugstore.

  The municipal organization of social insurance shall enact the measures on the examination and approval of qualification of the fixed medical organization and fixed retail drugstore jointly with the administrative departments of sanitary and medicine.

  Article 42 The municipal organization of social insurance shall establish the fixed medical organization and fixed retail drugstore according to the principles of overall planning, reasonable arrangement, convenience for seeing a doctor, giving attention to the needs and encouraging competition.

  National medical organization shall not refuse once being chosen by the municipal organization of social insurance to be a fixed medical organization. Other fixed medical organization shall be established by the municipal organization of social insurance and medical organization through consultation.

  The municipal organization of social insurance shall make agreement with the fixed medical organization.

  Article 43 The fixed medical organization shall insist the principles of “curing on the basis of the sickness, reasonable check, reasonable using the medicine and reasonable curing”, and provide good, efficient and cheap medical service to the insured person according to the provisions of these measures and the agreement.

  Article 44 The fixed medical organization shall establish the system to check and manage the therapy and medicine separately, standardize the medical behaviors and lower the proportion of the expense paid by the insured person himself to the total amount of the medical expense, and reduce the economic burden of the insured person.

  Article 45 The fixed medical organization and fixed retail drugstore shall establish the interior administration system corresponding to the medical insurance system.

  Article 46 The fixed medical organization shall have medical service facilities, which meet 80% of the requirements on the standards of the basic medical insurance service facilities; the fixed medical organization and fixed retail drugstore shall have more than 80% of the medicine listed in the catalog of the basic medical insurance and the local supplementary medical insurance.

  Article 47 The fixed medical organization and the fixed retail drugstore shall implement strictly the provisions of the government concerning the standard of medical expense and the price of the medicine, and shall publicize them.

  The fixed medical organization shall provide the detail list of daily expense in the outpatient service or being in hospital to the insured person.

  Article 48 The fixed medical organization shall implement relevant administration provisions on the medicine catalog, curing items and the standards for medical service facilities of the basic medical insurance, and the medicine catalog, curing items of the local supplementary medical insurance, when it provides medical service.

  If the fixed medical organization uses medicine, curing item and medical service facilities out of the range stipulated in the preceding paragraph for the insured person, it shall ask him for approval.

  Article 49 When the insured person goes to the fixed retail drugstore to buy medicine with medical insurance certification, the fixed retail drugstore shall comply with the following provisions:

  1. the person to sold over-the-counter medicines shall accord with the provisions in paragraph 2 of Article 33 of these measures;

  2. the sale of off-the-counter medicine shall according to the prescription of the fixed medical organization;

  3. taking into account according to provisions on medical insurance.

  Article 50 When the municipal organization of social insurance carry out check and supervision, the fixed medical organization and the fixed retail drugstore have the obligation to provide relevant materials and the detail list of expense. If they do not provide materials or the materials are not enough, the municipal organization of social insurance shall refuse to pay corresponding expense.

  Chapter 5 The Settlement of Medical Expense

  Article 51 The medical expense of the insured person, which occurred from seeing a doctor or buying medicine and accords with the provisions of basic medical insurance, local supplementary medical insurance or birth medical insurance, shall be transacted according to the following provisions based on the certification of medical insurance of the insured person:

  1. if it shall be paid from the overall fund of basic medical insurance, the fund of local supplementary medical insurance or birth medical insurance, the fixed medical organization shall take it into account according to the actual amount;

  2. if it shall be paid from individual account, the fixed medical organization or fixed retail drugstore shall transfer and deduct the amount from the individual account of the insured person. If the individual account is not enough to pay off, it shall collect from the insured person directly.

  The fixed medical organization, and the fixed retail drugstore shall collect the charge, occurred from seeing a doctor or buying medicine, but not in the scope stipulated by the provisions of basic medical insurance, local supplementary medical insurance or birth medical insurance, from the insured person directly.

  Article 52 The medical insurance premium may be settled by means of service item, service unit, or illness category, or be paid in advance according to the total amount.

  The municipal organization of social insurance shall establish settlement method according to the differences between medical organization and the actual situation, and specify it in the agreement made between the municipal organization of social insurance and the fixed medical organization.

  Article 53 The insured person, who meets the requirements stipulated in Article 23 of these measures and whose expense of outpatient service shall be paid by the overall fund of basic medical insurance, shall go to the municipal organization of social insurance to examine and reimburse the expense of outpatient service, on the basis of his medical record of outpatient service, detail list of the expense, and the original receipt of the expense within the next year of medical insurance.

  Article 54 If the insured person goes for emergency treatment in other domestic city, or is approved to transfer into the hospital in other domestic city, the medical expense of being in hospital shall be examined and reimbursed according to relevant provisions, on the basis of relevant materials such as medical record of being in hospital, certification of diagnosis of out of hospital or brief summary of out of hospital, definite and detail list of the expense and the original receipt of expense.

  The insured person with the permanent residence in the city, who is sent to work in other domestic city for a long time, or the insured person who lives in other places after retirement, shall examine and reimburse their basic medical expense and local supplementary medical expense occurred in the local fixed organization of medical insurance, on the basis of relevant materials such as medical record, certification of diagnosis of out of hospital or brief summary of out of hospital, definite and detail list of the expense and the original receipt of expense.

  If the insured person goes abroad or be in hospital because of emergency in Hong Kong, Macao or Taiwan, he shall examine and reimburse his medical expense in the municipal organization of social insurance on the basis of certification of his unit, passport for going abroad or special pass for Hongkong, Macau or Taiwan, medical record or brief summary of out of hospital, definite and detail list of the expense and the original receipt of expense

  Chapter 6 Supervising Medical Insurance

  Article 55 The supervisory organization of social insurance, which is composed of representatives of governments, enterprises, trade unions and other social organizations is established in the city.

  The supervisory organization of social insurance supervises the implementation situation of laws, regulations and rules on medical insurance, and supervises the income and outlay, usage and management of the fund.

  Article 56 Every unit and individual has the right to impeach the illegal or rule-breaking behaviors of the fixed medical organization, fixed retail drugstore, insured person or the working personnel of the municipal organization of social insurance.

  The municipal organization of social insurance shall reward the impeacher. The amount of reward shall be 20% of that of the illegal amount, and shall be paid from the overall fund of basic medical insurance.

  Article 57 The unit and insured person have the rights to inquire about the situation of payment of medical insurance premium and treatment to the municipal organization of social insurance.

  Article 58 The unit participating insurance shall publicize the payment situation of medical insurance premium to employees once half a year.

  Article 59 The municipal auditing organ shall audit the financial payment and avenue of the fund of medical insurance timely in every year. The result of the auditing shall be reported to the supervisory organization of social insurance.

  The municipal organization of social insurance shall establish and strengthen the financial system and interior auditing system of the fund of medical insurance.

  Article 60 The administrative chief department of sanitary at all levels shall strengthen the supervisory and management to the fixed medical organization, contain the implementation of medical insurance provisions in the check of comprehensive target administration of fixed medical organization, and link it up with the responsibility system of tenure target of the dean.

  Article 61 The municipal administrative department of price shall strengthen the supervisory on fixed medical organization and fixed retail drugstore to carry out the policy on drug price and medical service of the country, province and municipality.

  The municipal administration department of medicine shall strengthen the supervisory on the fixed medical organization and the quality of medicine of the fixed retail drugstore.

  Article 62 The municipal organization of social insurance shall carry out affiliated supervisory check to fixed medical organization and fixed retail drugstore regularly or irregularly jointly with relevant departments of sanitary, price and medicine.

  Article 63 When the municipal organization of social insurance carries out check, the checked unit shall report the situation according to the facts, and provide relevant materials as required, and shall not refuse being checked, lie nor disguise.

  When the municipal organization of social insurance checks the paying situation of the insured unit, it may require the unit to provide materials, such as employment situation, wage schedule and financial table etc. concerning the payment of medical insurance premium, and also may record on tape, film and paper, take pictures and copy relevant materials but shall keep secret for the unit checked.

  Article 64 The municipal organization of social insurance shall publicize the collection, payment, cash on hand and application of the fund of social insurance audited timely in every year.

  Article 65 The municipal organization of social insurance shall establish the expert committee of medical insurance, and develop the following activities:

  1. providing consultation for the municipal organization of social insurance to make relevant policies

  2. providing skill guidance for the municipal organization of social insurance to carry out supervision and check on medical insurance, and providing appraisal opinion on difficult medical problems occurred in the supervision and check.

  3. appraising the dispute between the insured person and the fixed medical organization on leaving hospital.

  The expenditure required by the expert committee of medical insurance for activities shall be drawn from the fund of medical insurance collected in the same year by the municipal organization of social insurance according to the proportion of less than 0.1%.

  Chapter 7

  Legal Responsibilities

  Article 66 If the employing unit does not pay the medical insurance premium as stipulated, the municipal organization of social insurance shall order it to correct in limited time. If it does not correct in due time, it shall be imposed a fine of 10% of the medical insurance premium not paid or of the short amount from the order date.

  If the employing unit does not pay the evaded medical insurance premium according to provisions, the medical expense occurred in the period shall be paid by the employing unit referring to the provisions of these measures.

  Article 67 If the insured unit provide medical insurance for person not in the scope stipulated, the relation of medical insurance is invalid, and the insured unit shall be imposed a fine of more than 5000 yuan but less than 10000 yuan. As to charges having been paid by the fund of social medical insurance, the municipal organization of social insurance shall take it back from the insured unit; if the party consists a crime, he shall be investigated criminal responsibility by judicial organ.

  Article 68

  Anyone, who violates the provisions of these measures, does not register for social insurance, inform wrong number of insured persons, refuses to provide relevant materials or provides untrue materials, shall be ordered to correct in limited time by the municipal organization of social insurance. If he does not correct in due time, the chief official of the insured unit shall be imposed a fine of more than 2000 yuan but less than 5000 yuan according to the seriousness of the circumstances.

  Article 69

  Anyone, who disturbs or obstructs the missionary of the municipal organization of social insurance to perform official duties, shall be punished by the department of public security according to law. If he consists a crime, he shall be investigated criminal responsibility by the judicial organ.

  Article 70 If the insured person commits anyone of the following behaviors, the municipal organization of social insurance shall take back the expenditures having been paid by the fund of social medical insurance according to law, and impose the person directly liable a fine as much as the amount paid by the fund of medical insurance. If the behavior consists a crime, the judicial organ shall investigate his criminal responsibility according to law.

  1. lending his identification of medical insurance to others for seeing a doctor;

  2. falsifying medical record, prescription or furnish to get extra money, or falsely claim the money as his own.

  Article 71 If the fixed medical organization or the fixed retail drugstore violates the medical insurance agreement of the fixed medical organization or of the fixed retail drugstore, the municipal organization of social insurance shall investigate its responsibility of breach of contract according to the agreement.

  Article 72 If the fixed medical organization commits anyone of the following behaviors and causes the damage to the fund of medical insurance, it shall compensate the loss, and be imposed a fine of more than 5,000 yuan but less than 20,000 yuan by the municipal organization of social insurance. If the circumstance is very serious, its qualification of fixed medical organization shall be suspended or revoked:

  1. using the fund of medical insurance to pay the medical expense of non-insured person;

  2. putting the medical expense ought to be paid by individual in the range of expense ought to be paid from the fund of medical insurance;

  3. embezzling the individual account of others;

  4. taking the unqualified insured person in hospital for treatment, extending the period of in hospital at discretion, allowing person to be in hospital only in name, making false medical record, keeping business record in subsection or taking the insured person in over-standard sickroom without his consent;

  5. using other means to increase the expense ought to be paid from the fund of medical insurance.

  The person directly liable for the behaviors stipulated in the preceding paragraphs shall be warned, circulated a notice of criticism or revoked his right of subscription of medical insurance by the municipal organization of social insurance according to the seriousness of the circumstance.

  Article 73 The fixed retail drugstore violating the provision of Article 49 of these measures shall be imposed a fine of more than 1,000 yuan but less than 10,000 yuan by the municipal organization of social insurance. If the circumstance is very serious, its qualification of fixed retail drugstore shall be suspended or revoked.

  Article 74 The fixed medical organization or the fixed retail drugstore violating the provisions of price management shall be punished by the administrative department of price according to relevant provisions.

  The fixed medical organization or the fixed retail drugstore violating the regulation of medicine management shall be punished by the supervisory and administrative department of medicine according to relevant provisions.

  Article 75 The working person of the municipal organization of social insurance, who abuses his authority, neglects his duties, or acts to serve his friends or relatives, shall be granted administrative penalty by his employing unit or relevant department. If he causes damage to the fund of social insurance, he shall shoulder the responsibility of compensation. If his behavior consists a crime, he shall be investigated criminal responsibility by the judicial organ.

  Article 76 If the party protests the notice of payment or the notice of demand payment, the decision of punishment or the treatment of medical insurance made by the municipal organization of social insurance, he may apply for reconsideration or bring litigation according to law.

  In case that the employing unit does not pay the medical insurance premium according to provisions, or does not reimburse the medical expense in the period of not paying the medical insurance premium according to these measures, the employee may complain to the municipal organization of social insurance and relevant department, and may apply for arbitration to the labor arbitration organization.

  Chapter 8 Supplementary Provisions

  Article 77 The average monthly wage of city-and-town employees of the previous year in the whole city shall subject to the number announced by the municipal statistical department. The average monthly wage concerned in these measures of the first half year shall be calculated according to the average monthly wage of the year before last, that of the second half year shall be calculated according to the average monthly wage of the previous year.

  Article 78

  Employees in the branch or working offices established out of the city by enterprises of the city shall participate in the basic medical insurance in the site of the offices.

  The medical insurance for foreigners and persons coming from Hongkong, Macao or Taiwan, and employed in the municipality shall be transacted according to relevant provisions of the country.

  Article 79 Employing unit, who can not pay the medical insurance premium in time because of special difficulty, may apply to the municipal organization of social insurance for deferred payment. The municipal organization of social insurance shall decide whether or not to approve. The longest period for the deferred payment approved shall not exceed 3 months.

  The insured person, whose standard of living is lower than the lowest safeguard standard of living of the municipality because having paid too much medical expense, may apply to the municipal organization of social insurance for subsidies of basic medical expense.

  In case that the payment of medical insurance premium is stopped without the approval of the municipal organization of social insurance, the medical expense of the employee shall be paid by the employing unit referring to these measures.

  Article 80 The employed person with registered permanent residence in the municipality in individual economic organizations shall refer to these measures.

  Article 81 The year of medical insurance begins at July 1 and ends at June 30 of the next year.

  Article 82 The specific measures on medical subsidies for public servants and supplementary medical insurance for enterprises shall be formulated by the municipal government separately.

  Article 83 These measures shall go into effect as of July 1, 2003.

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